[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]




 
      MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES 
                        APPROPRIATIONS FOR 2018

_______________________________________________________________________

                                 HEARINGS

                                 BEFORE A

                           SUBCOMMITTEE OF THE

                       COMMITTEE ON APPROPRIATIONS

                         HOUSE OF REPRESENTATIVES

                      ONE HUNDRED FIFTEENTH CONGRESS

                              FIRST SESSION

                                _________

  SUBCOMMITTEE ON MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED 
                                AGENCIES

                 CHARLES W. DENT, Pennsylvania, Chairman

  JEFF FORTENBERRY, Nebraska                       DEBBIE WASSERMAN SCHULTZ, Florida
  THOMAS J. ROONEY, Florida                        SANFORD D. BISHOP, Jr., Georgia
  DAVID G. VALADAO, California                     BARBARA LEE, California
  STEVE WOMACK, Arkansas                           TIM RYAN, Ohio
  EVAN H. JENKINS, West Virginia
  SCOTT TAYLOR, Virginia

 
  NOTE: Under committee rules, Mr. Frelinghuysen, as chairman of the 
full committee, and Mrs. Lowey, as ranking minority member of the full 
committee, are authorized to sit as members of all subcommittees.


    Maureen Holohan, Sue Quantius, Sarah Young, and Tracey E. Russell,
                            Subcommittee Staff

                               __________

                                  PART 3

                                                                   Page
  Veterans Affairs.............................................       1
                                                                      
  Office of the Inspector General..............................     141
                                                                    
  Public Witnesses.............................................     235
                                                                    
  Veterans Affairs Electronic Health 
  Record.......................................................     321
  
  
                                                                    

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                    U.S. GOVERNMENT PUBLISHING OFFICE

  28-157                   WASHINGTON : 2018

                            
                            
                            
                            



                      COMMITTEE ON APPROPRIATIONS

                                ----------                              
             RODNEY P. FRELINGHUYSEN, New Jersey, Chairman


  HAROLD ROGERS, Kentucky \1\                          NITA M. LOWEY, New York
  ROBERT B. ADERHOLT, Alabama                          MARCY KAPTUR, Ohio
  KAY GRANGER, Texas                                   PETER J. VISCLOSKY, Indiana
  MICHAEL K. SIMPSON, Idaho                            JOSE E. SERRANO, New York
  JOHN ABNEY CULBERSON, Texas                          ROSA L. DeLAURO, Connecticut
  JOHN R. CARTER, Texas                                DAVID E. PRICE, North Carolina
  KEN CALVERT, California                              LUCILLE ROYBAL-ALLARD, California
  TOM COLE, Oklahoma                                   SANFORD D. BISHOP, Jr., Georgia
  MARIO DIAZ-BALART, Florida                           BARBARA LEE, California
  CHARLES W. DENT, Pennsylvania                        BETTY McCOLLUM, Minnesota
  TOM GRAVES, Georgia                                  TIM RYAN, Ohio
  KEVIN YODER, Kansas                                  C. A. DUTCH RUPPERSBERGER, Maryland
  STEVE WOMACK, Arkansas                               DEBBIE WASSERMAN SCHULTZ, Florida
  JEFF FORTENBERRY, Nebraska                           HENRY CUELLAR, Texas
  THOMAS J. ROONEY, Florida                            CHELLIE PINGREE, Maine
  CHARLES J. FLEISCHMANN, Tennessee                    MIKE QUIGLEY, Illinois
  JAIME HERRERA BEUTLER, Washington                    DEREK KILMER, Washington
  DAVID P. JOYCE, Ohio                                 MATT CARTWRIGHT, Pennsylvania
  DAVID G. VALADAO, California                         GRACE MENG, New York
  ANDY HARRIS, Maryland                                MARK POCAN, Wisconsin
  MARTHA ROBY, Alabama                                 KATHERINE M. CLARK, Massachusetts
  MARK E. AMODEI, Nevada                               PETE AGUILAR, California
  CHRIS STEWART, Utah
  DAVID YOUNG, Iowa
  EVAN H. JENKINS, West Virginia
  STEVEN M. PALAZZO, Mississippi
  DAN NEWHOUSE, Washington
  JOHN R. MOOLENAAR, Michigan
  SCOTT TAYLOR, Virginia
  ----------
  \1\}Chairman Emeritus

 
  

                   Nancy Fox, Clerk and Staff Director

                                   (ii)
                                   
                                   
                                   


     MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES 
                        APPROPRIATIONS FOR 2018

                              ----------                             

                                            Wednesday, May 3, 2017.

                     DEPARTMENT OF VETERANS AFFAIRS

                                WITNESS

HON. DAVID J. SHULKIN, SECRETARY OF VETERANS AFFAIRS

                    Chairman Dent Opening Statement

    Mr. Dent. Good morning.
    Today, we are pleased to welcome back a good friend, Dr. 
David Shulkin, the new secretary of the Department of Veterans 
Affairs. The last time you appeared before the committee, you 
were VA. Under Secretary for Health. Now, you have been kicked 
upstairs after a unanimous Senate confirmation vote--to repeat 
that, it was unanimous and that says a lot in this political 
environment. So congratulations.
    With your extensive health background, I know you have got 
a great background in the Philadelphia area. I just learned, 
too, you were in Morristown in Chairman Frelinghuysen's 
district for some time. You certainly bring a lot of experience 
to the job, although I am sure these days that the challenges 
are very daunting for you.
    We realize this hearing is a little bit unusual. Rather 
than the typical budget hearing we usually have at this time of 
year, we are limited to a discussion of the skinny budget 
materials that OMB had sent to the Hill in March. The two-page 
entry for the VA doesn't give us much to go on in terms of 
program priorities or plans for the Choice successor program.
    But the skinny budget does give us one remarkable bit of 
news for the VA. Apparently, the administration is proposing a 
$4.4 billion or 6 percent funding increase for the agency. In 
addition, there is $2.9 billion proposed in new mandatory 
funding for the VA. You are probably the only domestic federal 
agency not facing a substantial cut. And so I suspect I am 
going to need a Kevlar vest when talking to my fellow 
Appropriations subcommittee chairmen.
    So when we see your full budget later this month, we will 
be asking some tough questions about the merits of your 
proposed increases when we know others will be struggling.
    Despite not having a complete budget, I am sure the members 
will find plenty of VA topics to ask you about this morning: 
How do you envision VA striking a balance between care in VA 
facilities, versus non-VA community facilities; making the 
electronic health record work for veterans, especially as they 
see more doctors through Choice; your efforts to tackle 
appointment scheduling problems; how you plan to approach 
disability claim backlogs and appeals; your plans to decrease 
veteran suicide and homelessness; your campaign to limit opioid 
abuse among veterans; and plans to access care for rural and 
female veterans.
    And that is probably just a start. The members will think 
of other things I am sure.
    So Mr. Secretary, we are going to include your full 
statement today in the hearing record, and we will be pleased 
to hear your oral statement. But before you begin, I will ask 
our ranking member, Ms. Wasserman Schultz, if she has any 
opening comments that she would like to make, then after that, 
the chair and the ranking member of the full committee.
    With that, Ms. Wasserman Schultz is recognized.

       Ranking Member Wasserman Schultz Opening Statement

    Ms. Wasserman Schultz. Thank you, Mr. Chairman.
    And welcome, Mr. Secretary. It has been a pleasure to talk 
with you over the last few weeks and good to have you in my 
office yesterday.
    We do appreciate you being here in your new capacity and I 
echo the chairman's comments, particularly given that it is an 
awkward situation that we find ourselves in. You are operating 
on a bigger stage than you were previously, and with greater 
responsibility that comes with the duties of being the 
secretary of VA.
    Mr. Chairman, since fiscal year 2008, the VA has seen a 
tremendous 70 percent increase in DVA accounts. DVA medical 
accounts have grown from $36.7 billion to $64.4 billion. And 
the overall discretionary accounts have increased from $43.6 
billion to $74.3 billion. And fiscal year 2018 is no different. 
The President's skinny budget even requests $78.9 billion for a 
6 percent increase from the 2017 enacted level.
    The 2018 budget also requests legislative authority and 
$3.5 billion in mandatory authority to continue the Veterans 
Choice Program. And what is a question that arises is that this 
would support a program that was initially meant as a stop-gap 
temporary fund.
    Mr. Secretary, while I am certainly, you know, thrilled to 
have you here today, it is unfortunate that we won't be able to 
discuss the specifics of the VA budget request. And the lack of 
detail makes it extremely challenging for the committee to 
properly do our job.
    Moreover, given this 70 percent increase over the past 10 
years, it is critical that this committee has the opportunity 
to analyze and understand these numbers, as well as know more 
about why the VA continues to have issues of mismanagement, 
wait times and less than adequate care.
    While I can understand that this degree of growth has its 
growing pains, it is crucial that we understand how these 
issues are being addressed. And once we more fully understand 
those issues, at what point do we ask if this continued growth 
is unsustainable?
    Mr. Secretary, I ask these questions with genuine concern 
for the future of the VA.
    Obviously our driving concern must be to provide the best 
care to our veterans. However, if we don't control costs and 
ensure that the resources this committee provides are used in 
an appropriate and efficient fashion, we actually hurt our 
ability to help veterans and deliver on our mission of 
providing top-quality care.
    You know, it comes to mind to that, while we are providing 
additional resources, we are not seeing what would normally 
come as the commensurate response from the people who are 
receiving these services, because of the challenges that the VA 
is having in providing those services efficiently.
    Top-quality care is really our top priority and we need to 
make sure that we help you deliver on that mission.
    With that in mind, Mr. Chairman, it is imperative that we 
discuss a number of key issues, including the Choice program 
and the state of the VA's electronic health records.
    How does the VA envision Choice, a mandatory program, 
working with Community Care, a discretionary program? After 
creating the Community Care Account, which includes $9.4 
billion in advance fiscal year 2018 appropriations, why does 
the budget request also include $3.5 billion for the Choice 
program?
    Additionally, where is the VA in implementing and improving 
its electronic health records system, and in executing 
Congress' mandate for full interoperability with the DOD 
systems? As we discussed this past Monday in my office, Mr. 
Secretary, a solution to this issue is long overdue.
    And finally, I hope you can address the significant number 
of vacancies at the department and when these positions are 
expected to be filled. Currently, 11 Senate-confirmable 
positions remain vacant, including the under secretary for 
benefits, the under secretary for health, the under secretary 
for memorial affairs, the general counsel, the assistant 
secretary for information and technology, the assistant 
secretary for policy and planning, the assistant secretary for 
management and the chairman of the Board of Veterans Appeals.
    And by the way, the veterans' appeals process is an 
absolute mess. And so for it to have no chair for as long as 
that has occurred is really unacceptable.
    And from our discussions, I really believe that you 
earnestly want to reform and improve the VA It is reflective in 
the confidence that was placed in you, with a unanimous vote 
for your confirmation from the United States Senate.
    And it is our duty, I believe, to ensure that you have 
adequate resources to do so and the proper oversight is in 
place to guard against abuses and mismanagement. As you can 
see, we have a lot to discuss today.
    And, Mr. Chairman, thank you for the opportunity to share 
my concerns, and I yield back.
    Mr. Dent. Thank you, ranking member.
    At this time, I would like to recognize the chair of the 
full committee, Mr. Frelinghuysen of New Jersey.

        Full Committee Chairman Opening Statement

    The Chairman. Great. Thank you, Chairman Dent and Ranking 
Member Wasserman Schultz.
    So, first of all, I want to give you a shout-out for 
passing your bill last year, September. Thank you for that 
effort. You were the pace setters. I wish we could have 
followed your pace, but in reality, we didn't. But I can't 
think of a more important department than the Department of 
Veterans Affairs.
    I mean, those who have served our country, and serve our 
country right now in dangerous places, deserve, when they get 
home, to get the best care possible. And I know you from your 
time in New Jersey and the wonderful things you did there.
    And, for good reasons, you were unanimously confirmed by 
the Senate. There is not a lot of unanimity over there, but I 
am glad that they focused their attention and support for you.
    Two areas of particular interest to me--I don't want to 
take time away from your remarks or your questions. The 
continuing appeals and benefits backlog, it is a nightmare. I 
have even shared with you some of the 3- or 4-year waiting 
periods for people. Obviously, evidence has to be collected and 
verified, but in reality, it is a pretty nightmarish prospect, 
and certainly the confirmation of your undersecretaries might 
be helpful in that regard. So hopefully that will happen.
    And over the years this has been a continual interest to 
me--is electronic medical records. I think, 3 years ago, then-
Chairman Rogers hosted Chuck Hagel, the Secretary of Defense, 
and Ric Shinseki, one of your predecessors. And we received a 
commitment from former General Shinseki that we would have, 
within a year, some sort of a solution.
    I know the Department of Defense--and, given the resources 
they have been given--is getting up to speed. But I do view 
your systems as sort of the weak link.
    So I just personally feel that this is something which is 
enormously important. In a day and age when we have so much 
information passing back and forth, obviously, encrypted and 
protected, to not have that available to our health care 
providers is pretty inexcusable.
    But good luck and Godspeed, and thank you, Mr. Chairman.

       Full Committee Ranking Member Opening Statement

    Mr. Dent. Mrs. Lowey, I would like to recognize you.
    Mrs. Lowey. Thank you very much. And I would like to thank 
Chairman Dent and Ranking Member Wasserman Schultz for holding 
this important hearing.
    And I welcome Secretary Shulkin today.
    We as members of Congress, and you as the Secretary of 
Veterans Affairs, have a duty to provide the best care 
available to our veterans, who have sacrificed and faithfully 
served our Nation. The VA faces serious challenges in meeting 
their health needs.
    After working 4 years to reduce the claims backlog, it is 
once again increasing, and the Choice Program will soon run out 
of money and is in need of reform.
    And the VA and Department of Defense are not significantly 
closer to the interoperability of electronic health records 
than they were years ago. We owe it to all current and future 
veterans to tackle these challenges now, and this subcommittee 
is committed to achieving that goal.
    I must say, after reading your resume, I am so optimistic. 
As was referenced before, Chairman Rogers and I had, I think, 
four hearings, right, Chairman Frelinghuysen? We also met in 
closed-door sessions. We hadn't been able to resolve this.
    Now, I have my own personal preference about who is to 
blame, as we were talking about it before, but that is 
irrelevant now. And, looking at your resume, I am so 
enthusiastic, and I know you are going to get this done.
    In my own district, I have worked to secure federal funding 
to improve rehab facilities and ensure that veterans can 
receive a high quality of care. But for too many, the VA is 
unable to provide the types of services they require.
    From women struggling to find care in a health system that 
has traditionally served men to veterans who were turned away 
from VA facilities when they are most in need, the VA has a 
responsibility to serve all veterans who seek the care and 
treatment they have earned.
    In light of these challenges, Congress awaits the details 
of the President's fiscal year 2018 budget request. The budget 
framework requests an increase of 6 percent for the VA, but 
lacks detail, providing just seven bullet points of vague 
proposals. While you may not be able to speak to details of the 
budget proposal now, I hope you will return after its release 
so we can fully discuss it.
    Mr. Secretary, I again thank you for being here today. 
Thank you for your commitment to improving the lives of 
veterans, and thank you for assuming the responsibility. I look 
forward to hearing about all your success, sooner rather than 
later, so we won't, in a bipartisan way, continue to talk about 
backlogs and the lack of records.
    So we have confidence in you and I thank you for appearing 
here today.
    Mr. Dent. Thank you, Mrs. Lowey. At this time I would like 
to recognize Secretary Shulkin for 5 minutes.

        Secretary Shulkin Opening Statement

    Secretary Shulkin. Chairman Frelinghuysen, Chairman Dent, 
Ranking Member Lowey, Ranking Member Wasserman Schultz, and all 
of you who are here today, I was so impressed with your opening 
statements and so many topics that you have thought about and 
that you care about, and that I know are serious issues--and we 
are trying to do things differently at the VA--that I have a 
terrific opening statement.
    But I am willing to--Mr. Chairman, to actually forgo it and 
get right into your questions, unless you would prefer me to go 
through the opening statement, because I think we have so many 
issues, and I want to use your time--most valuable. I have 
submitted it for the record. I would be glad to read through 
it, read through my whole statement, but I will leave it up to 
you.
    You would like to hear it?
    Mr. Dent. Yes.
    Secretary Shulkin. Good. Okay. Okay. I told you, it is 
terrific.
    Mr. Dent. The abridged version, about 5 minutes' worth.
    Secretary Shulkin. Okay. I will try to do it quickly, but 
thank you.
    Okay. So thanks for the opportunity to be here today to 
talk about the President's 2018 budget. I also want to thank 
you all for your support of the 2017 budget that really gave 
us, for the first time, our full budget from the start of the 
fiscal year.
    It really speaks well of the U.S. Congress, and really, of 
the American people, that, despite all these differences--and 
you have mentioned this several times--that we can come 
together on this topic to support our Nation's veterans. I have 
submitted the full statement for the record.
    The President's 2018 budget reflects his strong personal 
commitment to our Nation's veterans. It provides the necessary 
resources to continue the ongoing modernization of the VA 
system.
    The budget requests $78.9 billion in discretionary funding 
for VA, a 6 percent increase from the 2017-enacted level. It 
provides $4.6 billion more for medical care, a 7.1 percent 
increase, and the $3.5 billion more in mandatory budget 
authority that was mentioned to continue the Veterans Choice 
Program.
    More veterans are opting for Choice than ever before--five 
times more in fiscal year 2016 than fiscal year 2015--and 
Choice authorizations are still rising. We have issued 35 
percent more authorizations in the first quarter of fiscal year 
2017 than in the same quarter of 2016. All told, including both 
care VA facilities and in the community, we project a 6.6 
percent increase in ambulatory care for 2018 over 2016.
    I urge you to support and fully fund our 2018 request to 
enable VA to meet increasing demand for VA services, to 
modernize the VA systems and to invest in choice.
    As you know, I came to VA during a time of crisis, when it 
was clear that veterans were not getting the timely access to 
high-quality health care they deserved. I know VA has made 
significant progress in improving care and services to 
veterans, but I also know that much more must be done if VA is 
to continue keeping President Lincoln's promise to care for 
those who have borne the battle.
    Last week, I had an opportunity to meet two courageous 
young Americans, Michael and Sarah Verardo of Rhode Island. All 
Michael ever wanted to do was to be a soldier, and he became a 
soldier serving his country--serving in the Army's 82nd 
Airborne Division.
    Then he lost a leg and part of his arm in an IED explosion 
in Afghanistan. He suffered other wounds as well. They told me, 
when he sought care from the VA in 2014, they did not receive 
the care. We cannot allow ourselves to ever again fail our 
American heroes like the Verardos. Meeting Michael and Sarah 
underscored for me the urgency of VA modernization.
    My five priorities as Secretary are to provide greater 
choice for veterans, to modernize their systems, to focus 
resources more efficiently, to improve the timeliness of our 
services and suicide prevention among veterans.
    We are already taking bold steps towards each of these 
priorities. Two weeks ago, the President signed a 
reauthorization of the Veterans Choice Act, ensuring veterans 
can continue to get care from community providers.
    Just last week, the President ordered the establishment of 
a VA. Accountability Office, and we are moving as quickly as we 
can within the limits of the law to remove bad employees.
    VA has removed medical center directors in San Juan, 
Shreveport, Louisiana, and recently, we have relieved the 
medical center director right here in Washington, D.C., and 
removed three other executive service leaders due to misconduct 
or poor performance.
    We simply cannot tolerate employees who act counter to our 
values or put veterans at risk.
    Since January of this year, we have authorized an estimated 
6.1 million community care appointments, 1.8 million more than 
last year, a 42 percent increase. We now have same-day services 
for primary care and mental health at all of our medical 
centers across the country.
    Veterans can now access wait-time data for their local VA 
facilities by using the easy online tool where they can see 
those wait times. No other health care system in the country 
has this type of transparency.
    VA is setting new trends with public-private partnerships. 
Last month, we announced a public-private partnership of an 
ambulatory care development center with a donation of roughly 
$30 million in Omaha, Nebraska, thanks to Mr. Fortenberry's 
help there. Veterans now have--or will have a facility that is 
being built with far fewer taxpayer dollars than in the past.
    Finally, VA is saving lives. My top clinical priority is 
suicide prevention. On average, 20 veterans a day die by 
suicide. A few months ago, the Veterans Crisis Line had a 
rollover rate to a backup center of more than 30 percent. 
Today, that rate is less than 1 percent.
    In support of our efforts to reduce suicides, we have 
launched new predictive modeling tools that allow VA to provide 
proactive care and support for veterans who are at the highest 
risk of suicide. And I have recently announced that VA will be 
providing emergency mental health care to former service 
members with other than honorable discharges at all of our 
medical facilities. We know that these veterans are at greater 
risk for suicide, and we are now caring for them as well as we 
can.
    These are just a few of the efforts that are under way, but 
are already improving the lives of veterans. But to keep moving 
forward, we need your help. We need Congress to help us realign 
our capital infrastructure, to dispose of property we don't 
need and to support facilities where veterans can get better 
served.
    We need Congress to fund our I.T. modernization to keep our 
legacy systems from failing and to increase the 
interoperability of electronic health records essential to any 
high-performing integrated health system. We are also weighing 
options for adopting a commercial off-the-shelf alternative to 
our legacy systems. I have scheduled the decision for this in 
July.
    If it makes sense to go to the off-the-shelf route, we will 
need some additional support from you as well.
    We need Congress to authorize the overhaul of our broken 
and failing claims appeals process that many of you have 
mentioned. Working closely with veteran service organizations 
and other stakeholders, VA has drafted legislation to modernize 
the system.
    We have submitted our proposal to the 114th Congress, and 
we have resubmitted it in this current Congress. We need 
Congress to act on this.
    Most of all, we need Congress to ensure the continued 
success of choice for veterans. Extending the Choice Program 
past its August end date was an absolute necessity, and thank 
you for that. But extending the program was just the next step 
towards the modernization of community care that veterans 
deserve.
    We have charted a course for modernization and are already 
moving forward, but we need your help to keep up with the 
Choice Program's growth, maintain our momentum, and make our 
community care plan a reality for all veterans for generations 
to come.
    In closing, let me again express my thanks to the 
Appropriations Committee and to this subcommittee for the 
support that you have shown veterans in recent years. Without 
that support, we could not have expanded Choice to a record 
number of veterans while also curing so many veterans of 
hepatitis C. You have made that possible, and 77,000 veterans 
are now free of hepatitis C as a result.
    Thank you for the opportunity to be here today. I look 
forward to all the questions that you may have.
    [The information follows:]
    
    
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    Mr. Dent. Yes, at this time, I would like to recognize the 
chair of the full committee, Mr. Frelinghuysen, if he has any 
questions.

            VISTA ELECTRONIC HEALTH RECORDS

    The Chairman. Very briefly, you talk of the legacy system. 
The acronym is VistA. Now, you are looking at an off-the-shelf 
system.
    Isn't the issue here different I.T. systems at every 
hospital? So, where are you in the overall--very briefly, where 
are you--in terms of some--maybe some good news in the mix?
    Secretary Shulkin. Right. Well, we only have 130 different 
systems, okay. So the VistA system is something that, frankly, 
VA should be proud of. VA invented it. It was the leader in 
electronic health records. But, frankly, that is old history, 
and we have to look at keeping up, and to modernize the system.
    I have said two things, Mr. Chairman, in the past. I have 
said--number one is VA has to get out of the business of 
becoming a software developer. This is not our core competency. 
I don't see why it serves veterans. I think we are doing this 
in a way that, frankly, we can't keep up with.
    So, I have said that we are going to get out of that 
business. We are either going to find a commercial company that 
will take over and support VistA, or we are going to go to an 
off-the-shelf product, and that is really what we are 
evaluating now. We have an RFI out for essentially the 
commercialization of VistA that we would no longer be doing 
internally.
    The second thing I have said is that--and I think it was 
referenced in several of your comments--you have asked the 
Department of Defense and VA to work together probably for 10 
or 15 years. And we have always found ways not to do that.
    Secretary Mattis and I have talked about this. We believe 
that we need to find ways to work together.
    So when I come out in July, I am going to be talking about 
a process that led to a decision to get us out of the software 
development business and to find a way to work even closer with 
the Department of Defense than we have. And we are working 
rapidly towards that decision, and I am committed to that date.
    The Chairman. Thank you for that progress.
    Mr. Dent. Thank you. At this time, I would like to 
recognize Mrs. Lowey.
    Mrs. Lowey. Thank you so much--thank you so much, Mr. 
Chairman. There are so many questions, but I must continue this 
discussion, having been part of this issue of records for the 
last 5, 6, 7 years.
    And I gather we have spent $1.4 billion on this--I don't 
even know what I want to call it, project, search, 
interoperability. But what I am confused about, it is my 
understanding that the Defense Department has already rolled 
out the system.
    It seems to me you make a lot of sense saying, we are not 
going to be in this business anymore, we want an off-the-shelf 
system. However, in order to foster--to ensure there is 
interoperability, what is wrong with the Defense program, and 
why wouldn't you, at least at the outset, explore that?
    Because if you choose another system, and they have their 
system, what is it going to be? Another billion dollars that we 
could use for suicide prevention, for treatment, for all kinds 
of important things.
    I have to tell you, as the ranking member, Chairman 
Frelinghuysen and I go to a lot of committee hearings. But this 
affects my heart. And when I talk to veterans in the district, 
and I know the challenges they are facing, and I know that you 
have all the competence, background to do it, why wouldn't you 
start--or are you looking at the system the Defense Department 
has rolled out?
    Secretary Shulkin. Yes, so, first of all, I hear your----
    Mrs. Lowey. Frustration.
    Secretary Shulkin. That is probably a good word.
    Mrs. Lowey. I am smiling, so--we have had hearings where 
the anger was----
    Secretary Shulkin. Yes, yes. No, listen, Congress has been 
very clear on this for years and years. And that is why I 
believe that you and the American people and the veterans 
deserve a clear direction on this. And I am committed to doing 
that.
    I can tell you we are exploring all options. I am sure you 
understand this is a highly complex issue. And I have lived 
through personal electronic medical record conversions in 
hospitals that I have led. These are not easy projects in 
single hospitals, let alone talk about the size of the VA 
system. So we are taking this very seriously. I can assure you 
we are exploring all those options.
    We also as we get more veterans out into the community, out 
into the private sector hospitals, we have to be very concerned 
about interoperability with those partners as well. So if there 
was an easy solution here, I am sure it would have been made 
already. But we are going to make a decision and we are going 
to move forward with it, and we are going to need your help in 
being able to implement that.
    Mrs. Lowey. I just want to say thank you, Mr. Chairman. And 
I want to thank you for assuming the responsibilities that our 
veterans certainly are looking for and they deserve. And I wish 
you the best of luck. And I look forward to your coming back 
sooner rather than later, because I don't want to have another 
hearing on interoperability.
    Secretary Shulkin. Right.
    Mrs. Lowey. So thank--and I want to remind you again, $1.4 
billion has already been spent on trying to get the Defense 
Department and the VA coordinated. So thank you so much again. 
We look forward to hearing from you as soon as possible.
    Secretary Shulkin. Thank you.
    Mr. Dent. Thank you, Mrs. Lowey.

          THE FUTURE OF COMMUNITY CARE

    Mr. Secretary, we understand that you are floating ideas 
for a system to consolidate the various non-VA care programs, 
including Choice. While we realize your proposals are by no 
means locked down, it sounds like you are contemplating a plan 
that would allow veterans to seek urgent care outside the VA 
system. It will be followed by a discussion with a VA care 
provider about whether the veteran should be seen in the 
community or by the VA. That decision would be based on the 
results of a local health market analysis identifying the 
capacity, quality and cost of the various services at the local 
VA.
    Is the basic premise of this proposal to keep services 
within the VA, subject to availability, quality and capacity, 
rather than open the doors more broadly to non-VA care?
    Secretary Shulkin. Let me try to describe it, Mr. Chairman, 
a little bit differently than that.
    First of all, I think you are correct that what we have 
identified coming out of the 2014 wait-time crisis out of 
Phoenix was that the VA, I don't believe had the appropriate 
management systems in place. And the way I believe that you run 
a clinical system is that you put your clinical urgency first.
    So, if somebody is waiting for a routine examination, that 
is normal. But somebody shouldn't be waiting if they have a 
tumor in their chest or if they have blood, you know, coming 
out of parts of their body that they shouldn't have it coming 
out of. That needs urgent care right away. So we are going to 
prioritize and to make sure that veterans aren't waiting.
    Secondly, we are trying to build an integrated system of 
care. That means if you look at this from the veteran's 
perspective, which is really the only perspective we should be 
looking at this from, you want to take what the VA does best 
for veterans that you can't find as well in the private sector. 
And you want to take what the private sector does best that the 
VA doesn't do as well.
    And you want to make that an integrated experience for the 
veteran. And that is what we are trying to do. Currently, one-
third of our care happens outside the VA walls; two-thirds 
inside. And we are working now to get the proper mix in each of 
the communities, because it will look different in New York 
City than it will in Arkansas, and try to figure out in that 
community what is the proper mix of inside VA and working with 
the community. And that is what we are hard at work at doing. 
And I think that this will benefit the veteran the most.
    Mr. Dent. And to follow up on that. What cost governors 
would you include to keep the program costs to a manageable 
level?
    Secretary Shulkin. Yes. Well, I am very sensitive to cost. 
And my belief is that one of the reasons why we got into the 
problems that we did in VA is because we were not properly 
funding the actual demand. And that is why I think it is so 
important that we, and you work with us, to get what the 
President has requested for the 2018 budget. Because I think 
that we need that.
    But I am not looking for non-sustainable increases year 
after year the way that we have in the past. And I think as 
Congresswoman Wasserman Schultz said, that is an unsustainable 
solution. The problems that we have in the VA are not primarily 
financial. These are primarily system issues that we haven't 
kept up with and we haven't modernized.
    So I am looking for an investment this year to help us 
modernize our systems. The I.T. system will be one example of 
where we need to come back, but I am not going to be seeking 
increases of this type in future years to come.
    So, we do need to put cost mitigation strategies in place. 
One of the areas that we are focusing on that I have already 
announced is fraud, waste, and abuse. I think that there are 
huge opportunities to identify waste and abuse in the current 
system. There are not the proper safeguards in place. And we 
are going to be taking some aggressive actions to do that.
    There are other cost mitigation strategies that I am 
seeking as part of Choice. One of them would be for the VA to 
be able to do value-based purchasing. The private sector has 
moved towards this where there are accountable care 
organizations to focus on quality and cost, and where you can 
purchase care based on the best value, which is cost over 
quality.
    We don't have those tools in the VA. In fact, we are 
restricted from using that. We have to pay a flat Medicare fee 
schedule. So, I am seeking the same tools that the private 
sector has to be able to control costs and improve quality.

       WORKFORCE AND FACILITY INFRASTRUCTURE NEEDS

    Mr. Dent. And can I just quickly follow up? If Congress 
were to adopt your ideas, what would that mean for workforce 
and facility infrastructure needs?
    Secretary Shulkin. In this budget?
    Mr. Dent. Yes.
    Secretary Shulkin. We are seeking the budget so that we can 
hire the proper health care professionals. We now have 45,000 
clinical openings in the Veterans Health Administration, and 
another 4,000 openings outside of the Veterans Health 
Administration. So for a total of 49,300 employees that we are 
seeking.
    I think that, frankly, the crisis that went through and the 
lack of good press, and so the impact on the morale of the 
workforce has really hurt us in recruiting. Of course, we had a 
hiring freeze in place up until April 12th. So we have fallen 
behind.
    And, in particular, in my priority areas like mental 
health, I need 1,500 new mental health professionals to join 
the VA. So we are really prioritizing that right now and this 
budget would allow us to get up to that staff.
    Mr. Dent. Thank you, Secretary Shulkin.
    At this time, I would like to recognize the ranking member, 
Ms. Wasserman Schultz, for 5 minutes.
    Ms. Wasserman Schultz. Thank you, Mr. Chairman.
    First and foremost, I just wanted to suggest that, as a 
number of members have mentioned it, because the Secretary is 
limited to only speaking about the skinny budget, it would be 
incredibly helpful and important, once we have the President's 
budget released, for us to ask him to come back and hold a 
hearing on the actual, full budget request.
    So, I would ask both the chair--both chairs--to please 
consider doing that, just so we can delve into a little bit 
more detail. Thank you.

              VETERANS CHOICE PROGRAM

    I want to focus on the Choice Program for a moment, because 
you have asked for an additional $3.5 billion, and we talked 
about it yesterday a little bit. But, you know, we recently 
extended, as you mentioned, the Choice Program past the August 
expiration date, and there was $950 million left in the Choice 
account.
    So, in part, obviously, rather than letting that funding 
languish, and considering that there is still a need, that made 
a lot of sense. But, we did envision the Choice Program to be a 
temporary program initially.
    My understanding, and correct me if I am wrong, was that it 
was really supposed to be a bridge for the VA to transition to 
the Community Care Program, until we could get the Community 
Care Program in a place where it is able to provide the kind of 
timely services that we need it to.
    If that is not the case, then can you explain the 
differences between the two? And you have also proposed Choice 
2.0. So we have Choice, Choice 2.0 and Community Care. I am not 
sure it would ultimately help us realize our goal of efficiency 
if we have three different programs in the private sector to 
help make sure we can meet the needs of our veterans.
    Secretary Shulkin. Right. I couldn't agree with you more. I 
am looking for one program. Three programs doesn't work. We now 
know, having two programs, that didn't work very well. We 
confused veterans.
    We had two programs, Community Care and Choice. They had 
different rules. They put veterans at risk in their credit 
because some--some paid first dollar, and others didn't, and 
you had to call different numbers to use them. We are proposing 
a single program for Community Care.
    As far as the intent of Congress for 3 years, look, 
Congress stepped up in a big way after the crisis when, 
basically, the country and Congress agreed that the current 
situation with veterans waiting for care was unacceptable.
    VA did exactly what Congress asked us to do, which was to 
put into place additional options for veterans to get care in 
the community. And now, we are seeing those authorizations and 
appointments occurring in the community.
    When I started at VA a little bit less than 2 years ago, we 
had 20 percent of our care in the community. Today, it is about 
32 percent. So you can see we are expanding those options. I 
don't think there is any turning back from this.
    So whether it was intended to be authorized for 3 years or 
not--you know, I know that is what the legislation said--I 
think what we have seen is veterans need that care. They are 
coming to VA to seek that care, and we need to continue to 
support that. That is my opinion. So the $3.5 billion that was 
built into the program is very much a needed resource for our 
veterans.
    Ms. Wasserman Schultz. And I understand, given that your 
goal is one program--are you analyzing which program, 
ultimately, would be phased out? Because we have a tendency to, 
instead of phasing out programs, because they have people with 
a vested interest in them, simply, you know----
    Secretary Shulkin. Yes.
    Ms. Wasserman Schultz [continuing]. Going along to get 
along, rather than rocking the boat. And so, if we are adding 
$3.5 billion to the Choice Program and it--you know, it had 
$950 million left, there have been challenges with the Choice 
Program, and confusion, and there are still challenges with the 
Community Care program, in what direction is the VA thinking of 
going when we--and what is the timeline for ultimately----
    Secretary Shulkin. Right.
    Ms. Wasserman Schultz [continuing]. Phasing out one program 
and only having one?
    Secretary Shulkin. Right. Well, with almost certainty, I 
can tell you there will not be three programs, because the 
current Choice Program will run out of money by the end of this 
calendar year. So that program is going to go away, and should 
be through December of this year.
    What we are hoping to do is to work with you so that we can 
introduce a Community Care funding program--the chairman 
referred to it as Choice 2.0--which is a program that makes 
sense for veterans, which is a single program that operates 
under one set of rules for how veterans get care in the 
community.
    And that new legislation, which we believe needs to be 
introduced by late summer or early fall in order to make the 
timeline, would end up with a single program.
    Ms. Wasserman Schultz. So you would eventually envision 
phasing out Community Care with the advent of----
    Secretary Shulkin. Yes.
    Ms. Wasserman Schultz [continuing]. Choice 2.0. Thank you. 
I yield back.
    Mr. Dent. Thank you.
    At this time, I would like to recognize the gentleman from 
Florida, Mr. Rooney, for 5 minutes.
    Mr. Rooney. Thank you, Mr. Chairman. I would like to just 
sort of continue on, you know, the same line briefly, or just 
maybe make a statement that our chairman of the full committee, 
as well as Mrs. Lowey, Ms. Wasserman Schultz--pretty much 
everybody up here--agrees. We have been giving you all a lot of 
money.
    And I have been on this committee with General Shinseki, 
who I served under at Fort Hood with Mr. McDonough. He was a 
military man, Mr. McDonough, you know, businessman, you are a 
doctor.
    By the way, we have a lot in common. Even though I am from 
Florida, I grew up in Philadelphia. I have got a Pittsburgh 
connection, so I am rooting for you.
    But you know--and you talked about working with General 
Mattis and trying to get this continuity of care, and we all 
talked about on the stump when we are, you know, down in our 
districts that if you are--if you put the uniform on and serve 
this country, we are going to take care of you. As you 
mentioned Lincoln, we often reference Washington, the country 
can measure itself by how it treats its veterans.
    And one of the things that we say, from the time that you 
enlist or the time that you get commissioned to the time that 
you die, you will not be, you know, left out in the cold, we 
are going to take care of you.
    And one of the things that people ask me about is, well--
how--where does it fall through the cracks? And we often talk 
about how, even though we are giving you all the money that you 
need, that, you know, the difference between DOD and the VA is 
way too big.
    And whether it is, you know, the electronic records or just 
the fact that you have to basically start all over when you 
leave the military and you PCS and you get into the veterans, 
you know, program--whatever it is.

        INTEROPERABILITY WITH DEPARTMENT OF DEFENSE

    I guess my first question to you is, if General Mattis has 
a better idea than you do, will you agree to go to his program 
just to get this moving? I ask you this just to get this 
moving. I ask you this for this reason: you could be the best 
VA secretary of all time if you solve this one problem.
    And I mean, every time we sit up here and talk to people at 
this table, that--we always keep asking the same question. And 
I know that there is a lot of bureaucracy, and I know there is 
a lot of pride, and whatever the problem is, but, you know, we 
just hope that this--if it means you saying to Mattis, ``you 
know what, you are right, you have a better program, we are 
going to go with your program,'' will you do it?
    Secretary Shulkin. Yes. First of all, thank you for your 
comments, and I appreciate your perspective on this issue and 
how important it is.
    I am only here for one reason, and that is to solve the 
problems that have plagued VA I wish it was only one problem, 
by the way. But I agree with you, this is certainly an 
important problem for us.
    Anybody, whether it is Secretary Mattis or anyone else who 
has a better idea than I have, I am going to take it. The 
answer to your question is yes. We want to resolve this issue 
in the best way, and if it means taking somebody else's idea, 
we are going to do that.
    Mr. Rooney. I mean, it would be so good to be able to go 
home and stand up on the stump and tell these guys, I come from 
a district with a lot of retirees in Florida, a lot of military 
retirees--and tell these guys, ``if you put on the uniform of 
this country, we are going to take care of you.''
    Basically, if you need the health or the mental health 
after you serve, it is--one of the advantages of joining, is 
that you know that you are going to be taken care of when you 
get out. So, that would be a huge help to all of us up here who 
are trying to convince people that fighting for this country 
has benefits well beyond just, you know, the pride of service.

         TRANSITIONING CARE BETWEEN VA FACILITIES

    One quick thing, since I am running out of time, and this 
is more specific to my district. I am having--my constituent 
services representatives down in Florida are telling me that we 
are getting a lot of people that are moving to Florida, as they 
always do, from other parts of the country.
    And they are going in to get care at our VA, and because of 
whatever breakdown in coverage, they are told that in my 
district, that--they are told to start a new treatment plan or 
return to the State--to where they came from, where they were 
already getting care for whatever problems that they were 
having.
    And this is kind of absurd from the standpoint of that I--
we have actually got five or six specific cases where people 
that live in Florida can't get the care that they were getting 
in their other State, so they are actually, rather than 
starting over in Florida, going back to their State where they 
came from and using that VA, because they are already in that 
system.
    This, again, gets to that system where there shouldn't be 
any lapse in coverage, but there is. Can you talk about the--
have you heard about this at all, or?
    Secretary Shulkin. I haven't heard about your specific 
situations, but I hope your directors are watching this right 
now, because what you described is unacceptable. We have one VA 
system. Veterans should be able to get care at any VA that they 
go into, and that is our commitment.
    I am not at all doubting that it doesn't work all the time. 
I certainly hear many examples where it does work, and people 
are able to get care--they are travelling, they lose their 
medications, they are able to get to a VA, get them refilled, 
get the care they need. That is the system that we are--that is 
our expectation of how we manage the system, and I will 
reclarify that to our field.
    [The information follows:]

    One of the many advantages to our Veterans is the seamless 
care that we can provide throughout all of our VA facilities 
and this is possible through our national electronic record. 
All facilities need to make sure that front line staff offer a 
consistent message that no matter what type of services the 
Veterans are seeking, the site at which they are presenting has 
immediate access to their VA healthcare record.
    The Office of Primary Care Operations will be confirming 
this expectation with field facilities during either the next 
Primary Care VlSN Point of Contact call (May 18, 2017 at 1:00 
pm EDT) and/or the Primary Care Interactive Office Hours (May 
22, 2017 at 1:30 pm EDT).

    Mr. Rooney. Thanks, Doctor. Good luck.
    Secretary Shulkin. Thank you.

                JOINT LEGACY VIEWER (JLV)

    Mr. Dent. Thank you, Mr. Rooney. Mr. Secretary, if I could 
just interject on that point for a moment, could you just 
describe the current Joint Legacy Viewer----
    Secretary Shulkin. Yes.
    Mr. Dent [continuing]. And what it can do to share DOD and 
VA records, just for the benefit of some of the members?
    Secretary Shulkin. Right.
    Mr. Dent. And we will go to Mr. Bishop.
    Secretary Shulkin. Yes, and I am sorry--I am sorry that 
Congresswoman Lowey left for this, because I didn't say this to 
her, but we did certify interoperability with the Department of 
Defense in April of 2016. That is through the Joint Legacy 
Viewer, that is probably where a lot of her $1.4 billion went 
to, although I don't think it was that much.
    And what this does is this allows any VA clinician, any DOD 
clinician, to be able to access records from the other system. 
So it is a read-only system. It is being used tens of thousands 
of times a month by our clinicians in both systems.
    So, it does work and it is a lot better than before, when 
we didn't have that ability. It is better care. But it is not 
the complete interoperability that I think that all of us would 
hope for. It is a read-only system at this point.
    Mr. Dent. Thank you for that clarification.
    Now, Mr. Bishop.
    Mr. Bishop. Thank you very much, and welcome, Mr. 
Secretary. And let me join my colleagues in congratulating you 
and thanking you for your commitment to get these problems 
fixed.

                   THIRD-PARTY BILLING

    Let me go to an area of improving timeliness of service, 
which is third-party, uncollected billing. The fiscal year 2016 
report on the appropriations had directed the VA to submit an 
annual report identifying the amount of third-party health 
billings that are owed to the VA, and the annual amount that is 
collected.
    It additionally required that the VA include a plan to 
capture uncollected third-party billings. The VA was directed 
to initiate a pilot program and figure out how best to capture 
the uncollected billings. The difference between billings and 
collections in fiscal year 2015 was $4.7 billion. And in fiscal 
year 2016, it was $5.164 billion.
    This is alarming because it means that billions in 
uncollected dollars are not available to the VHA to provide the 
services to veterans. What is the status of the pilot program, 
and who in the department is responsible for the fiscal 
management of third-party billings and collections? And if you 
could answer that quickly----
    Secretary Shulkin. Yes, thank you.
    Mr. Bishop [continuing]. I want to move to another area.
    Secretary Shulkin. Congressman, I will try to answer this 
quickly.
    I think you have identified an area of significant risk for 
us, that we have opportunity to do this in a much better way 
than we are currently doing this, so I think you are correct.
    We currently collect around $3.4 billion a year. We 
actually will be asking for, in our new Choice legislation we 
hope to work with you on, the ability to do this better.
    We, right now, are not allowed to require that veterans 
give us their other health insurance. So a lot of that gap 
right there is because we don't know their insurance numbers, 
and we don't know their insurance company from which to collect 
it.
    But we are looking at--and we have a RFP that will be 
released in the next couple of weeks, to be able to see whether 
the private sector can actually help us do collections better, 
and that is part of our pilot work that we are doing. We are 
actually using another federal agency to help us with these 
collections, and that does seem promising.
    So, I can get you a more detailed answer, because I don't 
want to take up the time now, about the results of the pilot 
project.
    [The information follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
   
    
    Mr. Bishop. Thank you very much and I look forward to that.
    Secretary Shulkin. Yes.

           MYVA INITIATIVE AND VISN REALIGNMENT

    Mr. Bishop. Mr. Secretary, your predecessor, Mr. McDonald, 
started an initiative known as MyVA, to modernize and reorient 
the VA. The MyVA vision was to provide a seamless, unified 
veteran experience across the entire organization and 
throughout the country.
    In your testimony, you mention that you intend to modernize 
the VA as well. Can you tell us how your plan differs from Mr. 
McDonald's, and how you plan to--and whether or not you plan to 
build upon the MyVA? And, can you also provide an update of the 
Veterans Integrated Service Network's realignment? That is the 
first part of the question.
    And then the other has to do with facility realignment. You 
mention an actual infrastructure realignment strategy, and the 
last time VA made a major effort to set infrastructure needs 
was the Capital Asset Realignment for Enhanced Services, the 
CARES project. Do you envision that the department will embark 
on a similar effort?
    And if so, when will we see a plan to invest and divest VA 
capital assets? Is the strategy that you plan to propose 
similar to the military base realignment--the BRAC process?
    Secretary Shulkin. Yep. Well, there is a lot there, 
Congressman, so I will try to do this quickly.
    The MyVA program under Secretary McDonald, I think, no 
doubt, has the correct intent, which is to design a veteran-
centric experience, and to focus on that experience. And we 
know that there was significant and good improvement being done 
under that program, because we could measure it.
    What I have said to the Department is that one of the 
benefits of me having been in the Department under Secretary 
McDonald is that I already know what was working. And I don't 
want to stop the progress that was being made.
    But I also don't believe we were making progress fast 
enough. So I am looking to essentially continue the parts of 
that program that work. But I am seeking much broader, bolder 
transformation of this Department because I think it is what is 
needed. And that is why I have sent my five priorities forward.
    In terms of the VISN realignment, we used to have 21 VISNs. 
We are now down to 18. Whether 18 is the right number or not, I 
think we are always continuing to take a look at that.
    But we are going to change the role and function of the 
VISN from what it currently is, which is another layer of 
administrative complexity--some people may call that red tape--
to a much more profound function in managing their local 
markets and moving toward this value-based purchasing concept 
and making sure that veterans get the best of care in the 
community and the best in VA care.
    So we are working on that transformation as we are building 
our Choice Program.

              FACILITY REALIGNMENT

    The realignment--the CARES program, I wasn't here when that 
was implemented. I do know that we have closed 1,000 
facilities, so that--there has been progress made in that in 
the past. But I don't believe I have heard anybody, with 
enthusiasm, bringing back the CARES model. I think that we 
learned a lot of lessons in that.
    Whether they are--whether the BRAC is a model that we 
should take a look at, we are beginning to have discussions 
with members of Congress about their suggestions. We do believe 
that we have, I know, today, 431 vacant buildings and 735 
underutilized buildings.
    And we want to stop supporting our maintenance of buildings 
we don't need, and we want to reinvest that in the buildings 
that we know have capital needs. So we are going to be looking 
forward to working with you on that.
    Mr. Bishop. Thank you very much, Mr. Secretary.
    Mr. Dent. Mr. Womack.
    Mr. Womack. Thank you.

          FOCUS ON CORE COMPETENCIES

    Mr. Secretary, welcome. And thanks for the breakfast 
yesterday and the opportunity to engage you in conversation 
before this hearing.
    It has been my experience, down through the years, that 
organizations--particularly large organizations--that find 
themselves in a bit of trouble sometimes, and many--many times, 
stem from the fact that they get away from their core 
competencies and they expand into areas where they are not 
terribly knowledgeable, capable and certainly not efficient.
    And they sometimes serve as kind of a weight, an albatross, 
if you will, around the neck of the organization, and it causes 
a lot of other things to be compromised in the process. And I 
suspect that the VA probably fits into this category.
    And so, specifically, my question is this: you have spent 
some time talking about I.T., which, I am beginning to believe, 
is not a core competency of the VA. We have had many 
indications that the construction of property is not--Aurora, 
Colorado, being, probably, the poster child for it recently--
not a core competency.
    And you talked about collections just a moment ago. And 
that would not necessarily be a core competency.
    So I am going to throw this on the table and let you 
respond. Is it your intent as the Secretary of VA to protect 
the core competencies of the VA by outsourcing, for lack of a 
better term, some of the other things that have served to kind 
of bog down the system?
    Secretary Shulkin. I think your assessment of what has 
happened in VA is probably pretty accurate. I think that we 
have learned the hard way and taken too long to make decisions 
in areas that, frankly, we just don't deserve to be in that 
business. And I think you have identified a few.
    My only modification, if you wouldn't mind, on the I.T. is 
I think I.T. has to be a competency of any organization 
nowadays. I mean, I can't imagine not. What we don't want to be 
doing is being in the software and product development 
business. But managing I.T. systems does need to be a 
competency of any successful company today, I believe.
    I don't know whether ``outsourcing'' is the right word. I 
do believe that, if we are going to serve veterans, we need to 
be working with a core group of our employees and staff that 
functions on our core functions.
    But when we have strayed outside, building buildings, you 
know, doing software development, doing--you know, claims and 
billing, I do think that we should be looking toward private-
sector solutions, or, at the very minimum, private-sector--
private-public partnerships where we can get the competencies 
into the Federal Government.

             PREDICTING FUTURE DEMAND

    Mr. Womack. The last question I have is that one of the 
problems facing the Congress, and many previous Congresses, is 
the fact that the entitlement programs that we know, the 
mandatory side of spending, continue to chew up available 
revenues, and--putting a lot of downward pressure on the 
discretionary piece of the budget. And that is getting worse 
and not better.
    And I think part of that is because--and this is good 
news--the people are living longer. They are receiving benefits 
from those systems for a lot longer period of time than, 
actuarially, they were expected to at the time.
    Do we have a pretty good handle on the number of people 
that will be entering the VA system, so that we can rightsize 
the funding request to ensure that we meet those needs, and not 
play from a position of weakness by being behind?
    I have only got about 45 seconds left. But can you help me 
have confidence in knowing that we know what is going to be 
filling that pipeline, say, over the next generation?
    Secretary Shulkin. We certainly have a handle on the 
demographics of the veteran population. As you know, we have 22 
million veterans today. And that is expected to decline.
    What we can't predict is, obviously, new conflicts that 
would happen, because that can change the picture. What we 
can't predict is new science that would show that there is 
additional mandatory coverage that we would need to include, as 
science shows that there is a connection between military 
service and some of the disabilities. And that work is always 
ongoing.
    So I think that we do have actuarial models in health care, 
cemeteries, and benefits that we can share some of the 
parameters for needs. But they are not fully accurate because 
of the unknowns that are out there. So--but I think, for what 
you are asking, we can share that with you.
    Mr. Womack. Thank you for your service, and congratulations 
on your appointment.
    I yield back.
    Secretary Shulkin. Thank you.
    Mr. Dent. Thank you, Mr. Womack.
    I would like to recognize Ms. Lee for 5 minutes.
    Ms. Lee. Thank you.
    Thank you. Good to see you, Mr. Secretary.
    Secretary Shulkin. Good to see you.
    Ms. Lee. I, too, want to congratulate you and just say I am 
glad you are at the helm of the VA, say--and thank you for 
being here.
    Secretary Shulkin. Thank you.

                        OAKLAND REGIONAL OFFICE

    Ms. Lee. A couple of questions, and I will try to ask them 
very quickly. One is relating to the Oakland VA Regional 
Office.
    In January of 2014, the OIG found that there were 
significant delays, of course, in processing the claims. And 
the management didn't provide the oversight needed to ensure 
timely and accurate processing of informal claims. We had about 
1,248 informal claims. Now, this was before the National Work 
Queue.
    Now we are on the National Work Queue. And, I would like to 
find out, has this helped reduce the claims backlog 
significantly? And is it helping to streamline and reform 
benefit claims processing, specifically regarding the Oakland 
VA Regional Office? That is the first question.

               HEALTH DISPARITIES AMONG MINORITY VETERANS

    Second question has to do with what we have briefly 
discussed as it relates to minority veterans. I have looked at 
your health disparities report, which is a very thorough 
report. And, of course, it cited the fact that minority 
veterans were diagnosed with PTSD at rates higher than white 
veterans.
    Also in the report, you go into some of the recommendations 
to begin to address not only PTSD in terms of its disparity, 
but all of the others. And it says that we need more research 
and more information.
    And I am wondering, though, as it relates to this report 
and the recommendations, as it--specifically relating health 
disparities with minority veterans, where are we on any of it? 
And are the recommendations being followed up?
    I can't help but wonder why more research would be needed. 
We have an Office of Minority Health over at HHS. And so I am 
not sure if you are coordinating, in terms of health 
disparities, with Health and Human Services.
    Just exactly what is going on? Because this is, I think, a 
very good report. And I know many, many minority veterans who 
are really struggling with all of the issues around health 
care, especially PTSD.
    And finally--and I have asked this of the OIG, and also 
when we were at the VA hospital--in terms of the utilization of 
minority and women-owned businesses, it is my understanding 
that you don't disaggregate the data.
    I would like to find out how we are doing as it relates to 
African-American, Hispanic and Asia/Pacific American--Islander 
firms and companies. And we--I still haven't been able to drill 
down and get that report. The VA is a significant entity that 
contracts quite a bit of money out.
    And I would like to find out how minority-owned contractors 
are faring. But we need to understand what the data is showing 
so that we can do better, because I have had a lot of 
complaints that--from minority-owned businesses that they can't 
seem to penetrate and get into the system for a fair shot.
    Secretary Shulkin. Okay. Well, thank you, Congresswoman 
Lee.
    These are all really important issues. So, on the claims 
backlog and what the impact of the National Work Queue has 
been, we do believe that that has been helpful. And we are 
seeing improvements in productivity.
    I would like to get back to, for the record if it is okay, 
the impact from where you were measuring it at 1,248, in 
Oakland, and see where we are today so that we can track that 
progress together, because I think that is important.
    [The information follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
    
    
    
    On the health disparities report, I agree with you. I think 
the work that our national center is doing has identified 
significant issues. This, of course, is an example where I 
think VA is actually leading, and addressing issues that are 
important for all of the American public.
    And in health care, we know that disparities are a very 
significant issue, particularly in many of our geographies 
across the country. I think VA is leading in this area, but we 
still have additional work to do. And we are treating this as a 
priority issue and looking at the recommendations you have 
talked about.
    The research that the report recommended I think, is 
research on disparities in veterans. VA research has 
significant health services research components to it. And the 
difference between the health services research in VA and in 
HHS, like in the Agency for Healthcare Research and Quality, is 
our research is specific to veterans.
    And so, we do believe that there are some questions that 
are important to ask in order to understand what the most 
effective interventions are. But I don't think that is a reason 
for us not to be implementing the other recommendations. There 
is important work to be done. And we are focused on this now.
    Ms. Lee. Mr. Secretary, yes.
    Secretary Shulkin. Yes.
    Ms. Lee. Let me just comment on that, because I know the 
research is very important. But I know, specifically, and when 
you look at African-American veterans with PTSD, you have got 
other factors that weigh in. And the Office of Minority Health 
could let you know what those external socio-determiners----
    Secretary Shulkin. Yes.
    Ms. Lee [continuing]. Are.
    Secretary Shulkin. Yes.
    Ms. Lee. It would really weigh in to help come up with 
treatment modalities that make more sense right away.
    Secretary Shulkin. Yes. I completely agree.
    The research that we--research is only good if you act on 
it. And there are some things that we already know. And I think 
that this is where we are looking at this in terms of 
implementing the recommendations that we know need to happen. 
And it is a way that, frankly, VA can lead and help the rest of 
American health care also implement these interventions.
    Ms. Lee. Do you have a working group that----
    Secretary Shulkin. We do.
    Ms. Lee [continuing]. You put together?
    Secretary Shulkin. Yes.
    Ms. Lee. I would like to talk to you a little bit more----
    Secretary Shulkin. Great. Great.
    Ms. Lee [continuing]. On that. Thank you.
    Thank you, Secretary----
    Secretary Shulkin. And then on the small businesses, on the 
minority--I don't know how that data can be essentially 
categorized to answer your questions. Let me, please, look into 
that and get back to you on that.
    [Clerk's note.--The Department of Veterans Affairs was 
unable to provide a response to the question, despite having 
had 120 days to produce it.]
    Ms. Lee. Okay. Thank you.
    Thank you, Mr. Chairman.
    Mr. Dent. Thank you.
    Ms. Lee. Thanks. Good seeing you.
    Mr. Dent. I would like to recognize the gentleman from 
California, Mr. Valadao, for 5 minutes.
    Mr. Valadao. Thank you, Chairman.

                      BLUE WATER NAVY VETERANS ACT

    Thank you, Mr. Secretary.
    As I am sure you are aware, in 2002, the VA reinterpreted 
the language of the Agent Orange Act of 1991 to apply only to 
veterans who actually set foot in the Republic of Vietnam or 
served in the inland rivers of Vietnam, or Brown Water 
veterans.
    Veterans who served on ships, or Blue Water veterans, were 
not included, and must prove service connection and exposure to 
Agent Orange. However, proven exposure for Blue Water veterans 
is nearly impossible due to a lack of record-keeping and 
inability to know the precise location of the dioxins--in this 
case, Agent Orange--in the air or water runoff.
    The VA continues to deny claims for Blue Water Navy 
veterans, despite studies showing higher rates of cancer and 
non-Hodgkin's lymphoma among shipboard veterans than those who 
fought on the ground in the country.
    This year I introduced legislation to right this wrong, 
H.R. 299, the Blue Water Navy Veterans Act, which currently has 
over 270 bipartisan cosponsors, including over half of this 
distinguished subcommittee.
    While I stand ready to work with my colleagues to pass this 
bill, the Department of Veterans Affairs has the power to right 
this wrong itself, without the help of Congress.
    Have you been made aware of this issue since you have taken 
over as Secretary? And to your knowledge, is the VA working 
towards a solution on this issue?
    Secretary Shulkin. Thank you for that question.
    Yes, I have been made aware of this issue. I would say 20 
percent of my in-box is on this issue, so I hear from a lot of 
people. What I have done is, I have actually sat down and I 
have met with some of the leaders in this Blue Water Navy 
movement to understand exactly what they believe the science 
shows and what they are recommending.
    Commander Wells is certainly one of them; John Rossi, 
another that I have recently met with in my office. They have 
followed up with additional information which I really 
appreciated because I am trying to bring myself up to speed on 
this. The VA's position on this has been pretty much the 
science isn't there.
    I am not convinced that is the full story. And so, I have 
asked them for additional information and additional 
recommendations so that as you said if the Department of 
Veterans Affairs has the ability, and I agree with you, to 
change some of these, and if the evidence suggests that that is 
the right thing to do for veterans, I am going to recommend 
that.
    So this is very active. I can tell you this week alone I 
have been reviewing additional studies. So I will be, you know, 
certainly willing to engage in further conversation with you 
and I am aware of your legislation.
    Mr. Valadao. Thank you. And I do appreciate the fact that 
you acknowledge that there is other science out there. Because 
there are some studies out there that, especially with the way 
they treat the water, clean the water, that actually says it 
concentrates the chemicals and makes the situation worse for 
those serving.
    Secretary Shulkin. Yes.

                         NEW THERAPIES FOR PTSD

    Mr. Valadao. And I appreciate you bringing that up.
    Then Mr. Secretary, I also understand that the Air Force is 
conducting clinical human trials at Tinker Air Force Base to 
investigate transcranial magnetic E-resonance therapy, MERT, on 
veterans suffering from PTSD and TBI, traumatic brain injury. 
After four weeks of active treatment, compared to the baseline, 
the treatment reduced an average PCLM score from 66 to 37.
    The Air Force concluded that the preliminary results 
suggest that MERT is a promising treatment modality to help 
veterans suffering from PTSD. With this information can you 
please share with the committee what the VA is doing to 
capitalize on this promising new treatment to address PTSD in 
the veteran community?
    Secretary Shulkin. Well, I am very familiar with the--with 
the MERT technology and I am very concerned about finding new 
therapies that help our veterans with PTSD, as well as other 
conditions related to the brain. We do use--VA has extensive 
use already of transcranial magnetic stimulation. The issue is 
whether the MERT technology adds additional value to what we 
are currently using.
    I have recently, in the last 10 days, visited Walter Reed. 
I have talked to them about this. We are looking at the 
science. I would like to see the results of the Air Force 
studies as they are coming on-line because basically if there 
is evidence in science suggesting that this is helpful and 
effective and especially a non-invasive technology, we 
absolutely want to be using it.
    Today, I am not aware of evidence that suggests that MERT 
adds advantages in terms of scientific advantages, over the 
transcranial magnetic stimulation that VA and Walter Reed and 
others are using, and I have talked to my DOD colleagues. Now, 
with new information coming out of the Air Force, I would be 
very open to seeing that.
    Mr. Valadao. All right. Well, thank you again.
    Thanks, Chairman.
    Mr. Dent. Thank you, Mr. Valadao.
    At this time I would like to recognize the gentleman from 
West Virginia for 5 minutes, Mr. Jenkins.
    Mr. Jenkins. Thank you, Mr. Chairman.
    Mr. Secretary, thank you also for the opportunity to visit 
with you in advance of this meeting to talk about your 
leadership and direction, and I applaud your efforts.

                       ACCESS AND QUALITY WEBSITE

    Let me start off with a word of compliment. I learned 
yesterday from the discussion with you about your push to 
provide transparency, quality data, information about wait-
times, our veterans' satisfaction, patient satisfaction. And 
you shared with us the Web site, accesstocare.va.gov.
    Secretary Shulkin. Thank you for that plug.
    Mr. Jenkins. And you didn't ask for this, but I'll give it 
to you.
    Secretary Shulkin. Yes.
    Mr. Jenkins. But I did look after you made mention of this 
and as I understand it from our discussion, this data has been 
out there. It has been available, but nobody was willing to 
authorize that the switch get flipped to make this available, 
and you did that.
    Secretary Shulkin. Yes.
    Mr. Jenkins. So thank you for doing that and I encourage 
people to take a look. Transparency is good.

              ACCOUNTABILITY AND WHISTLEBLOWER PROTECTION

    I want to make mention of this most recent executive order 
relating to some of the whistleblower and the accountability 
efforts. I can't tell you the number of times, whether it be a 
VA employee or others, about frustration or concern. Maybe very 
briefly describe this executive order and what kind of 
reassurances to those on the ground, at the grass roots, feel 
as though their concerns, their voices are going to be heard 
about reforming the system and truly holding it accountable and 
holding people accountable for good--the need for good 
performance.
    Secretary Shulkin. Well I think it is--I think that it is 
very important that people understand that we are taking these 
issues extremely seriously. That any organization that has been 
in trouble has to look towards its own leadership. And so we 
want to make sure that the people who are serving in our 
leadership positions are consistent and fulfilling the values 
that we owe our veterans.
    And so when we become aware of issues of poor performance 
or people that have strayed from those values, we are taking 
action. And I think you can see that there has been a large 
number of those actions taken recently. Because of that, the 
executive order has asked us to establish an accountability 
office that will report directly to me as the Secretary.
    As part of that, we are putting our whistleblower office in 
that accountability office to make sure that our employees know 
that if they raise issues to us, and if they are legitimate 
issues, that those employees will be protected. We do not 
tolerate retaliation and that is the way we learn and get 
better as an organization by addressing issues that are brought 
to our attention.
    So these two concepts of adhering to our values and 
protecting our employees that raise issues are absolutely 
essential to our success.

                           PROVIDER PAYMENTS

    Mr. Jenkins. One area I would like you to have staff look 
into, we get a number of calls to our office relating to the 
payment processes of the VA. You have described an effort to 
work collaboratively with academic health centers, local 
hospitals that have real connections to the VA, make one plus 
one equal three, working together.
    One of the challenges that I have heard, really starting 
with the restructuring of the payment system of the VA, from 
June of 2015 and it continues today.
    I have got an academic medical center that really values 
and appreciates their good working relationship. The problem is 
the VA doesn't pay in a timely fashion. They have got literally 
hundreds of thousands of dollars in accounts receivable, from 
their standpoint--over 120 days. I have got a local hospital 
with over $10 million in accounts receivable from the VA over 
120 days past due.
    So, I am not sure what is going on in the accounts payment 
and claims processing, but I think we have got some real 
timeliness issue. And I hope that that will be taken seriously.
    Secretary Shulkin. Yes, you have to understand that this is 
the world I came from. And I do believe, if you deliver a 
service, that you deserve to be paid and you deserve to be paid 
timely. It is too hard operating those health care 
organizations and not get paid for the work that you are doing.
    So I absolutely believe we have to get better at that. And 
I am not being defensive about this. We are not doing a good 
enough job in that area.
    The way that I would suggest that we proceed is, when you 
find a community hospital that thinks that they have $10 
million that we owe, please let us know, because, when we have 
dug into these, we absolutely owe them money. But it is usually 
not the $10 million.
    There are duplicate claims in there. There are rejected 
claims in there that--sometimes they are looking at charges 
instead of the fee schedule that we pay them.
    But we can work through that. We can put a team on that and 
get them the money that they deserve, and get it to them 
quickly.
    Mr. Jenkins. Thank you.
    Thank you, Mr. Chairman.
    Mr. Dent. Okay. Mr. Taylor.
    Mr. Taylor. Thank you, Mr. Chairman.
    And thank you, Mr. Secretary, for being here today.
    And look, I--we understand that there is nothing little 
about the big challenges that you face in your current 
position, so appreciate you for that.
    I just have a--and I come from an area that has Hampton VA, 
which is the fastest growing--you know, OIF, OEF, women's 
veteran population is there. Personally, I am in the VA system 
myself, as well, so this is something that I am very passionate 
about, and I am looking forward to working with you to figure 
out some of these challenges and fix them.

                         CORRESPONDENCE POLICY

    Quick question for you: if--one of us submits a question 
for your office, what is the--what is your policy in terms of 
the response? How many days?
    Secretary Shulkin. Yes, we categorize them into two types 
of responses. There are some that need urgent responses, and I 
think that we are shooting for that for--I know I am going to 
get this wrong, because we just shortened the timeframe to 
become more responsive--14 days was our short one. And then--is 
it 30 days for our longer one? So he says I got it right.
    So if there is something really urgent, we are going to do 
it in 14 days; otherwise, 30 days. And I know that that has not 
been the past experience from VA to your offices. This is our 
new commitment to respond to you in a more reasonable timely 
way.
    Mr. Taylor. Thank you.

                      SUICIDE PREVENTION TRAINING

    Let me touch on the--I have a bunch of questions, but let 
me touch on some of the most urgent ones.
    Suicide is obviously something that has just been talked 
about, something that is also dear. I have a friend that has, 
you know, committed suicide. We have these issues, of course, 
in our area.
    One of the things that I did submit to your office and 
haven't received yet is questioning your--the uniform policy, 
because I understand that the VA, according to the I.G., of 
course, is--has sort of decentralized, if you will. Is there a 
uniform policy, currently, with people who are trained to 
intake folks who come up, physically, that either, you know, 
exhibit signs of suicide or say that they are--suicide?
    And furthermore, is there a uniform policy for the crisis 
hotline, which, I understand, is also being manned by call 
centers? What is the uniform policy there? And what is the 
training that those folks at the call centers get?
    Secretary Shulkin. Yes, I have seen some communication. So 
are you saying we are over 30 days already?
    Mr. Taylor. Yes, Mr. Secretary.
    Secretary Shulkin. Okay, well, this is how I learn, so 
thank you. My guess is you will be getting a response pretty 
soon.
    Mr. Taylor. Appreciate it.
    Secretary Shulkin. But I am aware of the issue--that there 
was concern about a lack of consistency of training between 
suicide prevention coordinators that live in our medical 
centers and Veterans Crisis Line responders who respond either 
from Atlanta or upstate New York.
    They are different professionals. Our Veterans Crisis Line 
responders are licensed mental health professionals. They 
receive much more clinically intensive training. Our suicide 
prevention coordinators don't have to be that. They are doing 
different functions. Many of them came out of different 
disciplines.
    And so there are different trainings. But among those two 
categories, there should be consistency among Veterans Crisis 
Line responders and suicide prevention coordinators.
    So we will take a look for your correspondence to make sure 
we get you back the response very soon.
    Mr. Taylor. I appreciate that, Mr. Secretary.
    Also, just one other thing on suicide. Is there any 
openness to a potential public-private type things with 
qualified nonprofits?
    So, for example, when I--when I say that, I--you know, 
there are a lot of veterans of course who are not comfortable 
with going to the VA or not comfortable with walking up or 
calling, but may need help, but may feel more comfortable with 
some of the nonprofits out there that--they themselves 
typically are manned by a lot of veterans as well, too, have 
gotten out and seen this problem firsthand.
    Is there any openness to a sort of pilot program 
potentially for public-privates to help with that?
    Secretary Shulkin. Well, not only an openness. We think it 
is absolutely essential. There is no other way to do this. Of 
the 20 veterans a day that are taking their life by suicide, 14 
of them do not get their care in the VA system. So they are out 
in the community. Six are within the VA system.
    So if we don't reach out and do the types of partnerships 
that you are talking about, and getting everybody involved, 
there is no way we can adequately address this. So we have been 
outreaching. We are working with Give an Hour, working with the 
Cohen Veterans Network, we are working with a lot of our VSOs 
on this. We have public service announcements.
    If you have groups--there is a new group I just reached out 
to called Headstrong, the Galleon Organization. So, if you have 
new partnerships you would like us to explore, we are 
absolutely open to those.
    Mr. Taylor. Thank you, Mr. Secretary.
    Can you--I will have follow up, like I said, in the next 
round. But, just really quick, you have mentioned earlier that 
some of the under--underutilized buildings--I think there are 
735--and then how many were vacant, you said?
    Secretary Shulkin. 435.
    Mr. Taylor. 435. I will hit you on the next round. Thank 
you, Mr. Secretary.
    Mr. Dent. Thank you.
    At this time, I would like to recognize the gentleman from 
Ohio, Mr. Ryan, for 5 minutes.
    Mr. Ryan. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary. Good to see you again.

                         PATIENT-CENTERED CARE

    Appreciate our meeting yesterday. Let me just say publicly, 
I think what you are doing in your patient-centered care area 
with Tracy Gaudet is some of the most exciting stuff going on, 
not just in the VA, but in government today, of really figuring 
out quality solutions, integrating care, all the rest.
    I just want to say thank you for throwing your weight----
    Secretary Shulkin. Thank you.
    Mr. Ryan [continuing]. Behind that. I think it is really, 
really important, and I think we are going to start seeing a 
lot of savings because of that, and healing a lot of vets. So I 
want to say thank you right out of the gate.

                        VETERANS CHOICE PROGRAM

    In our conversations that we have had already, I appreciate 
the balance that you are trying to strike between the VA 
clinics and the Choice Program. And I know that is not always 
easy.
    One problem area that we have become aware of in my office 
is that, despite the Choice Program being authorized and 
appropriated, we still have veterans traveling significant 
distances to try to get their care. And if a veteran has a 
clinic within 40 miles, but the clinic doesn't offer the 
services they need, the veteran is being told they are 
ineligible for the Choice Program and being referred to the 
nearest VA clinic with the services offered.
    There appears to be no policy that places a cap on the 
distance the veteran would have to travel if they fall into 
this loophole.
    And in my district, which includes veterans in Warren, 
Ohio, traveling 3 to 4 hours to a round-trip weekly, sometimes 
more than once a week, to receive treatment in Cleveland. And I 
was at my son's little soccer practice and I had a couple of 
vets at the same time grab me about this issue.
    The primary care physician or primary coordinator of 
benefits has independent authority to assign a veteran to 
travel an extreme distance with no limit established by the VA. 
Or they can refer them in the community of care to a local 
doctor, or they can elect to refer them to Choice. However, it 
requires a justification that there is an excessive burden on 
the veteran.
    And you mentioned in your testimony establishing a priority 
on transparency. However, I can't find, and my staff can't 
find, a readily issued pamphlet, flyer or billboard which would 
explain to our veterans what defines a burden that would make 
them eligible for Choice in this particular situation.
    I have cosponsored legislation with Representative Stefanik 
and Dr. Ruiz to correct this issue. So my question to you is: 
Do you have the authorities you would need to fix the problem? 
And what can we do quickly, instantly to provide more 
transparency and enroll our vets in the decisions for their 
care? And if we can't fix it immediately, is there a 
legislative issue that we need to deal with?
    And I guess lastly, and more comprehensively, will the 
Choice 2.0 consolidation with Community Care correct this 
problem?
    Secretary Shulkin. Yes, well, lots of important questions 
that you have in that.
    So in designing a health care system, I would not 
necessarily have picked mileage and wait-time as my criteria 
for how to design the system. I understand why Congress did, 
and you know frankly, to put a National program up so quickly, 
I think it was a very well thought-out effort that Congress 
had.
    But now that we have had time to experience this, I believe 
a health care system should have a clinical basis to the way it 
is designed. So it is my intent in working with you to present 
an alternative to 40 miles and 30 days; in other words, to 
eliminate that and to replace it with something that makes 
sense from a veteran's clinical needs.
    So, to look at access and clinical quality as the 
alternative to geography and wait-time. Under the current 
system that we have, which is still having to follow the rules 
that were set by Congress, 40 miles and 30 days, we do, as you 
correctly said, have the ability to define excessive burden. 
What we found, quite frankly, right after I became secretary, 
was that we had put out five, sort of, bullet points about 
examples of excessive burden.
    The field had interpreted that as those were the only 
exceptions they could use. We have now clarified that. What we 
are trying to do is to get the veteran and their doctor, or 
their provider, to have an interaction about what excessive 
burden is.
    And we have now loosened up the requirements so that the 
field can make reasonable judgments about excessive burden. 
Because some of the examples, like the ones you are giving, 
really aren't acceptable.
    Mr. Ryan. Right.
    Thank you, Mr. Chairman.
    Mr. Dent. At this time, I would like to recognize the 
gentleman from Nebraska for 5 minutes, Mr. Fortenberry, vice 
chairman of the subcommittee.
    Mr. Fortenberry. Thank you, Mr. Chairman.
    Secretary, welcome.
    Secretary Shulkin. Thank you.
    Mr. Fortenberry. Are you enjoying the new job?
    Secretary Shulkin. Yes, thank you.
    Mr. Fortenberry. Well, apparently you are and I am grateful 
for your projection of an attitude of entrepreneurship and 
innovation, as well as compassion for this essential mission. 
So thank you very much.
    Secretary Shulkin. Thank you. I appreciate that.

                      PUBLIC-PRIVATE PARTNERSHIPS

    Mr. Fortenberry. In your opening statement, you also 
referenced the new idea that has emerged that has now been 
empowered by legislation, of a unique public-private 
partnership that is going to happen in Omaha. I want to unpack 
that a little bit more for the committee, just so that everyone 
understands how potentially transformative this could be.
    The community wanted to go on the point--community 
leadership came to congressional leadership and said, you know, 
we have built housing for veterans; we have built housing for 
troops. Could we possibly participate, through some charitable 
entity in updating and upgrading the hospital there which is in 
serious need of not only a facelift, but serious innovation--
modernization.
    So working with my predecessor, Congressman Brad Ashford, 
we got the empowering legislation to you. The community has 
committed about $30 million to build upon the money that had 
been set aside for a new hospital, about over $50 million. And 
we are going to move forward.
    I think it is exactly the model of what you are talking 
about in terms of creating the 21st century architecture for a 
modern VA that is looking to community resources when available 
to go, not just into looking for charitable funds for donation 
purposes, but an integrated service environment as you 
referenced earlier.
    This new facility will be an add-on to the existing 
hospital, ambulatory care facility; be proximate to Creighton 
Med School, as well as the University of Nebraska Med School 
who you already work with.
    So the synergies of their design will become a bit 
seamless, or as we say, non--the veteran won't know the 
distinction between the type of care that they are getting. 
They are just getting the best possible care under VA auspices 
using private sector resources, charitable monies that have 
gone into the clinic, because that is the objective.
    So, I wanted to spend a little time just unpacking that 
further, and hopefully, given the very difficult, sad 
experiences we have had with watching burgeoning cost overruns, 
the Denver hospital being the poster child, that this way of 
proceeding forward is undoubtedly going to tap into a large 
pool of good will that exists out there in the country among 
charitable organization and leadership in various communities, 
to want to assist you in modernizing, innovating and creating 
the types of partnerships that utilize the best of the private 
sector, but always under VA's auspices.
    So I am excited by this, and I am sorry to spend so much 
time on it, if you want to comment on that.
    I also want to mention 50 miles down the road in Lincoln, 
we have a traditional, beautiful campus for a VA clinic. A 
similar type of dynamic is occurring where a charitable 
foundation with the city has agreed to build out veterans' 
housing on the site of the old clinic.
    We are awaiting the decision as to what is going to happen 
with the new clinic. So if you could give us some update on 
that process, that would be helpful. But again, once again, the 
synergies being created with existing facilities, preserving 
traditional, beautiful architecture in proximity to the city's 
own private sector medical resources, again is a new opening 
dynamic of what I hope is a new chapter of the VA.

                          RECREATIONAL THERAPY

    Third point, right quick. I have become aware and a little 
bit involved with a charitable organization called Project 
Hero. Your under secretary, Dr. Poonam Alaigh, has given a 
memorandum of understanding to your VA directors that they can 
partner with this organization using recreational activity, 
bicycling primarily, to be integrated into VA's services.
    Studies have--there are metrics on this already showing 
improved health care outcomes, lower costs, sense of well 
being, drops in suicides. The study comes out of Georgetown. 
Again, I just wanted to highlight that for you because I think 
this is one of those types of programs consistent with what I 
said earlier.
    It has been developed because of compassion and initiative 
by the private sector, looking to partner with the VA. And we 
have got a great opportunity here.

                       PUBLIC-PRIVATE PARTNERSHIP

    Secretary Shulkin. Right. Well, thank you.
    Just briefly on your three points. The project in Omaha, 
Nebraska is exactly what I think we are looking to do in the 
VA, which is do things differently. In this case, we are going 
to build a new facility. It is going to be good for veterans 
and absolutely good for taxpayers.
    This is going to leverage the federal dollars in ways that 
in the past we wouldn't have been able to do before. And if it 
really wasn't for your leadership and support in getting this 
through legislatively and the whole way through, it wouldn't be 
happening. So I think this is a transformative model.
    We have four other sites that you authorized after Omaha, 
Nebraska, that we can do. So I am hoping that other committee 
members are listening because we have a list of 20 sites that 
now are eligible for this. I think this should become the way 
that we build a future modern health care system, so thank you 
for your leadership again on that.

                        LINCOLN, NEBRASKA CLINIC

    Secondly on Lincoln, absolutely we are moving forward with 
a new clinic there. It should be awarded this fall and through 
the whole build and design process, even though I pushed really 
hard, probably the opening gate is going to be in early 2020. 
So it takes a while to do this. But that is well underway and 
it is really towards the top of our list.

                          RECREATIONAL THERAPY

    On your third point about Project Hero, you know, one of 
the great things about VA is--is that it defines health care 
much broader than just physical illness. It defines it as 
physical, psychological, social, economic, and an example of 
using sports and adaptive sports to help people get better and 
have a sense of well being is something that frankly VA taught 
me a lot about.
    And this is a great example. And so we are very supportive 
of this and other work around the country like this, and thank 
you for bringing this to our attention.
    Mr. Dent. Thank you, Mr. Fortenberry.
    At this time, I will move into our second round of 
questioning and I will start.

                     CHOICE PROGRAM FUTURE FUNDING

    Dr. Shulkin, in the one-page fiscal year 18 skinny budget 
we received in March, there is a VA request for $2.9 billion in 
new mandatory funding, presumably to complete the fiscal year 
2018 funding for the Choice Program, after the mandatory $10 
billion of the program is completely exhausted in January.
    Does this indicate the administration's intent to fund the 
successor Choice Program with mandatory funding?
    Secretary Shulkin. Yes.
    Mr. Dent. Okay. Next question.
    Being an appropriator, I always try to keep my eye on the 
bottom line of new initiatives. I am aware of at least two 
proposals. While we certainly support them from a policy 
perspective, our budget antennas are on alert.

                    OTHER-THAN-HONORABLE DISCHARGES

    You have announced that you intend to provide emergency 
health services to veterans who have other than honorable 
discharges. You have also testified in the Senate that you are 
interested in expanding caregivers--to veterans from before the 
post-9/11 era.
    How do you plan to fit these added costs into your budget 
when you are obviously already struggling to cover expenses for 
your current VA patients?
    Secretary Shulkin. Chairman, maybe this doesn't fit into 
the budget but basically, I don't care. [Laughter.]
    I sat in a session that was organized by members of 
Congress, members of the House, where there was a young man who 
sat right in the Capitol Rotunda who said that he had been 
deployed to Afghanistan six times. And on his return, he found 
out that his wife left him. And so he took off across the 
country to try to find her. He was declared AWOL and other than 
honorable.
    You could see he was suffering from severe mental and 
emotional disorders. And he went to a VA and he shows up at a 
VA and says I am here because I need help, I am suicidal. And 
the VA says, I am sorry, you are not a veteran. Well, he had 
served our country six times--six tours. That is just not 
acceptable.
    When we say that there are 20 veterans taking their life 
every day, we know it is this group that is among the highest. 
No one wants to help them. Well, I am not just going to sit by. 
So I don't want more money for this. We are going to find a way 
to help these people and then connect them in the community to 
resources and get them help because that is the right thing to 
do.
    So I am going to find the way to do that because I think 
this is our----
    Mr. Dent. That is a very compelling story and I am glad you 
are taking that initiative.
    Secretary Shulkin. And I am sorry, Chairman, what was the--
what was your other question?
    Mr. Dent. Caregivers.

                           CAREGIVERS PROGRAM

    Secretary Shulkin. Caregivers. Yes. So--so the Caregivers 
Program is really, really important. We were authorized to be 
able to do that for post-9/11 veterans and there have been 
tremendous successes. But we frankly didn't get this program 
right. We have been issuing in some areas up to 90 percent 
revocations of caregivers that we had authorized. Something is 
wrong there.
    So we just issued a national suspension of revoking 
caregiver status and we are now in a pause where we are going 
to look at what are the right policies in order for veterans to 
get access to caregivers. It is our intent to be able to bring 
this to pre-9/11 caregivers because frankly, the most 
vulnerable group right now are elderly veterans.
    And the worst situation is when somebody is in their home 
and they have to leave their home to go to an institution--a 
nursing home. Because, one, most veterans don't want that; most 
people don't want that. And secondly, it is the most expensive 
way to care for elderly people.
    If we can keep them in their home with caregivers, we 
should be doing that. So we are looking at how do we use the 
current money and potentially come up with even better policy 
than what we have today. And we are going to be announcing that 
in probably the next couple months.
    Mr. Dent. Thank you.

                           SCHEDULING SYSTEM

    The VA's antiquated scheduling system has been a particular 
concern to you, I know. We understand you are on a dual-track 
to modernize it, piloting a commercial system MASS, as well as 
upgrading your existing system. I guess you call it VSE.
    It seems like these efforts might lack a unified strategy. 
Why are you interested in investing in two systems 
simultaneously? And will the scheduling system be further 
tinkered with in the electronic record overhaul?
    Secretary Shulkin. Yes. On the surface, I agree with you. 
This makes no sense at all. Why would you invest in two 
different paths. We awarded a commercial off-the-shelf product 
called MASS. That is the system that we think meets our 
solutions and that is the one that we are implementing. We are 
working right now on a pilot site to be able to create the 
interfaces so that we can do that.
    The rollout of that across a system as big as ours is going 
to take several years. In the meantime, we had developed an 
internal system, one of the, frankly, last I hope that we ever 
develop, but this one is developed already with taxpayer 
dollars. And we did an evaluation in the month of February. We 
have rolled it out to eight sites. It is actually working. It 
is much better than what we have right now.
    So as an intermediate stop-gap measure, we are rolling it 
out across the country because it has already been developed, 
and it will help in that intermediate period of time until we 
can get a commercial off-the-shelf system up.
    Mr. Dent. Thank you, Secretary Shulkin.
    At this time, I would like to recognize the ranking member 
for 5 minutes in a second round.

                         MILITARY SEXUAL TRAUMA

    Ms. Wasserman Schultz. Thank you, Mr. Chairman.
    I want to focus on military quality of life, because at 
that hearing that we had in March when we had an opportunity to 
meet with the senior commissioned officers, we discussed the 
Marines United scandal, which we discussed in my office 
yesterday.
    Many of the victims of that really horrific social media 
site are now veterans. And I have met with a number of them, as 
have many of the women members. And I would like to know what 
the VA is doing to provide them with the necessary care and 
support they need, because these are women who have had, you 
know, without their permission nude photos of themselves 
posted. They have been subject to extreme humiliation.
    With regard to the military sexual trauma system that the 
VA has, how have you let veterans know that this service is 
available and what outreach have you had?
    Secretary Shulkin. The VA has an extensive system for 
treating military sexual trauma. We actually have worked with 
the Department of Defense so that the VA is a place where 
people can go confidentially and get treatment. Women or men 
who have suffered military sexual trauma can come into any of 
our Vet Centers and there will not be a connection of their 
medical record back to the Department of Defense.
    Ms. Wasserman Schultz. Mr. Secretary, and I appreciate 
that, but specifically what kinds of outreach are you doing to 
not only make sure that victims of sexual assault in the 
military are aware of those services, but also specifically the 
victims of the Marines United scandal?
    Secretary Shulkin. When we met in your office, you actually 
suggested that that is something we should be doing. I don't 
believe that we have done that. I agree with you it is 
something we should be doing. And so as a result of our 
conversation, we are putting together a plan for that specific 
outreach. So thank you for that suggestion.
    Ms. Wasserman Schultz. Okay. No, you are welcome. I mean, 
we have female veterans that are committing suicide at a rate 
of six times that of women civilians. And, you know, 
identifying ways and implementing strategies to address the 
unique mental health needs of women is critically important. 
And so I would appreciate it if you and your staff would follow 
up with us on that.
    Secretary Shulkin. Yes.
    [The information follows:]

    VA is committed to assisting the individuals affected by 
the Marines United issue to the fullest extent possible.
    Since becoming aware of this situation, staff in VA's 
national MST Support Team has reached out to colleagues in DoD 
Sexual Assault Prevention and Response Office, leadership in 
the Services' Sexual Assault Prevention and Response programs, 
and DoD Health Affairs to remind them of the availability of 
MST-related services through VA.
    VA's current MST treatment authority (provided by 
Sec. 1720D of Title 38, United States Code) requires that 
sexual assault and sexual harassment experiences occurred while 
a Veteran or Servicemember was on active duty, active duty for 
training, or inactive duty training. As such, VA has concerns 
that the authority may not cover care for all individuals 
affected by this issue--for example, those incidents of 
harassment occurring after an individual has left the military. 
VA will continue to explore what is possible to provide under 
its current authority, in order to extend support to as many 
affected individuals as possible.

                  SENATE-CONFIRMED POSITION VACANCIES

    Ms. Wasserman Schultz. The other question that I wanted to 
touch base on is what I mentioned in my opening remarks. And 
that is the--the openings--the really significant and serious 
openings that you have in all of your Senate-confirmed 
positions. And you mentioned that you were going to be making 
an adjustment in how you fill those positions.
    But I am actually wondering, one, if there are any problems 
that the Administration is facing in identifying candidates for 
those positions. Are you having trouble filling them? And in 
particular, I find it extremely troubling that the Under 
Secretary of Health, the Assistant Secretary for Information 
and Technology, given the very serious problems we have talked 
about here today, and the Chairman of the Board of Veterans 
Appeals, are all positions that remain empty.
    What is the timeline for filling those? And do you have 
candidates that you are considering? And are you having trouble 
filling them?
    Secretary Shulkin. Well, I appreciate your concern about 
that. I am very impatient, and of course, I want my team in 
place. We have obviously very good career, acting professionals 
that are handling these right now, but I want permanent people 
in place. The Under Secretary for Health and the Under 
Secretary for Benefits--I am not sure if you are aware--it is 
mandated that we form commissions to actually search for those 
positions.
    The Under Secretary for Benefits Commission met 
approximately 10 days ago to go through candidates and are 
recommending several of them for me to see, and then me to 
recommend to the President. And the Under Secretary for Health 
Commission, I just saw the committee members appointed this 
morning. That will be going forward in the next probably two 
weeks as well.
    For CIO, I have met a number of candidates. We are vetting 
them right now, trying to move forward with an offer. And at 
the Board of Veteran Appeals, we are also trying to vet a 
candidate also.
    So, I hope that, you know, these processes, having gone 
through it myself, my own vetting process, 13 months, it takes 
too long. And we are looking to move through this as soon as we 
possibly can.
    Ms. Wasserman Schultz. Thank you, Mr. Chairman.
    I will have one in the third round. So I appreciate it. 
Yield back.
    Mr. Dent. Thank you.
    At this time, I would like to recognize the gentleman from 
Florida, Mr. Rooney, for 5 minutes.
    Mr. Rooney. Thank you.

                        CHOICE PROVIDER PAYMENTS

    And Mr. Secretary, I just want to say that your office I 
guess is watching this hearing and has already gotten with my 
office regarding some of the issues that we are discussing with 
our constituents. And I want to give a shout-out to Mary Kay in 
Lake City. And if you are still watching, Mary Kay, I have 
another issue for you to work on.
    That is with regard to--a lot of my district is very rural. 
And, you know, I do have some of the coast, but a lot of the 
people that live in the district live in the countryside. And 
one of the issues they complain was with the Choice Program is 
that that is long wait-times. They are receiving complaints 
about long wait-times for VA appointments, referrals, payments 
through the Choice Program.
    And the payment and reimbursement process to the providers 
is difficult, probably exacerbated because it is rural. So we, 
you know, obviously, in that situation, you have smaller 
hospitals and clinics. And many of the providers that are 
technically participating in the Choice Program are refusing to 
accept Choice patients because they know that they will have to 
wait a long time to get paid themselves.
    So some providers that don't accept the Choice patients 
will only do so if the veteran agrees to pay for the services 
up front, and that leaves the veterans in that same bind they 
were in before Choice, which was either face the excessive 
wait-times at the VA facility with no option to obtain 
immediate care elsewhere without paying out of pocket first. 
And obviously, that is not the point, or that is not what we 
are looking to do.
    So, I mean, you as a doctor can probably appreciate, you 
know, what these people that want to take the Choice Program to 
help veterans, but they know that it is going to take forever 
to get reimbursed. It would be like, ``hey, will you pay me 
first, and then, you know, we will deal with getting reimbursed 
later.'' I don't know if that is the rationale, but it sounds 
like that.
    The OIG has criticized the VA's monitoring oversight for 
these contracts and reported that these contracts still don't 
have performance measures to ensure the contractors pay their 
providers in a timely manner. And the OIG made this 
recommendation January 30th of this year.
    So as you work to expand the Choice Program, how are you 
implementing the OIG's recommendations specifically with regard 
to timely reimbursements?
    Secretary Shulkin. Well, there is no doubt that this is an 
area of significant risk for us; that monitoring and making 
sure that the providers are paid is critical because of the 
issues that you are saying. The veterans are being put in the 
middle. I would not recommend that veterans put out money for 
this. That, as you said, is not the point of it.
    What we have done is we have done multiple contract 
modifications. We have actually advanced money to the third-
party administrators. I have suspended the requirement that 
providers have to provide their medical records to us in order 
to get paid.
    We are improving our payment cycles through the Choice 
program, but it is not perfect by any means. We have to get 
better at our auditing of these processes. And those were the 
I.G. recommendations, and we are working on doing that. So this 
is a significant area of risk for us.
    In the reauthorization, or the redesign, of the Choice 
program, what we are calling Choice 2.0, we want to eliminate 
the complexity of this process. The private sector does not 
have to do the type of adjudication of claims that we do. They 
do auto-adjudication. They do electronic claims payments.
    We just are not able to, under this legislation, do all the 
things that, frankly, we know are best practices. That is what 
we want to get right in Choice 2.0.
    Mr. Dent. Thank you.
    At this time, I would like to recognize the gentleman from 
Ohio, Mr. Ryan, for 5 minutes.
    Mr. Ryan. Thank you, Mr. Chairman. It is nice of all you 
Pennsylvania guys to let an Ohio guy participate in this 
hearing. I appreciate that.
    Mr. Dent. We beat Ohio State last year, that is why.
    Mr. Ryan. Blind squirrel finds a nut every now and again, 
Mr. Chairman. [Laughter.]

                   CHOICE AND COMPLEMENTARY MEDICINE

    Mr. Secretary, a couple of quick questions, one with regard 
to the Choice Program again.
    There are a lot of people who want to--and we have seen 
it--I have seen it in the last few years at the D.C. VA and 
other VAs, where you have Centers of Excellence, where there 
are all these complementary services that are being provided 
that are having--showing significant success in reducing pain, 
managing pain, reducing opiates, which is a huge thing for us 
to be able to do, providing these alternative approaches.
    And I just want to make sure, as we are moving to try to 
better administer the Choice Program, that these evidence-based 
programs are covered in the Choice program so that they can 
access, whether it is acupuncture or mindfulness-based stress 
reduction. I have seen programs like Project Welcome Home 
Troops, where they do a lot of breathing exercises with these 
veterans that are having transformative effects with their 
post-traumatic stress. Transcendental meditation is another one 
that they use.
    There are a lot of videos online you can watch where these 
vets that are on 10 or 12 prescription drugs, after going 
through some of these therapies that aren't traditional, I 
guess you would say, going down to two or three meds, which is 
a huge savings for us.
    And you are actually giving these vets the tools they need 
to be able to go out into the world and function and get a job 
and be productive members of our society. So I want to make 
sure, as we move with the Choice Program, that these--again, 
evidence-based programs are covered by the Choice Program.
    Secretary Shulkin. Yes. Those types of services and 
providers are part of the Choice Program. We are expanding the 
network so that we have more access to those types of 
providers.
    Mr. Ryan. Great. I think that is going to be a big thing, 
not just for the vets, but out in society as well.

                         APPEALS MODERNIZATION

    The other issue is we are talking about dealing with the 
appeals process. And we had this conversation, again, 
yesterday. But the legislation currently is not going to affect 
the hundreds of thousands, almost 500,000 people who are 
already caught up in the stagnant appeals process.
    So I say this not to you, because I have already said it to 
you, but to members of the committee and to the public. I think 
it is important for us to figure out how we can help you start 
to reduce this backlog. How do we get more appeals judges, 
maybe out of retirement, to get into this program?
    Congressman Womack and I are already working on some 
legislation to be able to do that. And so, if your department 
can provide us with the necessary metrics that we would need to 
figure out how many, you know, retired appeals judges from the 
Board of Appeals do we need to get back in the system, even on 
a part-time basis, to start getting through this backlog, and 
so if you could make sure----
    Secretary Shulkin. Yep. Yep.
    Mr. Ryan [continuing]. You get us that information.
    Secretary Shulkin. I appreciate that suggestion. At 470,000 
backlog claims right now, so even after legislation was passed 
and we fix the process going forward, we still have that 
backlog.
    I appreciate your offer to work with us and see if there is 
a way to help with that. And we have already worked up some 
numbers we would be glad to share with you.
    [The information follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
       
    Mr. Ryan. Great.
    Secretary Shulkin. Congressman Womack.
    Mr. Ryan. Great.
    Mr. Chairman, I think that is an important step for us, to 
try to dig into this 470,000 number. Is with the appeals that, 
some of them, are 30 years in the making. And for every 
additional piece of evidence or paperwork that they add, it 
just slows up the process.
    And we--I think we have got to make a concerted effort. 
Congressman Womack--I won't steal his term, but--was talking 
about a surge for judges to help dig through this.
    So thank you, again, Mr. Secretary, for all your 
leadership. We appreciate it.
    Thank you, Mr. Chairman.
    Secretary Shulkin. Thank you.
    Mr. Dent. Mr. Taylor from Virginia is recognized for 5 
minutes.

                        FRAUD, WASTE, AND ABUSE

    Mr. Taylor. Now I know that you are looking for 
efficiencies, and waste, fraud and abuse, and all those things. 
And I would like to just briefly touch on that.
    And I--but I--first, I want to applaud you for taking the 
stand and helping veterans that may have been dishonorably 
discharged, and some of that, because of effects and stresses 
that they had on their own personal lives and everything from 
war, quite frankly.
    That being said, even in our own VA, when we walk through 
it, and we we noticed and asked questions, and certainly saw 
that there were folks that were being treated there that may 
not be eligible via the system currently. So in a couple areas 
of Hampton, and it is in my letter to your office, as well, 
too--or e-mail, I think it is.
    It talks about how there are a couple of areas there where 
we--you have these veterans that are honorable, veterans--no 
issue. But, you know, when they need a knee replacement or 
something like that that is not service-connected, that they 
are not eligible for, that they may be getting treatment there 
in the VA.
    That is a huge cost, with zero reimbursements, potentially, 
from Medicare, Medicaid or their private insurer, whatever that 
might be. So one of the things that we sent in there--and I 
don't know if you--there is an active study for it now--is, if 
you exacerbate that across the whole VA system, that is 
significant dollars.
    And veterans, either knowingly or not knowingly, because 
this is not a politically popular thing to say--but I am a 
veteran and I don't care--if you know you are not supposed to 
be treated there, then you don't get treated there, because you 
are taking away from other veterans that should be treated.
    That being said, we want to take care of people as much as 
possible. But I am fearful that, in the political climate, that 
maybe the VA is seeing folks that aren't supposed to be there, 
that should be using their own private insurer, or whatever 
they are on, insurance-wise.
    So have there been any studies that are looking into that 
to figure out what is it that is costing the VA across the 
whole system?
    Secretary Shulkin. Yes. We absolutely have looked at this.
    As you know, there are--veterans are classified into eight 
priority groups. The first three, generally, are service 
connected. The next three, so four through six, are generally 
income related, low income. So, when you start getting to seven 
and eights, those are people that fall outside of that, and 
currently that is frozen.
    So not all veterans, as you are saying, are eligible for 
care in the VA system and so we are focusing on those that are 
service connected and lower income. So--and I think that is a--
--
    Mr. Taylor. If I may?
    Secretary Shulkin. Yes.
    Mr. Taylor. Has there been any review, if you will, where 
that may not be the case? I know that we are focused on the 
folks that are supposed to be in the system--that is supposed--
that need care and everything like that. But has there been a 
review across the whole spectrum to figure out, in fact, if 
they are--I am not trying to say it is fraud necessarily, 
maybe, but in some instances it may not be. They just may not 
know otherwise. But have we had a report across the system to 
figure out those inefficiencies and what those costs are for 
the VA.?
    Secretary Shulkin. Yes. We know exactly how many people are 
in each of these priority groups.
    Mr. Taylor. Not the priority groups. I am sorry. I didn't 
mean to interrupt.
    Secretary Shulkin. Yes.
    Mr. Taylor. Not the priority groups, but I mean folks that 
aren't supposed to be getting care that are getting treated.
    Secretary Shulkin. Well, I am not aware of any veterans 
that are getting care there that shouldn't be. If they are, 
then we have to address that and stop that, because we do 
check, except in emergency care, you know, eligibility criteria 
when people come in. And if they are not eligible for care, we 
generally are telling them that.
    Now, you know, maybe you are aware of some situations and I 
would really like to understand that better, because I think 
you are correct in your assumption that our care needs to be 
focused on those that are eligible for care, particularly when 
we have access issues. So I would be glad to talk to you more 
about that.
    [The information follows:]

                  Hampton VA Medical Center (HAMVAMC)

    VSSC Enrollment and User Data, FY2016 Non-Veteran/Humanitarian 
Patients = 1,095
    Urgent/Emergency Care: HAMVAMC is compliant with the Emergency 
Medical Treatment and Labor Act (EMTALA) and accompanying federal 
regulations. EMTALA requires hospitals with dedicated emergency 
departments (ED) to provide a medical screening examination to any 
individual who comes to the ED and requests such an examination, and 
prohibits hospitals with EDs from refusing to examine or treat 
individuals with an emergency medical condition. HAMVAMC ED will 
provide necessary stabilizing treatment for emergency medical 
conditions within the hospital's capability and capacity. Stabilized 
patients who require additional care and are not eligible for Veterans 
Health (VHA) enrollment are appropriately transferred to a community-
based hospital/provider.
    Some patients who are pending VHA enrollment determination may 
continue to receive VHA care until eligibility is adjudicated by the 
VHA/Health Eligibility Center (HEC). If a patient is later determined 
to be ineligible for VHA enrollment, VHA/HEC grants the patient a 60-
day waiver period in order for the patient to provide additional 
evidence or documentation to support eligible-Veteran status. After 60-
days and no supporting evidence, the patient will be appropriately and 
safely transitioned from VHA care to the community.

    I do want to just mention two things. First of all, our 
policy is for emergency mental health care for other than 
honorable, not dishonorably discharged. Dishonorably discharged 
we are not----
    Mr. Taylor. Sorry if I misspoke.
    Secretary Shulkin. Yes. Yes. Okay.
    Mr. Taylor. But I do applaud you for--I know that there are 
a lot of wounds that are mental of course and----
    Secretary Shulkin. Absolutely.
    Mr. Taylor. And I get that. I applaud you for those 
efforts.
    Secretary Shulkin. And the other thing I just want to 
mention is that your letter of March 29th, we did respond by 
April 6th. We actually made it in 14 days. There is additional 
information that your office wants on the protocols on the 
Veterans Crisis Line so we are providing that to you and 
certainly want to get you that detail.
    Mr. Taylor. Thank you. I appreciate it.
    Mr. Dent. Thank you, Mr. Taylor.
    At this time I guess we will move into a third round of 
questioning for those who remain. So with that, I thought I 
would just quickly touch on a couple of issues.

                        OPIOID ABUSE PREVENTION

    First, Mr. Secretary, as you know we included $50 million 
in the omnibus appropriations bill that is going to be 
considered on the floor, I guess right now, for VA opioid abuse 
prevention and treatment efforts. We realize that the VA has 
really come a long way in opioid management efforts since the 
horror stories at Tomah, Wisconsin and the Candy Land doctor 
situation.
    What are the most effective approaches the VA has 
identified to keep severely injured veterans away from opioid 
dependency? And how are you channeling your funding to achieve 
those goals?
    Secretary Shulkin. Yes. Well first of all, thank you for 
that additional support. I can tell you it is money well spent. 
We have seen a 32 percent reduction of opioid use in the VA 
since 2010, but we have a lot more work to do. So this is 
really a good investment.
    I would say, very briefly, that the VA approach to this, 
and we are leading American medicine in this--I just published 
an article on this--is a multifaceted approach. One is veterans 
need to sign an informed consent when they go on opioids.
    Secondly, we actually monitor the profile of doctors so 
they can compare themselves to how other doctors are 
prescribing.
    Third, we mandate participation in the State prescription 
data monitoring programs.
    Fourth, we do academic detailing where experts go out and 
actually educate our clinicians on this.
    And fifth, we are suggesting strong alternatives to opioids 
and providing those like complementary or integrated medicine 
in our facilities.

                       DISABILITY CLAIMS BACKLOG

    Mr. Dent. I would also like to ask you, too, on--this 
relates to disability claims backlog management issue. We were 
pleased to learn last year that the VA had reached an effective 
zero on the size of the disability claims backlog. And I know 
some claims are always going to exceed the target deadline 
because the VA is waiting for the veteran to produce some 
additional information. But you have brought that number down, 
I guess, from its peak of 611,200 in 2013.
    But we understand that the backlog is creeping back up 
because of your shift in workload priority from initial claims 
to appeal cases. We know that the burgeoning appeals caseload 
needs to be tackled, but this highlights the management dilemma 
you face. And I think Congressman Ryan touched on that a bit.
    What is your long-term plan to bring a balance between 
activity on initial claims and appeals workloads?
    Secretary Shulkin. Well, I don't think we are where we want 
to be on this. So we have to make continued progress. We are at 
100,000 disability claims over 125 days and that needs to come 
down significantly. We are doing a number of changes to our 
processes. One is called decision-ready claims. That will allow 
a veteran to seek a much quicker resolution to their disability 
claims and give them a choice when they have all their 
information available to be able to do that.
    We are still advancing our technologies, moving towards a 
paperless system. We have 10 sites now that are completely 
paperless. That moves everything through faster. We are looking 
at a number of other alternatives to do that.
    So we do have plans to get this down and we are not seeking 
additional funds to do that. We see it through process 
improvements.
    Mr. Dent. Thank you.

                     OFFICE OF AMERICAN INNOVATION

    And finally, Jared Kushner's White House Office of American 
Innovation has apparently chosen the VA as its first target to 
reshape federal bureaucracy by making it leaner and more 
effective. Has his office fanned out staff at the VA to analyze 
its operations and make suggestions at this point?
    Secretary Shulkin. Yes. We are in close contact with Mr. 
Kushner's office. They have been extraordinarily generous with 
their time. And what they have really been doing is trying to 
bring industry partners and industry best practices in to help 
the VA. So I don't think that they are staffed to come in and 
do their own assessments, nor do I think that is their intent. 
It is more to identify solutions that already exist in the 
private sector and bring them in and modernize our system.
    Mr. Dent. Well, thank you for sharing that.

                          AGENCY REFORM PLANS

    All federal agencies have received an executive order to 
reorganize their departments by September, in line with their 
fiscal year 2018 budget cost-cutting proposals. Your acting 
deputy has said that the VA would like to get started sooner 
than that.
    What changes do you expect in the way VA is organized and 
how it operates before the end of the year?
    Secretary Shulkin. Well, we are underway with this right 
now. I think, although I don't know all the specific solutions, 
because we are still working on it. I think what you should 
expect is that we are looking to have a smaller central office 
function, more streamlined. We are looking to move towards more 
shared services rather than siloed services in each of our 
administrations.
    And we are actually looking across federal agencies to see 
other things that maybe other agencies are doing better that 
they should be doing for us or vice versa, whether VA should be 
taking on some of the functions that other agencies are doing. 
We are working with other secretaries on that.
    Mr. Dent. Thank you, Secretary. That completes my 
questioning.
    And at this time, I will recognize the ranking member for 5 
minutes.
    Ms. Wasserman Schultz. Thank you, Mr. Chairman.

                          VETERANS CRISIS LINE

    I wanted to just ask you about the Veterans Crisis Line, 
because when we went to the D.C. VA hospital, we had a rather 
confusing conversation with their personnel that made it 
evident that there were a number of serious issues with the 
decentralized nature of the Veterans Crisis Lines--there being 
a National hotline, as well as a hotline at each hospital.
    And so the I.G.'s report that came out highlighted how 
significant the concerns are. And within days of the I.G.'s 
report, the VA said that the issue had been fixed.
    Can you explain how fixed it is and what does that mean? 
And what you are doing to ensure that our veterans are 
absolutely able when they are in crisis because of the risk of 
suicide being so high, are able to get the services that they 
need.
    Secretary Shulkin. I apologize for the confusion. There is 
only one centralized Veterans Crisis Line. Each of the medical 
centers do not have decentralized crisis lines.
    What the I.G. was referring to was the fact that when the 
VA responders on the Veterans Crisis Line receive more calls 
than they could handle, they went to backup centers that were 
located around the country. Those backup centers are certified 
SAMHSA backup centers, so they are trained responders as well, 
but they are not VA responders.
    We did not think that was satisfactory. So several months 
ago, we went out--we hired over 200 new responders, had to get 
them trained. They came online in the early part of 2017. We 
opened up a second center in Atlanta, Georgia.
    And now because of these new responders and the second 
center that is online, we are able to handle the calls that are 
coming in. We have less than a 1 percent backup center rollover 
rate at this point. That is why we came out and said that we 
fixed that problem.
    We have many days where we have zero rollover calls. 
Probably in the last 2 months, we average, you know, less than 
10 rollover calls on a given day. We are responding to over 
2,000 calls a day to veterans in crisis. We typically will send 
out 60 to 65 emergency responses to save veterans' lives.
    Ms. Wasserman Schultz. When we were at the VA hospital 
here, they described a system that was one that was based with 
their personnel, and one that kicked to the National system 
when it was after hours.
    Secretary Shulkin. Well, every--every VA has a mental 
health service. We have same-day services available. So if a 
veteran calls and is in crisis, they will be seen that day or 
their issue will be dealt with that day. So that does happen.
    Every one of our medical centers has a suicide prevention 
coordinator. Many of them more than one. That is there to deal 
specifically with the follow-up issues and to address people in 
crisis on that day. But there is only one National veteran 
crisis line, and that is run out of two locations in upstate 
New York and one in Atlanta.
    Ms. Wasserman Schultz. Do they all receive the same 
training?
    Secretary Shulkin. They all--well, as I was explaining to 
the congressman, the Veterans Crisis Line responders all 
receive the same training because they are licensed health care 
professionals. And the suicide prevention coordinators all 
receive the same training, but different training than the 
Veterans Crisis Line responders because they are not all 
credentialed or licensed mental health professionals.

                     OFFICE OF AMERICAN INNOVATION

    Ms. Wasserman Schultz. Okay. And then you mentioned the 
reorganization and Jared Kushner's office's goals. Are those 
goals aligned with yours? Are you waiting for Mr. Kushner's 
reorganization recommendations before you begin hiring?
    Secretary Shulkin. No, no. Again, the American Innovation 
Office is not intended to come in and do assessments and give 
recommendations. That is the executive order has asked the 
department to do that. So that is what we are doing. Mr. 
Kushner's office is helping us in identifying industry best 
practices and strategic partners that can help us advance these 
modernization goals.

                 DISABILITY CLAIMS AND APPEALS BACKLOG

    Ms. Wasserman Schultz. Okay. And then just as I run out of 
time, on the Board of Veterans Appeals and the backlog and the 
issue of the disability assessment backlogs as well, are you 
aware of online electronic technology that exists that 
previously had contracts with the VA that no longer do? And 
that could significantly address some of this backlog?
    Secretary Shulkin. No.
    Ms. Wasserman Schultz. Okay. I would like to follow up with 
your office so that you can be aware of this technology. And 
while I have no preference for any particular contractors, the 
timeline and story that I have heard about the process that 
they have gone through leaves me frustrated that we have a 
massive backlog and a potential avenue to help address it, but 
no way in for a contractor like them to actually be a part of 
it.
    Secretary Shulkin. No--thank you, I would like to hear 
about that.
    Ms. Wasserman Schultz. Thank you.
    I yield back.
    Mr. Dent. At this time, I would like to recognize the 
gentleman from Virginia, Mr. Taylor.
    Mr. Taylor. Thank you, Mr. Chairman.
    I just wanted to say before I give my question, you are 
correct. We had the letter. I have it right here, so maybe I 
misspoke in terms of, you know, getting the answers. You know, 
yes, you responded. So the office responded.
    Secretary Shulkin. Right. I am just glad we responded.
    Mr. Taylor. Sure. Thanks. I look forward to working with 
you on this.

                          FUTURE DEMAND ON VA

    Continuing with the budget and, like I said, I understand 
that you are looking for efficiencies. And you mentioned 
earlier about 32 percent of the care being outside the walls of 
the VA, which is a 62 percent increase in 2 years. Right?
    So, what is your office doing in terms of looking at inside 
and figuring out, yes, if we are looking at, and you are asking 
for the monies for Choice and to fully fund that in the 
mandatory--in the budget, that trajectory is pretty high. 
Right?
    So what are we looking internally in terms of reducing the 
budget internally, if the care is being seen there? Are you 
just seeing complete demand exploding?
    Secretary Shulkin. Yes. I think the reason why we got into 
the crisis in 2014 is because we were not being honest about 
what the real demand is. And once we opened up both internal 
access and community access, we started to see what the real 
demand is.
    So I think that we are reaching I believe--hope to be 
reaching a steady state where we are not going to see continued 
growth in the way that we have in the past, but that we are 
meeting the health care needs of our veterans and honoring our 
commitment.
    Mr. Taylor. Okay. Thank you.

                  VACANT AND UNDER UTILIZED BUILDINGS

    And the--back to the 735 under-utilized--do you have a 
rough idea what the cost is that you guys are spending that you 
don't need two per year on that.
    Secretary Shulkin. Yes, and in fact I have a chart that I 
gave to each of you, showing you where these are.
    But the cost of the 435 buildings right now that are vacant 
is $6.7 million a year. Our total cost is approximately $25 
million a year for all these buildings.

                      SUICIDE PREVENTION TRAINING

    Mr. Taylor. All right, thank you. And then, jumping back--
and I appreciate that, thank you. Jumping back to the suicide--
and you mentioned the two different folks that are trained----
    Secretary Shulkin. Yes.
    Mr. Taylor [continuing]. On suicide. So it is my 
understanding that--like Hampton, for example--Hampton VA, 
there is a call center that mans the suicide prevention 
hotline--or the suicide hotline, is that correct?
    Secretary Shulkin. No. No, the suicide hotline is a 
National hotline. The--you know, during business hours, the 
Hampton VA would be there to assist veterans in crisis.
    The National hotline is run out of our upstate New York 
office. And now, in Atlanta, they have a second office.
    Mr. Taylor. So I was in a contractor's office as well, too. 
And they said that they were the call center for the Hampton 
VA.
    Secretary Shulkin. Well, I am sorry. The--the VAs or--and, 
in some cases, the VISNs run a call center. They do not run the 
crisis line.
    They run regular calls that come in and want to be, you 
know, ask for appointments or get to certain places through a 
telephone operator. We do run call centers across the country.
    But they are--it is not--we only have one 800 number for 
our Veterans Crisis Line, and that is run out of upstate New 
York and in Atlanta.
    Mr. Taylor. So that--the Veterans--I am just trying to 
understand.
    Secretary Shulkin. Yes.
    Mr. Taylor. So the Veterans Crisis Line--and then--but if I 
call the Hampton number, say I am suicidal--
    Secretary Shulkin. Right. It will say, ``dial 7''. Right, 
the Hampton VA call center, what it will say is, ``welcome,'' 
and, ``if you are having issues related to suicidal 
ideation''--they use better words than that--``please dial 7. 
You will automatically be connected to our National Veterans 
Crisis Line.''
    Mr. Taylor. Okay, thank you.
    And I have no further questions. I look forward to working 
with you. Thanks for your time.
    Secretary Shulkin. Thanks.
    Ms. Wasserman Schultz. Mr. Chairman.
    Mr. Dent. Sure.
    Ms. Wasserman Schultz. I thank you. Just I really think 
that, if we are having a hard time understanding how the 
Veterans Crisis Line works, then imagine how veterans must 
feel. I don't think it is clear how it works and what happens 
from beginning to end, every hour of every day.
    I think--I am glad that you have an additional, you know, 
service center that has your employees staffing it. But I don't 
understand the difference between who handles suicide--suicide 
calls on the Veterans Crisis Line and other mental health 
calls. I don't understand how it works when you are outside of 
business hours.
    I am confident that there are different crisis lines that 
are at local VA hospitals, because we were told that they had 
people working at the D.C. veterans' hospital that handled 
that, and that it only went to the Veterans Crisis Line when 
they weren't open. So if you could provide, later, greater 
clarity, that would be helpful.
    Secretary Shulkin. What--this wouldn't be the first time 
that I have learned information that, then, I would agree with 
you. I would be confused, too.
    I think I have an understanding that is clear. But, please, 
let's make sure that it is the correct understanding. And I do 
want this to be clear. There should be no doubt how a veteran 
gets help when they are in crisis.
    And obviously, if we are not communicating that well 
enough, or if there is a system that I don't understand, I 
appreciate you raising that, and I will get back to you on 
this.
    Ms. Wasserman Schultz. Thank you. Especially because we----
    Secretary Shulkin. Yes.
    Ms. Wasserman Schultz [continuing]. Have lives at stake.
    Secretary Shulkin. Of course.
    Ms. Wasserman Schultz. Thank you very much.
    Mr. Dent. Thank the ranking member.
    At this time, I would like to recognize Mr. Fortenberry for 
5 minutes.

                   VACANT AND UNDERUTILIZED BUILDINGS

    Mr. Fortenberry. Thank you, Mr. Chair. And thank you again, 
Mr. Secretary, for listening to me earlier and, of course, 
embracing the transformative ideas--what I believe to--and you 
believe to be are transformative ideas that are kicking off in 
Omaha.
    And in this regard, as well--Congressman Taylor actually 
touched on the question, and others have, as well--but back to 
the idea of excess inventory. For instance, the Air Force is 
going to come here shortly and tell us they carry 30 percent 
excess inventory.
    And while yours is, in terms of cost impact, much, much 
lower, nonetheless, that is not a good use of dollars. Now, we 
throw around the word BRAC. I highly suggest that you do not 
use that term.
    But what we can do is work with you, I think, 
constructively--maybe you already have this option in law--to, 
for instance, sell excess buildings to the community 
surrounding you. Look at the types of services which the 
military is starting to do--now, this is a little more 
applicable to bases, but nonetheless, it might apply to you--
that can be contracted over--given over to local communities.
    That includes like, landscape maintenance for military 
bases, firefighting, some security as well. These are the types 
of ideas that go toward the possibility of not pulling forward 
things that are no longer applicable in an innovative VA 
without running into the difficulties of impacting communities 
adversely when you close something.
    So don't ever use the word BRAC, because it brings up a lot 
of bad memories. And it--you automatically set yourself up for 
controversy.
    I have suggested to the military that we call it MISC, 
acronym for miscellaneous--Military Installation Savings 
Commission. Maybe you can work on some word--acronym like that.
    But it is a, again, I think it is very consistent with what 
you are trying to do in terms of updating the VA.----
    Secretary Shulkin. Yes.
    Mr. Fortenberry [continuing]. Getting the best value for 
the dollar, ensuring that old ways of thinking are transformed 
into new ways to care for veterans. And while we are pulling 
forward excess inventory, that just doesn't make any sense for 
what you are trying to do.
    So those are just some final thoughts I had. I know you 
have covered that, when I was out of the room, more 
extensively. So I wanted to leave you with that.
    The other issue is I think you are going to forward to us a 
working list of possible changes, one of which you brought up 
the other day. You are in a catch-22 regarding not being able 
to study things that we have actually mandated----
    Secretary Shulkin. Right.
    Mr. Fortenberry [continuing]. You to study because we have 
mandated you can't study things.
    Secretary Shulkin. Right.
    Mr. Fortenberry. Ideas like that, even though they might be 
small--again, back to the transformative theme, we look forward 
to receiving those.
    Secretary Shulkin. Yes. Thank you.
    Mr. Fortenberry. Thank you, Mr. Chair.
    Mr. Dent. Seeing no further questions, I would like to 
thank everybody for their participation. Thank you, Dr. 
Shulkin.
    Again, I can see why you were confirmed unanimously. 
Congratulations, again.
    And this hearing stands adjourned. Any further subcommittee 
hearings will occur after the President's budget submission in 
late May.
    Secretary Shulkin. Thank you.
    Mr. Dent. Meeting is adjourned.
    
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                                         Wednesday, March 22, 2017.

   OVERSIGHT HEARING ON THE DEPARTMENT OF VETERANS AFFAIRS OFFICE OF 
                           INSPECTOR GENERAL

                                WITNESS

HON. MICHAEL J. MISSAL, INSPECTOR GENERAL, DEPARTMENT OF VETERANS 
    AFFAIRS

                    Chairman Dent Opening Statement

    Mr. Dent. Good morning, everybody. Thank you for coming out 
to this hearing, and I appreciate all your attendance.
    And since the full fiscal year 2018 budget hasn't arrived, 
we thought it would be useful to begin our VA hearings with a 
hearing focused on oversight issues. And the VA Office of 
Inspector General is really ground zero for oversight of 
veterans health and benefits.
    Mr. Missal, we are delighted that you are here, and we are 
glad the previous administration finally got around to making 
your VA IG appointment. I know that you were confirmed in April 
of last year, and so we were treading water far too long with 
an acting IG.
    And I understand you actually sought out this appointment, 
leaving the private sector to take this job, which is a very 
brave move, considering all the problems the VA has had and the 
volume of work that awaits you.
    We will be interested in the changes you have implemented 
to sharpen the focus of the IG's work in the areas you believe 
are most important in VA operations.
    We will include your full statement in the record and will 
appreciate your limiting your oral remarks to about 5 minutes.
    But before we ask you to begin, I will turn it over to our 
ranking member, Ms. Wasserman Schultz, for any remarks she 
might have this morning.

           Ranking Member Wasserman Schultz Opening Statement

    Ms. Wasserman Schultz. Thank you very much.
    It is good to see you again. Thank you for coming.
    Clearly, the Inspector General plays a vital role in 
ensuring that VA programs are implemented properly and that 
funds appropriated by this committee are spent wisely and in 
accordance with the law. And I really was very pleased with our 
conversation. It is very clear that you understand exactly what 
your mission is and are focused on it. And I look forward to 
working with you as we continue to address the issues that 
still persist at the VA and that we hold any and all bad actors 
accountable.
    We still have veterans waiting too long to receive both 
care and benefits, and it is well past the time for a cultural 
change at the VA and one that more vigorously embraces strong 
oversight.
    The Office of the Inspector General was integral in 
investigating and responding to the 2014 Phoenix scandal, and 
in response to this investigation, which uncovered numerous 
issues, Congress passed the Veterans Choice Act.
    The Office of the Inspector General was also crucial in 
examining the cost overruns at the Denver Medical Center, where 
the project costs increased from $604 million to $1.7 billion.
    Most recently, the IG has helped identify extremely 
troubling and wholly unacceptable issues at the Veterans Crisis 
Line. According to the report that was released this week, the 
Crisis Line continues to send nearly a third of its calls to 
outside backup centers. And I see that the VA released a new 
figure, that that is now at 1 percent, and I look forward to 
asking you about the discrepancy between what your analysis is 
and what this statement reflects. But that number was very 
significant, even in spite of opening a second call center 
designed to reduce that backlog.
    The concerns that I have about the Veterans Crisis Line 
already were confirmed by our visit to the D.C. VA Medical 
Center the other day, because during a presentation on mental 
health, we received conflicting responses on training and 
protocol for employees at the Veterans Crisis Line.
    Mr. Chairman, I know you agree that it is critical for the 
IG to have the necessary resources to conduct aggressive 
oversight and ensure that our veterans receive the health care 
they both deserve and need and receive such care in a timely 
fashion. No matter what steps the VA takes to address the 
challenges it faces in delivering health care, the VA will be 
unable to do so without proper oversight. Oversight and true 
reform lie squarely with Congress and the Inspector General, 
working together.
    Mr. Missal, I commend your work thus far, but I think we 
would both agree that there remains much to be done to repair 
both our veterans' and our Nation's trust in the VA system.
    And, again, thank you for being here today, and I look 
forward to working with you to address these issues.
    Mr. Chairman, I yield back.
    Mr. Dent. Thank you. I thank the ranking member.
    Let's go right to Mr. Missal.
    And we look forward to receiving your testimony. Please, 
you are recognized.
    Mr. Missal. Thank you.

                Hon. Michael J. Missal Opening Statement

    Mr. Chairman, Ranking Member Wasserman Schultz, and members 
of the subcommittee, thanks for the opportunity to discuss the 
oversight the Office of Inspector General provides to VA 
programs and operations.
    I have had the great honor and privilege of serving as the 
IG since May 2016, and today is my first opportunity to testify 
before this subcommittee.
    I would first like to thank the Congress for the increase 
in our fiscal year 2017 appropriation. Our fiscal year 2018 
appropriation of $159.6 million will greatly assist our ability 
to fulfill our mission of effective oversight of the programs 
and operations of VA.
    Although I did not come into this role with any 
preconceived notions of specific changes to make, I stated to 
the staff on my first day that we will always strictly adhere 
to the following three principles:
    First, we must maintain our independence and make sure that 
we do not have even the appearance of any impairment to our 
independence.
    Second, we must be fully transparent by promptly releasing 
reports of our work that are not otherwise prohibited from 
disclosure.
    Third, we must maintain the highest integrity of our work. 
This means that each of our reports must meet at least the 
following five standards: It must be accurate, it must be 
timely, it must be fair, it must be objective, and it must be 
thorough.
    In the past 10 months, we have made or are in the process 
of implementing a number of enhancements to our operation. 
Several of these initiatives represent concerted efforts by us 
to focus on the high-risk areas throughout VA, with the goal of 
being more proactive in our oversight. I believe that these 
changes will enable us to perform more impactful work in a 
timelier manner.
    We are a relatively small office compared to other Federal 
OIGs as a percentage of both the agency's full-time-equivalent 
staffing and budget. We are comprised of approximately 725 
full-time employee equivalents organized into five major 
directorates: Investigations; Audit and Evaluations; Healthcare 
Inspections; Contract Review; and Management and 
Administration. About 225 employees are based in Washington, 
DC, while the remaining 500 are dispersed throughout our 
approximately 40 field offices nationwide.
    Since fiscal year 2014, we have received approximately 
39,000 contacts to our hotline annually. Each year, we average 
about 350 reports and other work products, 475 arrests, 330 
convictions, and $3.125 billion in monetary benefits.
    Our return on investment averages $30 for every $1 expended 
on our oversight. This is a strong return and supplements the 
inestimable value we bring by helping VA improve its health 
care and benefits services that impact so many lives.
    We crafted our fiscal year 2017 appropriation with the 
intention and hope that it will be the first of several tiered 
increases to right-size our office over the next several years. 
The expansion plan would increase staff to 1,160 by fiscal year 
2021 and bring us to a level more equivalent with the increase 
in staffing and resources at VA and comparably situated OIGs.
    In consideration of the hiring freeze and the 
administration's anticipated efforts to scale back the size of 
the Federal Government, we reduced our fiscal year requirements 
by $27 million from the $197 million figure submitted last year 
as part of our 3-year expansion plan.
    Our budget request for fiscal year 2018 of $170 million, 
coupled with the anticipated fiscal year 2017 carryover, will 
cover the costs of normal inflation assumptions and at least 
100 additional staff over fiscal year 2017.
    The administration is proposing to straight-line funding 
for 2018 and 2017 enacted levels for a number of VA 
discretionary programs. Under this scenario, our fiscal year 
2018 budget would be $159.6 million, the same as 2017.
    This funding level overlooks potential inflation costs of 
at least $3 million for staff pay raises and infrastructure. 
Although we do not project that our operations would be 
adversely impacted at this funding level for 2018 because of 
available carryover funds, for subsequent years we would likely 
need to request a significant increase to our current funding 
to maintain current operations.
    In conclusion, with continued support from Congress, we 
look forward to increasing our ability to conduct impactful 
oversight of VA programs and operations for the betterment of 
our veterans, their families, and American taxpayers.
    Mr. Chairman, this concludes my statement. I would be happy 
to answer any questions that you may have or other members of 
the subcommittee.
    [The information follows:]
    
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    Mr. Dent. Thank you very much, Mr. Missal, for your 
testimony.

          PROBLEMS WITH SUICIDE HOTLINE

    Last year, the IG issued a report that was fairly damning 
in its critique of the operations of the Veterans Crisis Line, 
the suicide hotline, VA's major tool to prevent veteran 
suicide. At that time, VA countered that the IG report was 
using old data and the agency had made improvements to its 
operation, adding substantially more funding, installing new 
leadership.
    But the followup IG report issued on Monday suggests that 
the VA is still having significant problems with the suicide 
hotline. The new leadership has already left; the secondary 
site in Atlanta is understaffed; clinical guidelines are not 
being transmitted; quality-control measures are not being 
implemented; and staff lack training.
    Do you think the VA has made any progress in improving the 
performance of the hotline since last year?
    Mr. Missal. We took a look at the hotline and did our 
review beginning in June of 2016. I would note that there were 
seven outstanding recommendations that were still open from our 
February 2016 report. They were scheduled to be completed, 
according to VA's plan, by September of 2016. Those 7 
recommendations from our last report remain open, as well as 
the additional 16 that we had here.
    So I guess I would say that there are still many 
significant issues that we found with respect to the VCL.
    Mr. Dent. Members of Congress were very concerned last 
year, so we included language in the bill requiring the VA to 
maintain suicide hotline standards consistent with the 
guidelines of the American Association of Suicidology.

                POSSIBLE VIOLATION OF APPROPRIATIONS LAW

    At that time, VA had assured us that the hotline met those 
guidelines. And with your new report findings, do you think 
that the VA is in violation of our appropriations law?
    Mr. Missal. I don't know if I can make that assessment. We 
didn't look at it quite that way. We identified a number of the 
shortcomings in the training, in governance, in staffing, in 
leadership, et cetera. And so I think we did raise some 
significant issues.

                   IMPROVEMENTS IN SCHEDULING DELAYS

    Mr. Dent. There are some audits showing continued medical 
appointment scheduling delays that I wanted to discuss.
    Over the last 2 years, the IG has had the enormous job of 
auditing all the VA medical centers about allegations of 
scheduling delays and malfeasance. We understand that you have 
revisited some regions and have found that problems have been 
resolved in some areas but not in some others.
    What are the factors that have been key to improvements in 
some of these regions, if you could share that with us?
    Mr. Missal. I think, one thing I have found in the 10 
months since I have been here is the importance of leadership 
at various levels. VA health care is a very decentralized 
operation, and what is pretty clear when you go to either 
medical centers or the VISNs, the regions that they have 
divided the country into, the leadership at those areas are 
really critically important to the performance of either the 
medical center or the VISN.

              VA'S ANTIQUATED FINANCIAL MANAGEMENT SYSTEM

    Mr. Dent. I would like to now move to the VA's antiquated 
financial management system. Your reviews of nine VA care 
programs revealed a morass of problems in financial accounting, 
timely payment to providers, and inadequate internal controls. 
A significant share of these problems seems to be associated 
with the antiquated financial management system VA continues to 
use after its previous efforts to replace it had failed.
    Do you think the VA's selection of the Department of 
Agriculture as its Federal shared service provider to deliver a 
modern financial management system will work for the VA where 
prior attempts for new systems have failed?
    Mr. Missal. That is something we are going to look at very 
closely. They had a number of material weaknesses and 
significant deficiencies in their financial statements this 
past year, which was an increase over the previous year. They 
made the commitment that they are going to go with a shared 
service model, and we will test it and see if it has any 
improvements.

                    SHIFT TO COMMERCIAL/IT SOFTWARE

    Mr. Dent. Okay.
    And I would also like to just briefly mention the VA shift 
to commercial IT software for the health record. Secretary 
Shulkin has announced that he believes the VA should use 
commercially developed information technology software rather 
than continuing to build it in-house.
    From the OIG's review of VA IT, do you think this is the 
appropriate path for the VA to take? And with its current skill 
set, is VA capable of procuring IT and managing contracts 
sufficiently and diligently?
    Mr. Missal. IT has been a significant problem that we have 
identified in various programs and operations at VA. I heard 
the Secretary make that commitment, statement that he was going 
to go forward, and I think it remains to be seen whether or not 
that will be successful.

               RISK OF PURCHASE OF COMMERCIAL/IT SYSTEMS

    Mr. Dent. And can you just quickly elaborate on any risks? 
What are the risks that you see with the purchase of commercial 
IT systems for a healthcare system as enormous as the VA's? And 
how can the VA mitigate those risks?
    Mr. Missal. I think it is integrating those systems into 
VA. VA has a number of different IT systems and they need to 
make sure that they all work together. They have to make sure 
that they have the proper staffing, the proper training, and 
the proper funding to get it done.
    Mr. Dent. Thank you.
    At this time, I would recognize the ranking member, Ms. 
Wasserman Schultz, for 5 minutes.

           CHALLENGES OF VETERANS CRISIS LINE ROLLOVER CALLS

    Ms. Wasserman Schultz. Thank you, Mr. Chairman.
    Mr. Missal, I want to continue the chairman's line of 
questioning on the Veterans Crisis Line.
    You released a report on Monday----
    Mr. Missal. Correct.
    Ms. Wasserman Schultz. This report addressed the challenges 
that the Veterans Crisis Line was experiencing, particularly 
with rollover calls to the backup call center. And that was in 
spite of adding the Atlanta call center, a second call center. 
There were significant percentages of rollovers, which is why I 
find it baffling that, a day later, the VA releases, you know, 
a statement saying that they have addressed it and that now 
their rollover is 1 percent.
    That seemed completely incongruous with your report and 
nearly impossible for it to have been resolved in 24 hours. So 
can you address that pretty significant discrepancy and whether 
you think that the VA has addressed the problems in the report?
    Additionally, when we were at the D.C. VA Medical Center 
the other day, it seemed very clear, to all of us that there is 
not uniform training across the board between local medical 
centers and the national Crisis Line training. And that also 
seems to be causing problems for veterans who are in dire need 
and could risk life. And, in fact, there has been life lost due 
to lack of training.
    Mr. Missal. Sure.
    Okay. With respect to the rollover calls, our inspection 
period covered the middle of June to the middle of December 
2016. So we had the most recent data. I believe our last month 
was November of 2016. So we listed in our report all those 
numbers.
    The Atlanta operation was brought about to try to, among 
other things, limit the dependency on these backup centers. 
They started bringing it up in stages, beginning in the fall. 
As of the middle of December, it still was not fully 
operational.
    So we have not looked at it since that time, in the 3\1/2\ 
months or so since then. So I really can't comment whether or 
not their numbers are 1 percent or some other number.
    Ms. Wasserman Schultz. I think you can understand the doubt 
that I feel, given that the VA has already had a problem with 
fudging and altering data to reflect better numbers than 
reality.
    So do you have plans to follow up and actually take another 
look at the last few months so that you can confirm these 
numbers? Because it is hard to have confidence in these 
numbers, given their track record.
    Mr. Missal. Yes. There are 7 outstanding recommendations 
from our February 2016 report, 16 open from our current report. 
We consider both of those reports still open until we get 
satisfaction that they have met their commitments to complete 
those recommendations. So we will continue to look at the VCL, 
at a minimum, until those recommendations are fulfilled.

                             CHOICE PROGRAM

    Ms. Wasserman Schultz. Thank you. Because there are 
literally lives at stake from getting it wrong.
    In my remaining minute and a half, I just want to ask you 
about the Choice Program. Your report found that veterans are 
still waiting months for appointments made through the Choice 
Program.
    I just went to my own Miami VA Medical Center, and they 
gave me a very glowing picture of how much the wait times have 
been reduced. But, according to your report, veterans covered 
by Health Net, which is where the Miami VA is, on average, 
waited 84 days to get an appointment--42 days for the 
authorizations to be provided and then another 42 days for the 
appointment to be scheduled and the service provided.
    So, first, why is it taking the VA 42 days to provide 
authorization? And why is it taking Health Net 42 more days 
after the authorization?
    Mr. Missal. Right. The numbers you are talking about relate 
to our report on VISN 6. What we had previously done is we had 
looked at a specific facility. What we decided to do is look 
more broadly. VISN 6 governs VA facilities in the Virginia and 
North Carolina.
    And the reason it took as long as it did was there was a 
lot of administrative issues involved in doing that. There was 
confusion. The rules for Choice are very complex, for example, 
who is eligible to qualify.
    And so the funding for Choice is expiring in the middle of 
August of this year. One of the things I think needs to be done 
is to make it as uncomplicated as possible so that it is easier 
to sign people up, that veterans know exactly what their 
options are, and that the third-party administrators can move 
people through the system more quickly.
    Ms. Wasserman Schultz. Thank you.
    I yield back.
    Mr. Dent. Mr. Jenkins is recognized for 5 minutes.
    Mr. Jenkins. Thank you.

                   AIR QUALITY ENVIRONMENTAL CONCERNS

    Good morning, and welcome.
    The community outpatient clinic in Greenbrier County, as 
you well know, several years ago had complaints of air quality 
environmental concerns, both from employees and our veterans 
who were seeking care and treatment there. A report was issued 
by the OIG, and we had to go to bat to make sure that that CBOC 
continued, in a new location, in Greenbrier County.
    But can you go back, the status of your findings from that 
2015 report--what actions has OIG done with regard to that 
report? Which I believe you all did find environmental air 
quality concerns at that CBOC in Greenbrier County.
    Mr. Missal. Right. We did note ongoing air quality issues 
in that CBOC in 2015. It was closed as you know. It was the 
VA's responsibility to fix it. We have not been back since then 
to look at it, but we are well aware that these are commitments 
they made, and they need to follow through on those.
    Mr. Jenkins. Well, that facility is closed. It is not being 
used. There is a new CBOC facility. So the old issues are going 
to be at that old facility; we are not there anymore.
    But the OIG, obviously, hopefully, takes these issues of 
complaints from patients, our veterans, and employees seriously 
on environmental air quality. So one of my interests is 
followup activities after that report has been issued.
    Mr. Missal. Yes. I would say that we have a very active 
healthcare inspection program, where we get around to the 
medical centers, some of the CBOCs as well. And environment of 
care is one of the areas we look at very carefully. So for 
every facility we go in, we check the environment of care for 
issues just as you raised.

              STATE PRESCRIPTION DRUG MONITORING PROGRAMS

    Mr. Jenkins. Second, under care of the addiction recovery 
relating to opioid abuse/misuse, there is a real emphasis, and 
it was in that legislation, asking the VA to start 
appropriately sharing the prescription information to State 
prescription monitoring programs, PDMPs. It is referred to in a 
lot of different ways. Most every State has one up and running.
    What is the OIG doing to ensure appropriate information-
sharing from the prescription issuance on the veterans side, 
getting into State PDMPs so we make sure we enhance the quality 
of care, and also make sure we are avoiding diversion and not 
adding to the drug crisis, and opioid diversion problem?
    Mr. Missal. Right. Opioid misuse and other controlled 
substance misuse is a very great concern to us, and we have a 
very active program in this area.
    With respect to the PDMPs, we do have access to those. It 
is VA that can enter data. We can, though, see it, and we do 
use it on occasion in our work.
    With respect to opioid misuse/abuse and, actually, the 
stealing of opioids and other controlled substances, we have a 
number of investigations going on currently, and we have 
brought a number of cases recently which have resulted in jail 
time and other sanctions against individuals.
    Mr. Jenkins. Well, I understand a doctor at a VA will have 
access. They are an authorized recipient of data. They can tap 
in and look at the prescribing history.
    My question is, under CARA's direction to the VA, to have 
the VA actually submit information to State PDMPs, what is the 
VA doing about complying with that expectation?
    Mr. Missal. We haven't looked specifically at that. Given 
how decentralized it is, it is really going to be facility by 
facility to see whether or not they are complying with the 
rules. But that is something we are considering looking at more 
closely, because we agree, it is a major concern.
    Mr. Jenkins. Well, Bob McDonald, the previous VA Secretary, 
he said publicly multiple times the VA is going to start 
submitting their prescribing data to PDMPs. So I would 
encourage you--I appreciate your statement of, we are going to 
be looking into this. I think this is a priority issue, with an 
opioid crisis in so many parts of this country. I would hope 
you would move it from a ``we intend to look into it,'' because 
I do believe now there is actually a congressional mandate 
relating to the VA. And I think the OIG plays a key role in 
making sure that the VA fulfills its statutory obligation.
    This is back to this life-and-death issue, and we have to 
have better information systems. The VA has a responsibility, 
and I hope you will make sure the VA lives up to that 
responsibility.
    Mr. Missal. Yes, sir. We share your concern, absolutely.
    Mr. Jenkins. Thank you.
    I yield back.
    Mr. Dent. Thank you, Mr. Jenkins.
    At this time, I would like to recognize the former ranking 
member of the subcommittee, Mr. Bishop, for 5 minutes.
    Mr. Bishop. Thank you, Mr. Chairman.
    Welcome, again, to our distinguished IG.

                 VA INFORMATION SYSTEMS VULNERABILITIES

    It is critical that we put measures in place to protect 
sensitive information and to defend against those who would 
seek to gain unauthorized access to that information. The VA 
has an obligation to safeguard the data that we hold on 
veterans, and I know that everybody takes that responsibility 
seriously.
    In your statement, aspects of the VA IT security have been 
continually reported, you indicate, as material weaknesses for 
some 17 years.
    Mr. Missal. Correct.
    Mr. Bishop. From my understanding, in the latest 
information security information audit, you recommended 35 
actions that would improve the information security program.
    How many of those have been implemented? And what is your 
current assessment of the VA's vulnerability against cyber 
attack and ability to respond effectively to a successful 
attack?
    Mr. Missal. I don't have the precise information of how 
many of those recommendations they have implemented. We have 
talked to them frequently about this issue.
    We are just now starting our work for this year on 
cybersecurity and IT security, and we are going to be very 
aggressive in looking at it. And to the extent there are issues 
that we see as we are going through the audit, we will raise it 
again with them. We consider this very important, and hopefully 
they will make progress.
    Mr. Bishop. Can you submit that information to us in 
writing at a later date?
    Mr. Missal. Sure. Happy to do so.
    [The information follows:]

    In the OIG's FISMA report for FY 2015, we made 35 
recommendations. During our work for FISMA in FY 2016, we 
closed five of the 35 recommendations from FY 2015. However, 
for FY 2016, we added three additional recommendations so we 
have a total of 33 open recommendations related to FISMA. We 
also perform other IT security related work and currently 
recommendations remain open in two other reports:
    ``Review of Alleged Transmission of Sensitive VA Data Over 
Internet Connections''--Issued on March 6, 2013--Recommendation 
1 remains open.
    ``Review of Unauthorized System Interconnection at the VA 
Regional Office in Wichita, Kansas''--Issued on April 6, 2017--
Recommendations 2, 4, and 6 remain open.

    Mr. Bishop. Thank you.

                        PROCUREMENT DEFICIENCIES

    In your statement, you noted that the VA has systemic 
deficiencies in all phases of its procurement process. From 
your assessment, is it that the VA does not have the proper 
policies and procedures in place, or is it that they are not 
performing in accordance with the procurement standards? Or is 
it both?
    Mr. Missal. Procurement is an area that we feel is one of 
our priorities, because of the amount of taxpayer dollars at 
issue here. And what we have found is both. We have found both 
policies and procedures that are not up to what we would 
expect, and we have also found situations where they haven't 
followed the policies and procedures as well.

                   COLLECTING RACE AND ETHNICITY DATA

    Mr. Bishop. On another subject, after reviewing the 2016 
Advisory Committee Report on Minority Veterans, I am concerned 
the VA doesn't consistently collect race and ethnicity data.
    According to the Center for Minority Veterans, by 2040, 
minority veterans are projected to represent over a third of 
all of the veterans, despite the overall veteran population 
decreases. This is information that could be used to suggest 
policy reforms and recommendations to address the needs of an 
increasing minority veteran population, to include health 
disparities, academic affiliations, unconscious bias in hiring 
practices that may lead to a lack of diversity and specifically 
at the senior management level.
    Do you have any planned or any recent audits, inspections, 
or evaluations that focus on minority veterans and on women 
veterans? And if so, what are some of the recommendations, and 
how many of those remain open?
    Mr. Missal. We don't currently have anything on minority 
veterans.
    On women veterans, we are doing a national healthcare 
inspection to see the treatment of women veterans and how VA 
accommodates women veterans. That should be released shortly.
    I recognize the importance of all the issues you raise. And 
that is something, as we are looking at our workload going 
forward, it is something we will consider.
    Mr. Bishop. How can we make sure that the VA collects data 
on race and ethnicity so that we will have the data from which 
to make assessments?
    Mr. Missal. I am not aware of what process they have in 
place and what they are doing in that area to know. But, 
obviously, they should have policies and procedures for any 
program that they have. And that would be something, if we 
looked at that, we would focus in on the policies and 
procedures and how they are implementing those policies and 
procedures.
    Mr. Bishop. I was told that the VA does not collect data on 
ethnicity. So, for example, I couldn't ask you how many black 
veterans you have or how many Hispanic veterans you have or how 
many Asian veterans you have, because the VA doesn't collect 
that kind of data.
    And what I am suggesting is that we need to collect data in 
those categories. This data would assist you in your audits; it 
would assist us in our oversight. But we don't have that 
information. Perhaps you can make recommendations on what we 
need to do to get that information or if we can just ask for 
it.
    Mr. Missal. Sure. We can look into that, certainly.
    Mr. Bishop. Thank you.
    My time has expired.
    Mr. Dent. Mr. Valadao.
    Mr. Valadao. Thank you.
    Thank you again for taking some time today. And I know we 
are hitting on the wait times quite a bit, but I do want to 
follow up on that a little bit.

                           PATIENT WAIT TIMES

    The VA publishes a bimonthly patient access report for all 
VA medical centers and community-based outpatient clinics, 
which include information such as average wait times for 
veterans enrolled in the Veterans Health Administration.
    Currently, the VA medical center in Fresno, California, 
represents an average wait time of 12 days to see a specialist. 
However, I am hearing from constituents of mine all the time 
who report waiting a couple of months or more to get in to see 
the doctor. While I understand that 12 days is the average wait 
time, there is a big difference between 12 days and 2 months.
    In your experience, do you believe the average wait time 
data in the bimonthly patient access report accurately reflects 
the wait times that veterans experience?
    Mr. Missal. I haven't looked specifically at those, but 
what I can tell you is, in our VISN 6 report, where we looked 
at wait time across a large group of medical centers in 
Virginia and North Carolina, that the wait times that we 
calculated were significantly different than the wait times 
that the facilities had and the VISN as well. It was not just 
one; it was a number of different facilities had significantly 
different wait times.
    It is somewhat complicated because there are so many 
different dates that they use to calculate wait times. And what 
we found is the policies that were in place at the time were 
not being followed, and that is why our numbers were so 
significantly different.
    Mr. Valadao. Okay. Is there anything we can do to improve 
that? I mean, should we mandate some sort of--I mean, I don't 
like mandates normally, but it seems pretty simple. If someone 
calls in to make an appointment and it takes them 2 months, 
where is the confusion?
    Mr. Missal. I think they need to simplify how they 
calculate wait times, the number of different measurements they 
have. I can't emphasize enough how important oversight is to 
make sure that when they have a policy and procedure that they 
follow it and they follow it accurately.

                      ROLLOUT OF ONLINE SCHEDULING

    Mr. Valadao. And then there was a rollout in January 2017 
of the online scheduling. Have you had any experience with it? 
Have you seen how it is performing? Any early indicators that 
show any progress at all?
    Mr. Missal. We have not looked at it. I understand it is a 
pilot, but we haven't looked at it in any kind of detail.
    Mr. Valadao. All right. Thank you.
    I yield back the balance of my time.
    Mr. Dent. At this time, I would like to recognize Mr. Ryan 
for 5 minutes.
    Mr. Ryan. Thank you, Mr. Chairman.
    Thank you for your service. The deeper I get into the 
Appropriations Committee, the more valuable I find what you and 
your team do, so thank you for that.

                      OPIOIDS TREATMENT MANAGEMENT

    I want to just kind of continue on the line of questioning 
that Representative Jenkins was asking you about, CARA and 
opiate issues with regard to the VA. We also have reports in 
Ohio that were allegations of little or no oversight of the 
refills for opioids.
    Services other than medication therapy can reduce the need 
for opiates to deal with pain, as well. We saw in our trip a 
couple days ago to the D.C. VA Medical Center, they have a 
center of excellence, that they have done incredible work in 
the area of providing integrative medicine, and the clinic 
found significant evidence of decreased dependence on opioids 
through some of these techniques.
    A lot of these integrative treatments--yoga, meditation, 
acupuncture, art therapy--they are in very, very high demand. 
And I was surprised, because I went to the D.C. VA a couple 
years ago to look at these programs, and the scheduling a few 
years back versus the scheduling now, of people just being able 
to walk in and access some of this care, has increased 
significantly, which I think is--you know, the veterans are 
voting in the marketplace of what their options are there.
    So, when reviewing the recent clinical assessment program 
reviewed for Cleveland, Ohio's VA clinic, I don't see any 
mention of routine reviews for the opioid management or 
reviewing inclusion of integrative medicines. And the report on 
opiate addiction treatment protocols fails to recognize 
SAMHSA's inclusion of non-opioid options for treatment of 
opiate substance use disorders. This includes options such as 
non-opiate 30-day shots, which you know about, that is 
minimally invasive for veterans' lives and removes the high 
provided by opioids.

                   OVERSIGHT FOR OPIOID PRESCRIPTIONS

    So my question is, what are we doing to appropriately 
provide oversight for these opioid prescriptions within the VA? 
And are we providing the appropriate amount of resources to the 
clinics to provide both the reduced opioid use within the realm 
of integrative medicine?
    Mr. Missal. Sure. We are doing a number of different things 
in this area.
    First of all, in our inspection program, we change up the 
various areas that we look at just so we can cover as many as 
possible. And a couple of years back, we did look at medication 
and how they were controlling the opioids and other controlled 
substances. We are now going to likely be putting that back 
into the upcoming inspection program that we have. We have had 
recent discussions on that.
    Secondly, we are working on a pain management report, 
covering how does VA deal with pain management issues, which 
would be opioids and other medication. That will hopefully be 
out relatively shortly. It is a national review of what they 
are doing. VA has an opioid safety initiative going on in an 
attempt to bring down the amount of opioid use, so we are 
looking at the impact of that as well.
    In addition, as we both are proactive and get referrals on 
potential misuse of opioids, we are aggressively looking at 
that as well. And we have a number of open investigations and 
have brought some other ones as well, aside from making sure 
people who have done something wrong are brought to justice as 
a deterrent effect as well, to make sure people know we are 
watching this as carefully as possible and will bring action as 
appropriate.

                ACTIONS AGAINST PRESCRIPTION DRUG THEFT

    Mr. Ryan. So how many people up to this point have we 
brought action against that was selling pills, stealing pills? 
How prevalent is that up to this point? I mean, do you have any 
early data on those?
    Mr. Missal. It is definitely in the hundreds of cases that 
we have brought or individuals involved over the years. I 
believe we have something like 90 active cases right now, which 
could involve more than one person.
    So it is an issue out there, and we are looking at it very 
closely.
    Mr. Ryan. So they are stealing and selling.
    Mr. Missal. They are stealing and selling, or some of the 
staff use it in the facilities themselves and then substitute a 
saline or other substance for the patients.
    Mr. Ryan. Thank you.
    I yield back.
    Mr. Dent. Thank you, Mr. Ryan.
    At this time, I would like to recognize the gentleman from 
Virginia, our Navy SEAL, Mr. Taylor, for 5 minutes.
    Mr. Taylor. Thank you, Mr. Chairman. I have a bunch of 
questions.
    Thank you for being here. We really appreciate it. This is 
certainly a personal issue for me. And our district has many, 
many veterans, fastest growing population of women veterans and 
OIF/OEF veterans. So I appreciate your time and your work.

                        RETIRING LEGACY SYSTEMS

    Let's talk about legacy systems really quickly. Is there a 
push in the VA currently to get rid of legacy systems? Because 
some of these systems are from the 1980s, which is incredible. 
And I understand it is expensive.
    That being said, is there a push to procure new systems 
that are relevant to today so you are not looking for parts or 
hardware and stuff like that that is not even made anymore as 
opposed to building on legacy systems that are still there?
    Mr. Missal. Right. Secretary Shulkin has made several 
recent statements about that, and what he has stated is that he 
is looking very closely at this issue. He wants to study and 
analyze whether certain systems should be replaced and how 
exactly to do it.
    So, at this point, my understanding is VA has not made any 
final decisions on what they are going to do with respect to 
their legacy systems as a whole.
    Mr. Taylor. Any idea on timing, like, when those decisions 
will be made?
    Mr. Missal. I hope it is as quickly as possible, because IT 
is an issue that we have identified as a problem in a number of 
our reports.
    Mr. Taylor. Thank you.

           UNIFORM TREATMENT PROTOCOLS FOR SUICIDAL VETERANS

    Shifting gears really quickly, on the suicide--and I 
understand the hotline and everything like that. But what is 
the proper procedure--not the procedure, but is there a uniform 
procedure if a veteran, any veteran, walks into a facility and 
says that they are, in fact, suicidal or having suicidal 
thoughts? What happens there? And is that uniform across the 
board?
    I know that you mentioned the VA being decentralized, but 
that seems like it would be something that would have to be 
uniform policy, you know, if somebody--not the hotline, but 
they walk in and they are a veteran and they have suicidal 
thoughts. What happens?
    Mr. Missal. Right. There are suicide prevention officers at 
the various facilities, and they are supposed to be notified 
immediately if a veteran is in danger in any way. And so they 
should be getting appointments immediately, depending on the 
urgency of the situation.
    Mr. Taylor. So if somebody--just a followup. If someone 
walks in--I walk in and I say I am having suicidal thoughts, 
what happens? You said, you know, they see about the urgency. 
They don't take me in?
    Mr. Missal. They should take you in right away. For 
something like that, I would expect them to take you in right 
away and have you see a provider immediately.
    Mr. Taylor. Just one other followup. I apologize. Is there 
a uniform policy across the board?
    Mr. Missal. I believe VA does have policies, but as I said 
before, they are decentralized. And they do change the 
application of some of the policies if it makes sense at a 
particular medical center.
    Mr. Taylor. I appreciate that.
    Just because I am dumb, just to clarify, so it is 
decentralized, but you are not positive that there is a uniform 
policy, if somebody walks in and they have suicidal thoughts, 
what happens.
    You know, I am not being argumentative, but I want to know, 
because this is an issue that has come up in our own VA, as 
well, too.
    Mr. Missal. I don't know of the specific policy, but my 
understanding is that if you are a veteran in urgent need that 
you will be seen immediately, or you should be seen 
immediately. And my understanding is that they would have some 
policies that cover that. I don't know how specific it is on 
the suicide perspective.
    Mr. Taylor. Okay. I will talk to you about that offline, I 
guess.
    Mr. Missal. Sure.

                       ELECTRONIC HEALTH RECORDS

    Mr. Taylor. I wanted to follow up on the interoperability 
and legacy systems, as well, too. I understand there is more of 
that. There has, you know, been a big push for electronic 
health records.
    Are you able to speak to the DOD, 100 percent--so if I come 
in and I am applying for VA disability, I get out of the 
military--obviously, 100 percent from VA are from DOD--are you 
able to see everything that I was treated for, where I was 
treated for, all those things, so that in fact you are able to, 
one, expedite that claim but also, two, reduce fraud? Because, 
obviously, veterans--and you may not hear this from this side 
that often, but veterans commit fraud sometimes, as well, too. 
So are you able to see those things with the current technology 
that is there?
    Mr. Missal. They have different systems right now. I know 
that is another issue under discussion, is should they try to 
have one system. There are workarounds, so there is information 
that is being transferred from DOD to VA----
    Mr. Taylor. So there is still discussion about whether they 
should talk or not or what system they should talk--even though 
100 percent of people in the VA are from DOD.
    Mr. Missal. That is correct.
    Mr. Taylor. Incredible. Thank you.
    Thank you, Mr. Chairman.
    Mr. Dent. Thank you, Mr. Taylor.
    I guess at this time we will move into our second round of 
questioning.

                         VA/IG STAFF EXPANSION

    A couple things about your agency's growth, Mr. Missal. As 
you are aware, Congress provided the IG a generous increase for 
fiscal year 2017 as part of what your predecessor describes as 
a multiyear increase to right-size the agency. And I think we 
took you up to about $160 million in fiscal year 2017, which is 
about $23 million above what you were in fiscal year 2016, or 
it is about a 17-percent increase.
    And I think you have about 790 full-time equivalents, 
plus--that is about 100 above what you were the year before. Is 
that correct?
    Mr. Missal. That is the plan. Correct.
    Mr. Dent. All right. So what progress have you made in 
expanding staff and adding new locations, especially out west, 
where you had not very much of a presence?
    Mr. Missal. Right. Well, we are in the process of trying to 
hire as aggressively as we can. We are looking for quality 
people. We want to make sure the people that we hire are of the 
very highest quality. Every day it seems we have other 
announcements going out, as we have exemptions to the hiring 
freeze that is in place now. And we will continue to do that 
until we get fully staffed up.
    With respect to new facilities, we are going to be opening 
a new office in Salt Lake City. We think that is strategic for 
our office, and we believe there is plenty of need in that 
area. And that is one of the offices we are opening; we are 
considering some other ones as well.
    Mr. Dent. Why Salt Lake City? You said it is strategic.
    Mr. Missal. Because of the medical centers in the area and 
the regional office for benefits. We don't have anything that 
close to that area. We also think it is a good workforce where 
we can attract good people.

             FOR PROFIT SCHOOLS USING THE POST-9/11 GI BILL

    Mr. Dent. Okay.
    I want to just talk briefly about for-profit schools using 
the Post-9/11 GI Bill. There have been questions from Congress 
about the quality of education some for-profit schools are 
providing veterans who use the Post-9/11 GI Bill. The stories 
we hear about flight schools, beauty schools, truck-driving 
schools, et cetera, that are charging high tuition with almost 
no class time and no job prospects, all paid for by the Post-9/
11 GI Bill.
    The Student Veterans Association of America recently 
published research saying that public schools received 34 
percent of all Post-9/11 GI Bill funding and produced 64 
percent of the degrees, but the for-profit schools use 40 
percent of the Post-9/11 GI Bill funds and produced only 19 
percent of the degrees.
    So is your office investigating high-cost, low-performing 
for-profit schools that are profiting from the Post-9/11 GI 
Bill?
    Mr. Missal. Yes. We have brought a number of criminal cases 
involving schools that have not lived up to the commitments 
that they made.
    In addition, we have an audit now involving the State-
supported agencies that are required to get involved in the 
authorization for those funds to be used. And we should have 
that report out in the next few months.
    Mr. Dent. Okay. I was going to ask you about that. So the 
audit is coming in the next few months.
    Mr. Missal. Yes.

                       DISABILITY CLAIMS BACKLOGS

    Mr. Dent. All right. Very good.
    On the issue of disability claims backlogs, we understand 
that there has been a small uptick in the size of the backlog 
of VA disability claims. Is your agency continuing to review 
the processing of claims to judge whether VA needs to implement 
new systems or workforce increases to keep the size of the 
backlog low?
    Mr. Missal. Yes. We have a benefits inspection group that 
goes and inspects the 56 regional offices and puts out reports 
as they finish their audits and reviews. So, yes, we are 
actively looking at the benefits.

                          GAO HIGH RISK REPORT

    Mr. Dent. Thank you.
    And then, on the GAO high-risk report, I guess the GAO's 
February report continues to categorize the VA as a high-risk 
enterprise in five areas--for example, ambiguous policies and 
inconsistent processes; inadequate oversight and 
accountability; information technology challenges; inadequate 
training; and unclear resource needs and allocation 
priorities--although the GAO report acknowledges the VA has 
made some improvements, notwithstanding.
    Do OIG findings lead you to that same conclusion?
    Mr. Missal. Yes. We recognize the five areas that GAO 
found, and many of our reports include one or more of those 
same inadequacies.

               PROGRESS IN REDUCING TIME BETWEEN REPORTS

    Mr. Dent. And on transparency and timeliness, you made a 
commitment to make publicly available all IG reports.
    Mr. Missal. Correct.
    Mr. Dent. We truly appreciate your leadership on that 
score. In last year's hearing, members were very frustrated 
that the IG was choosing not to release some reports.
    What progress are you making in reducing the amount of time 
between an investigation and the publication of the report? 
Members were also frustrated by that issue in last year's 
hearing as well.
    Mr. Missal. Right. I think we are making progress. We still 
have some work products that were in the works when I started 
that we are still pushing to get out that may be of an older 
time period. But I think the VCL is a good example of a model 
of where we want to go. We started that inspection around the 
beginning of June, and we now have it out in well less than a 
year. And we are going to try to do better than that.
    Mr. Dent. Thank you, Mr. Missal.
    My time has expired. I now recognize the ranking member for 
her questions.
    Ms. Wasserman Schultz. Thank you, Mr. Chairman.
    Mr. Taylor, when we were at the VA medical center on 
Monday, the very concern that you raised, about the 
inconsistency of the training, was evident in their description 
of how it works between the national crisis hotline and their 
local hotline. And I would like to talk with you more about the 
concerns, because I share them.
    Mr. Taylor. Sure.

                    DISCREPANCIES IN WAIT TIMES DATA

    Ms. Wasserman Schultz. Mr. Missal, I just want to ask a 
followup question about the discrepancy in your data on the 
wait times and what you attribute that to.
    I mean, can you clarify what you think is driving the 
discrepancy between the IG's data on wait times and the VA's 
data? Because you seem to allude to training and a lack of 
clarity on policies to be the cause. Do you think there is also 
a possibility that it is still manipulation?
    Mr. Missal. We don't rule out any possibility.
    With respect to VISN 6, where we found very different 
numbers than VA, I will give you a concrete example of the 
difference. So if a veteran has a preferred time, a veteran 
comes in and says, ``I want to be seen on June 1st,'' the 
policies in effect at the time said the scheduler is supposed 
to put a note there just to, again, make them do an extra step 
to double-check that that is a real date.
    And so we found many instances where there was no note. So 
if there was no note, then it would default to another date. 
And that is where we used the other date. VA, in calculating 
their wait times, didn't do that. So we considered it was in 
violation of the policy, and so----
    Ms. Wasserman Schultz. Because they didn't use the 
veteran's preferred date.
    Mr. Missal. They shouldn't have used the veteran's 
preferred date if there was no note there.

            CHOICE PROGRAM MEETING REQUIRED SPENDING TARGETS

    Ms. Wasserman Schultz. Okay. I see. Thank you.
    Another troubling aspect about the IG report noted that the 
VA was meeting--the Choice Program was meeting its required 
spending targets. And that is kind of odd, because we gave them 
$15 billion. And part of it was for infrastructure; the other 
part was for care.
    Right now, the Choice Program is on track to hit its 
expiration date with money left over. So how is it possible 
that the program didn't have adequate resources?
    Mr. Missal. I think the issue was with the start-up of it. 
It started up within 90 days from the legislation. It just took 
them a while to get the network up where they would be able to 
be more operational with respect to it. So the first part of 
it, they just didn't spend the money that was allocated to 
them.
    Ms. Wasserman Schultz. So, in the beginning, they seemed to 
not have adequate resources, or they weren't using the 
resources that they did have appropriately?
    Mr. Missal. They weren't using the resources because they 
hadn't yet built up the network of doctors and providers out 
there who the money would be going to.
    Ms. Wasserman Schultz. Okay.

                         VA OIG RESOURCES NEEDS

    And in the spirit of making sure that you continue to have 
the resources that you need, do you have the resources that you 
need at the moment to conduct proper oversight?
    And, I mean, I know that you mentioned during our meeting 
you were having a tough time getting reports out. Is the hiring 
freeze a problem now, and do you anticipate it making the 
problem worse?
    Mr. Missal. The hiring freeze clearly impacts us. It is 
hard to give you a precise estimate of the impact, but we are 
not able to hire the people that we would like to hire so that 
we can continue to do our effective oversight. And we are 
hoping, going forward, with additional funds, that we can put 
to good use every additional person that we are hiring.
    Ms. Wasserman Schultz. And you don't qualify for an 
exemption in the hiring freeze policy?
    Mr. Missal. Some of our positions do. According to OPM and 
OMB guidance, I am the head of the agency and allowed to grant 
the exemption. And under the memorandum, you can do it for 
national security or public safety. Much of what we do is in 
the public safety realm.
    We have given our plan for the exemptions to OMB and OPM, 
and they said to go ahead and follow that plan that we had, and 
we have been doing that.
    Ms. Wasserman Schultz. So are you concerned that you will 
be unable to hire the necessary additional auditors and 
employees that you need to be able to do the appropriate amount 
of oversight that is necessary here?
    Mr. Missal. I am concerned we are not going to have enough 
of them to do the oversight that we see we should be doing, 
yes.
    Ms. Wasserman Schultz. Because of the hiring freeze or not 
enough resources or both?
    Mr. Missal. A little bit of both, but the hiring freeze 
definitely is impacting the number of people we are going to be 
able to hire.
    Ms. Wasserman Schultz. In spite of the fact that you have 
the flexibility in those two areas.
    Mr. Missal. We can grant exemptions but only in certain 
situations. So, for our open positions, we estimate it is 50 
percent or so of the people in the open positions we are going 
to be able to hire pursuant to exemptions.
    Ms. Wasserman Schultz. I would suggest to all my colleagues 
on the committee that if there is a place that cries out for an 
exemption if this hiring freeze is going to continue, it would 
be the OIG at the VA.
    Thanks, Mr. Chairman. I yield back.
    Mr. Dent. Thank you, Ms. Wasserman Schultz.
    At this time, I recognize the gentleman from Arkansas, Mr. 
Womack.
    Mr. Womack. Thank you.
    I appreciate your testimony, sir. Thank you for your 
service.

                         PROACTIVE OIG AUDITING

    As you know, one of the things that we are able to do from 
time to time at this level is take care of our veterans by 
putting them on some solid ground from a small-business 
perspective, both from a service-disabled small business or 
just a veteran-owned small business. I have read and I have 
seen some data that shows that there is good oversight, or at 
least oversight, on the programs, but I don't think it has been 
audited since 2011.
    So my question would be specifically, other than just 
prosecuting people for fraudulent-type activity in these 
programs, which, as I said, we have read and heard about, is 
there something, in your experience, that we could be doing 
that would be more proactive in nature? Instead of us always 
reacting to a fraudulent activity, what can we do proactively 
that can give us the proper filters to ensure that we are not 
having to be reactive on some of these issues?
    I hope I am clear in my question.
    Mr. Missal. Sure.
    Mr. Womack. What would you recommend, if anything, that we 
can do that we are not presently doing?
    Mr. Missal. Well, a few things. One is the oversight, what 
kind of information you ask for about the program to see if it 
is fulfilling the goals that you have. Secondly is 
accountability, when you see that the programs aren't operating 
as they should be or there are issues, is to take action as 
quickly as possible.
    When we do an audit of a program, we are looking at a lot 
of different things. And we want our work--to answer four 
questions: First, why is it important to do? So, as you point 
out, those programs are very important. Second, what happened 
here? And third, why did something happen? Again, that gets to 
the root cause. If there are issues and for the sake of being 
able to anticipate, you want to get to the root cause. And 
finally, who is responsible for accountability?
    And so that is what we try to do, and, in your oversight 
role, I know that you try to accomplish the same objectives as 
well.
    Mr. Womack. Yeah, we can't see it all and uncover it all, 
but my concern is that there are likely some things we can do.
    Specifically, are we hampered, are we handcuffed at all by 
privacy information, by doctor-patient relationships, HIPAA-
like restrictions? Is there anything that we could be doing 
proactively from a legislative point of view that would kind of 
free up the organization to better understand or control these 
programs?
    Mr. Missal. Right. It depends. Obviously, VA, with their 
healthcare system, has certain privacy issues that are going to 
impact your oversight role. I think it really depends on the 
various programs that you have.
    But there are lots of opportunities to look at oversight. 
We try to be as broad as possible in what we look at, and that 
is why we use inspections, audits, reviews, and investigations, 
so that we can cover as broad an area as possible.
    Mr. Womack. Of the known and prosecuted cases, has there 
been established any kind of a pattern of conduct? Or are they 
just random? Do they cover the waterfront in terms of 
fraudulent activity?
    Mr. Missal. They really cover the waterfront. Obviously, 
the colloquialism ``rent a vet'' is very prevalent out there, 
so we look very carefully at those matters to make sure that 
the contracts are going to the veterans who qualify for it.
    Mr. Womack. Is there a geographic area more susceptible to 
this kind of behavior? I know, for example, in some of the 
Medicare issues that we see surfacing, there are pockets of 
places where this seems to be more prevalent than other places.
    Mr. Missal. Nothing has come to my attention that it is 
focused on particular geographic areas.

              HIRING FREEZE IMPACT

    Mr. Womack. And then, finally, as it pertains to the hiring 
freeze, I have a whole other set of questions on that. In your 
opinion, just in a few words, what limitations does the hiring 
freeze or any other personnel actions have on the ability to 
deal with the veteran-owned small-business or disabled-veteran 
business opportunities?
    Mr. Missal. We have to pick and choose among the matters 
that we----
    Mr. Womack. But is it a priority?
    Mr. Missal. It is a question of priorities, exactly. And 
the fewer people we have, the tougher it is going to be to hit 
our priorities.
    Mr. Womack. Okay. I know I am out of time. Thank you very 
much for your testimony.
    Mr. Dent. Thank you, Mr. Womack.
    At this time, I would like to recognize the gentlelady from 
California, Ms. Lee, for 5 minutes.
    Ms. Lee. Thank you very much.

              COLLECTING DATA BASED ON RACE AND ETHNICITY

    Good morning, I apologize for being late. I would like to 
follow up on one of the questions that Mr. Bishop asked with 
regard to data collection, in terms of disaggregating data 
based on race and ethnicity.
    Earlier this year, we had the chance to visit the VA 
medical center here in Washington, DC. One of the questions I 
wanted to get answered but couldn't quite get answered was the 
utilization of data to track minority-, women-owned businesses, 
and disabled-veteran-owned businesses. They were able to break 
down, for example, the percentage of women-owned businesses and 
other categories, but they did not break it down by race.
    So I want to find out--are you capable of doing that? 
Because it is extremely important to make sure that all 
companies are given equal opportunities. And when you don't 
have the data, we don't know if African-American businesses, if 
Latino businesses, or Asian-Pacific American businesses are 
participating in the contracting opportunities.
    Mr. Missal. Right. Well, I know that VA keeps data in a lot 
of different ways. We have access to VA's databases, but it is 
really up to them to decide how they want to categorize things. 
Obviously, if we see something that we think should be covered, 
we could make a suggestion, but it is really their 
responsibility to keep their data.
    Ms. Lee. But we do have some Federal Government 
requirements to be sure there is nondiscrimination and equal 
opportunity for all people in all companies.
    Mr. Missal. Sure.
    Ms. Lee. So I would think, in your position, in terms of 
investigating and making sure they are compliant, that is not 
their decision. I mean, we have laws that they should comply 
with to ensure that African-American, Latino, and Asian-Pacific 
American businesses are being treated fairly and equally.
    Mr. Missal. Absolutely. And that is something we could 
certainly look at, and then we would have to work with them to 
see how they can get the data.
    Ms. Lee. Okay. Could you do that, please?
    Mr. Missal. We can look into that, absolutely.
    Ms. Lee. Okay. Thank you very much.

                    EFFICIENCY IN PROCESSING CLAIMS

    Now let me ask about the Oakland office. First, I thank you 
very much for following up with some of the requests we have 
made. Last year, I am told that 53 percent of claims were 
processed, but we still have about 54 percent in terms of 
backlog.
    What needs to happen to become more efficient in processing 
these claims? We have had terrible problems at Oakland, and we 
are trying to get our hands around it. We have made some 
progress, but 54 percent of claims unprocessed, is not good.
    Mr. Missal. I think you see great discrepancies among the 
regional offices in terms of the backlogs they may have, how 
quickly they can get through the processes. And, again, I think 
one of the major issues is leadership and oversight of 
particular offices there. And so that is something VA should 
look at, to make sure that they have the proper people doing 
it, that they are following the policies, and they are moving 
the claims through as quickly as possible.
    Ms. Lee. What would be your oversight role in that, if any, 
to determine whether or not they are compliant with what we 
have requested? Do you audit them? Or review?
    Mr. Missal. We could audit. We could do a less formal 
process, which would be a review of some kind.
    Obviously, when we look at something, we generally make 
recommendations. We keep a report open until they complete the 
commitments they made in the recommendation. If we think later 
on that they have fallen back or they haven't fulfilled what 
they had said they would and they look like they had at one 
time, we will definitely go back in and look again.
    Ms. Lee. So I would have to make that request of you.
    Mr. Missal. You have just made it.
    Ms. Lee. Thank you very much.
    Mr. Dent. Thank you, Ms. Lee.
    At this time, I would like to recognize the gentleman from 
West Virginia for 5 minutes, Mr. Jenkins.

                     ALLOCATION OF FUNDING INCREASE

    Mr. Jenkins. Thank you, Mr. Chairman.
    There were discussions relating to your budget, and from 
the appropriations standpoint, a $159 million annual budget. 
You had this bump up. You identified 725 FTE equivalents, and 
you identified 5 areas.
    I want to talk about where you are putting the increased 
funding this last year and into which of these categories from 
an FTE--you mentioned you do investigations, you do audits, you 
do contract reviews. I am curious about what staff increases in 
the subcategory of investigations. And a followup on that 
topic.
    Mr. Missal. Sure. We have a number of offices which include 
investigators, and so we probably have more offices with 
investigators than any of the other directorates, just because 
we want to cover as broad an area as possible across the 
country. So what we have done is we have taken a look at all of 
the offices, the current staffing, and whether or not it makes 
sense to add staffing to that.
    My personal view is we have a number of smaller offices of 
investigators. We might have two or three. And, to me, it is 
just harder to be as productive as you can be. If you are going 
to work in teams and you have people going off doing different 
things, it is just harder to do that.
    So one of the things we are looking at is building up our 
smaller offices, because we think that will actually increase 
the productivity. It is almost as if one plus one equals three, 
as opposed to two.
    Mr. Jenkins. Can you share a breakdown of this, under the 
fiscal year 2017 budget increase that you got and the ability 
to hire new people, where in these five subcategories you are 
actually putting these FTEs?
    I hear you about the office size and the number of offices. 
What I am interested in is what your priorities are. You are 
putting more staff into contract review? More staff into 
audits? More staff into investigations? I would like to see 
where this staff is going and also, moving forward, where you 
think they need to go.
    You know, a little bit of this is audit the auditor. And my 
curiosity, while we appropriately have asked lots of questions 
about you holding the VA accountable to what we expect from the 
VA--I have two VA hospitals in my district. I hear oftentimes 
from employees, whistleblowers, about their concerns, what they 
are seeing. And we, of course, turn these folks, appropriately, 
over to your office.
    Mr. Missal. Right.

                  TIMELINE IN RESPONDING TO COMPLAINTS

    Mr. Jenkins. Tell me about your timeliness in terms of 
responding to complaints, the followup with that whistleblower. 
Because we often hear concerns that we have made the call, we 
don't get the time and attention, we don't get substantive 
followup.
    How do you evaluate your performance in responding to 
whistleblower concerns, the employees of these VA hospitals?
    Mr. Missal. With respect to responding to whistleblowers, 
we definitely can improve our performance there.
    We have a hotline group. The hotline group is in our 
management and administration group. And they are the ones who 
take the first look at the approximately 39,000 contacts we get 
to our hotline.
    Every one of those is triaged. So we triage each one of 
those 39,000. Some we can immediately deal with; others require 
additional review. Others we will share with some of the other 
directorates. If somebody says, one of your medical centers in 
West Virginia, they say there is a problem with a doctor, that 
will immediately go to our healthcare group. They will look at 
it to see what should be done. So, if it is an urgent 
situation, we look at it very, very quickly.
    But to your question about where am I looking to increase 
staff, hotline is one of them. I think we can do more. We can 
personalize more of the responses that we give to individuals.
    And the other area is in our healthcare inspection group. 
Right now, we have over 200 staff in investigations, over 200 
staff in audit. We have about 125 in health care. And given the 
focus of VA on health care, we need to increase that pretty 
dramatically.
    Mr. Jenkins. Well, I am very interested in serving our 
veterans and the employees who are taking care of the veterans. 
I appreciate the interest in the hotline needing to staff up, 
but I appreciate your sensitivity of the statement, quote, ``We 
can improve.''
    I will be looking for that improvement so that those who 
are contacting the Inspector General Office with a concern, 
that they don't feel like that is going on deaf ears. They 
don't hear back at times, and they think nobody is listening. I 
want to make sure you are listening. And from a staffing 
standpoint, that is why I want to see, are you investing in the 
area for the personnel to make sure we are responding to those 
concerns.
    Mr. Missal. I agree. Responsiveness and prompt 
responsiveness is very important to me, because if we don't 
have it, we are not going to have the confidence that we need 
to have for veterans and others to think we are doing our 
oversight work properly.
    Mr. Jenkins. Thank you.
    I yield back.
    Mr. Dent. Thank you, Mr. Jenkins.
    At this time, I recognize the gentleman from Georgia, Mr. 
Bishop, for 5 minutes.
    Mr. Bishop. Thank you very much.
    Your audit report found that the VA made about $247 million 
in improper GI Bill payments and $205 million in missed 
recoupments annually.

                 GI BILL BACKLOG AND PROCESSING DELAYS

    On 17 March, which was last Friday, the VBA website posted 
a message stating that veterans and servicemembers can expect 
processing delays due to an internal audit.
    When do you expect that the audit will be completed? How 
many current GI Bill claims are currently backlogged? And when 
will the VBA be able to start working through the growing GI 
Bill backlog?
    Mr. Missal. I don't have the specific numbers there.
    The report that you mentioned identified significant issues 
with both the payment and the recoupment, and we projected out 
what the impact could be if they didn't fix it as quickly as 
possible. So we are following up on that, since they are open 
recommendations, with respect to that report and that issue to 
make sure that they fulfill their commitments.
    Mr. Bishop. Do you expect any criminal investigations to 
come out of that?
    Mr. Missal. We do have criminal investigations as it 
relates to the GI Bill funding. And we have had a number of 
prosecutions, and we have active cases right now.
    Mr. Bishop. Okay. No further questions. Thank you.
    Mr. Dent. Thank you, Mr. Bishop.
    At this time, I would like to recognize Mr. Taylor.
    Mr. Taylor. Thank you, Mr. Chairman.

                    TREATMENT OF INELIGIBLE VETERANS

    I have a question, and this is something that maybe you 
don't get often from this side, I think. But, you know, I 
walked through my VA and asked a lot of questions, and it was 
pretty clear there were some folks there that probably were not 
eligible for the care that they were receiving.
    And, again, I mean, from this side, the political pressure, 
I think, is to treat veterans and be pro-, pro-veterans. But if 
there are folks that are not supposed to be--you know, they are 
not rated or they are not supposed to be treated there, then 
that is, you know, a pretty excessive cost potentially.
    My question is--and, like I said, I walked through and I 
saw this and asked a question, and they definitely verified 
that. Have there been any reports that are out there, or have 
you guys looked into it, as far as potential veterans that are 
being treated that aren't necessarily supposed to be being 
treated at the VA?
    Mr. Missal. I don't believe there has been any report 
certainly since I have been there. I don't know how far back to 
go to know whether or not we have done that. Certainly in 
recent time I don't believe we have looked at it.
    We do look at the Health Eligibility Center, which 
determines eligibility for care. We have done a lot of work in 
that area, but not to see whether people are getting services 
who should not be.
    Mr. Taylor. Obviously, we want everybody to be treated, of 
course. That is not the point. But, as you can imagine, if 
there are folks who are not rated to be treated but being 
treated at a VA, that could be tremendous costs across the 
whole system.
    So is that something that you would be interested in taking 
up or doing a report on to figure out? You know, ``I have the 
eligibility right here,'' and veterans know if they are 
eligible or not, based upon, you know, what is there, of 
course.
    So is that something that your office would be willing to 
do and a report on to figure out, okay, are there, across the 
board, in different--whatever the treatment might be, but folks 
that are--not necessarily that they are abusing it, but if they 
are not supposed to be treated, then they are not there. And 
then what is that cost to the VA? Is that something that you 
would be willing to do a report on?
    Mr. Missal. We would certainly look at it to see if it is a 
systemic or other large problem. Any information that you have 
that would be helpful to us, we would really value getting it 
from you.
    Mr. Taylor. All right. I appreciate that. I would love to 
follow up with you on that to get that report done. Thank you.
    Thank you, Mr. Chairman.
    Mr. Dent. The gentleman yields back.
    At this time, I recognize the gentleman from Ohio for 5 
minutes.
    Mr. Ryan. Thank you, Mr. Chairman.
    I want to review the numbers from your testimony for a 
minute here.
    As I understand it, your organization has a return of 
investment of $30 for every dollar of Federal funding, which is 
pretty impressive. Despite that, the skinny budget from the 
President is proposing to flat-line the VA discretionary 
programs, which you are included in. And so my concern is that 
this one-size-fits-all plan ignores your planned staffing 
increases designed to champion and protect our veterans health 
care and benefits, as you already do, by reducing costs.
    In addition to failing to meet this promise, if I continue 
to follow the math correctly, we talk about a potential repeal 
of the healthcare bill would cause 24 million Americans to lose 
their health care, which would increase veterans' participation 
into the VA program and generate an even larger need for you 
and your oversight and the precious funds that you have.

                          UNMET FUNDING NEEDS

    So the question is, is that a reasonable estimation to say 
that $30 million would be the number if we follow the 
President's intended funding? And if the VA sees an increase 
from the repeal of the current healthcare system options that 
many veterans take advantage of, would your staffing and budget 
needs also increase?
    Mr. Missal. It likely would. I don't know and I haven't 
seen the numbers of what the impact would be if there is a 
repeal, but any type of increase in the use of VA, whether it 
is the healthcare system, whether it is benefits, would then 
cause us to have additional responsibility.
    So there are other variables that could come into play that 
could impact the funding that we have and our ability to do 
effective oversight.
    Mr. Ryan. So you are flat-lined. And for every dollar, you 
save 30.
    Mr. Missal. Correct.
    Mr. Ryan. And if 24 million people lose their health care, 
I don't know what the exact number would be, but we would 
assume that hundreds of thousands, at least, would be 
veterans----
    Mr. Missal. Right.
    Mr. Ryan [continuing]. Who would then go into the VA system 
because they wouldn't have anywhere else to go. So that, to me, 
seems like it would have a huge impact on the VA and your 
ability to try to continue to save us money.
    Mr. Missal. Right.
    And if I could just add one thing, on the 30 to 1, that is 
the amount of dollars that we save or the impact that we have. 
We are one of the few IGs that also has healthcare 
responsibilities. And so on those, it is not a dollar return. 
What you are talking about is helping to save lives, helping to 
have better medical care. And so that should be on top of the 
30 to 1. And to use a commercial, we consider that priceless 
and very important to what we do.
    Mr. Ryan. Excellent. Thank you.
    Mr. Dent. At this time, I would like to recognize the 
gentleman from Arkansas, Mr. Womack, for 5 minutes if he has 
questions.

                        HIRING FREEZE EXEMPTIONS

    Mr. Womack. I won't need all that time. I just want to go 
back to hiring freezes for just a minute.
    You detailed in your written statement that, based on 
guidance from OMB and OPM, you have the authority to determine 
what positions in the OIG are subject to the Presidential 
memorandum on the freeze of hiring. You also stated you 
exempted some on the basis they were involved in national 
security or public safety responsibilities.
    And I apologize if this has already been covered. I got 
here late today.
    With that in mind, can you give us an example of a position 
within the OIG that involves national security or public safety 
responsibilities that would be exempted?
    Mr. Missal. Sure.
    On public safety, we have a number of positions that we 
feel should be exempted under public safety and we have 
exempted under public safety, such as criminal investigators, 
such as auditors looking at significant programs which could 
have a significant impact on taxpayer dollars, and our 
healthcare inspectors and providers who are looking at the 
medical centers, medical facilities to help make the healthcare 
providers at VA work more effectively.
    Mr. Womack. How tight are those conditions? In other words, 
you could probably make an argument from agency to agency that 
a lot of these types of positions are geared to do exactly what 
you just said. So is it as simple as giving it a general 
umbrella that because they work in this particular area that we 
can automatically exempt, or are they pretty tightly reserved 
there?
    Mr. Missal. We are looking at every position on a case-by-
case basis. We are taking the memorandum very seriously. We 
were asked to consult with OMB and OPM, and we did so. And they 
agreed with our plan in terms of the types of positions we were 
going to grant exemptions to.
    Mr. Womack. In those positions, what would be the churn 
rate, typical churn rate of in and out? Are these revolving-
door positions, or are these people who have been there a long 
time? How would you characterize the general character of this 
particular lot of employees?
    Mr. Missal. Our turnover rate is relatively low. We have a 
very dedicated and committed staff that is really focused on 
our important mission. And so when people come to us, they stay 
for quite a few years. Our hope is that when they come to us, 
that they are going to be there for a long time.
    Mr. Womack. And then, finally, for those that would not fit 
under that category that you discussed a moment ago, what would 
be an example of those kinds of positions?
    And then, if you can, is there a general breakdown as to X 
percent of my team should be exempted and X percent could be 
not considered for an exemption status?
    Mr. Missal. Right. A lot of the administrative positions 
that we have, I think, are harder to make the public safety or 
national security argument for. You are right; I mean, you can 
make arguments for virtually everything, because what we do is 
help improve the VA's programs and operations, help make them 
as effective as possible, and to ensure taxpayer money is spent 
properly. Everybody in our office, to some degree, is focused 
in on those two missions.
    But it is hard to say at this time exactly how many we will 
have. We estimate it is around 50 percent of the open 
positions. But we are looking at them position by position.
    Mr. Womack. That is all I have, Mr. Chairman. Thank you.
    Thank you again for your testimony.
    Mr. Missal. Thank you.
    Mr. Dent. Thank you, Mr. Womack.
    At this time, I recognize the gentlelady from California, 
Ms. Lee, for 5 minutes.

                  DATA REPORTING BY RACE AND ETHNICITY

    Ms. Lee. Great. Thank you again, Mr. Chairman, for giving 
me a chance to ask my second round of questions.
    I want to go back to the questions I asked you earlier with 
regard to the disaggregation of data as it relates to ethnic 
and racial inclusion in the business aspects and contracting 
opportunities.
    The ``National Veteran Health Equity Report'' ``released in 
2016'' suggested that ``tools for measuring parameters of 
interest by race/ethnicity should be incorporated into the next 
generation of the VA electronic health record user interface.'' 
As this data base develops, interventions to reduce health and 
healthcare disparities should be implemented and evaluated,'' 
especially identifying the causes of racial and ethnic 
disparities in the VA.
    Now, in this report, I didn't find the answer to some of 
the questions I had--specifically relating to emergency rooms, 
and wait times to see a doctor. I wanted to see, as it relates 
to the average wait time in an ER, this data disaggregated by 
race and ethnicity overall. Are all things equal? Are all wait 
times not very good, or are all of them are great? Or for 
veterans of color, is there a lower wait time? A higher wait 
time?
    I would like to get that information clarified, because I 
have had personal experience with this. I have visited in 
several emergency rooms in different parts of the country, and 
looking at the population of veterans, there seems to be some 
disparities there. I would like clarity on that.
    Mr. Missal. Okay. That is something that we can look at and 
we can see what data the VA has and what they should have as 
well. At this point, we have not looked at those particular 
questions.
    Ms. Lee. Okay. Well I would appreciate you looking into 
this. Because this is very serious, and I have seen many cases 
in California that give me some concern. We need to address it.

                           NURSING PAY SCALES

    Secondly, in a September 2016 report, you found that 
nursing care was the top critical need occupation for fiscal 
year 2016. To ensure adequate levels of staff to provide timely 
access to care, of course, continuity of care is extremely 
important.
    Going back to the Oakland regional office--there is a real 
discrepancy in the pay scale for registered nurses in the 
Oakland-Fremont area. There are regional pay disparities, which 
is causing a huge problem in retention at the VA outpatient 
clinic. I think Fremont is 30 minutes away from Oakland--and we 
can't figure out how to address these pay discrepancies, which 
cause retention problems in the medical facilities. I wanted to 
see if you found any recommendation on how to address that.
    Secondly, there is not a nursing shortage--but there are 
nurses, qualified nurses, who are unemployed and can't seem to 
find a job. So I am wondering, if there are licensing issues 
with the VA? Why is it that this gap still exists?
    Mr. Missal. Right.
    So we were asked legislatively to look at the largest 
number of open positions. You have identified nursing as one; 
there were five others that we looked at. And I think this was 
our third year that we did it. We are going to be doing it over 
5 years.
    One of our recommendations was that VA needs to have a 
staffing plan to do precisely the issues that you raise--to 
make sure that they have proper staffing, it is allocated the 
proper way, et cetera. And so we are still following up with 
them to ensure that they do have that proper staffing plan, and 
we will continue to do so.
    Ms. Lee. I know they don't have a plan. I don't know about 
other regions, but I know they just don't have it in my 
district. And I know that pay disparities and discrepancies are 
a problem in California. I also know that they are not hiring 
nurses who are looking for jobs. So that is another layer of 
trying to figure out what is going on. Also how are they 
following up or are they just not following up?
    Mr. Missal. I believe there was legislation introduced in 
the last Congress about increasing pay for certain positions at 
VA. And, you know, that could be one way to address the 
situation.
    Ms. Lee. Thank you very much. I appreciate your being very 
candid with us in your answers.
    Mr. Missal. Thank you.
    Mr. Dent. Before we conclude, I would like to recognize Mr. 
Bishop.

                           VA ANIMAL RESEARCH

    Mr. Bishop. Thank you.
    Just one matter. You recently received a letter, which was 
copied to members of our subcommittee, from the White Coat 
Waste Project requesting that you conduct an investigation 
regarding animal experimentation at the McGuire VA Medical 
Center.
    Do you intend to undertake that investigation? And do you 
have any idea how long that will take and whether or not--well, 
could you just furnish us with whatever your findings are?
    Mr. Missal. Sure. I got the letter about 5 o'clock last 
night.
    Mr. Bishop. Right.
    Mr. Missal. I read the letter. I responded to the gentleman 
who sent it, saying we will review it. And we are in the 
process of reviewing it and will determine whether or not it is 
something that makes sense for us to do.
    Mr. Bishop. Thank you.
    Mr. Dent. Thank you.
    I have no further questions, although I will submit--I do 
have questions, actually, but I am going to submit them for the 
record for you to respond to, Mr. Missal.
    And, again, I want to thank you and thank the ranking 
member and all the members who attended today's hearing.
    So, again, appreciate your testimony and your 
responsiveness.
    I should mention one thing before I adjourn. The 
subcommittee's next hearing is Wednesday, March 29, at 10 a.m. 
in this room. We are going to hear from outside public 
witnesses.
    So, having said that, this meeting is now adjourned.
    
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                                         Wednesday, March 29, 2017.

         PUBLIC WITNESSES HEARING

                    Chairman Dent Opening Statement

    Mr. Dent [presiding]. Good morning. I would like to bring 
to order this hearing of the House Subcommittee on Military 
Construction and Veterans Affairs. Today we are going to take 
testimony from public witnesses to hear the views of their 
organizations on matters related to this subcommittee's 
jurisdiction.
    We welcome you all here this morning.
    And I am happy to say that we were able to accommodate all 
the witnesses who wished to testify regarding the fiscal year 
2018 appropriations and oversight matters for MILCON-VA. As it 
turns out, all the witnesses are commenting on VA issues.
    I wanted to note that there are multiple appropriations 
hearings today at 10 o'clock, so several subcommittee members 
have conflicts and may not be able to join us or will be here 
intermittently.
    We will also be sure to share your views with them and with 
the committee as a whole. So again, thank you for being here.
    For public witnesses hearings we move quickly to 
accommodate everyone. Each witness will have 5 minutes to 
testify. I would not expect many questions, but if there are 
any from members please try to answer them as briefly as you 
can.
    The full written testimony that each of you submitted will 
be entered into the official record.
    With that said, we appreciate that you have taken time to 
share your expertise and viewpoints on current and future 
veterans affairs issues with the committee and look forward to 
a valuable meaningful discussion this morning.
    Let me turn to the ranking member of our subcommittee, Ms. 
Wasserman Schultz, for any remarks that she may have. I 
recognize the gentlelady from Florida.

           Ranking Member Wasserman Schultz Opening Statement

    Ms. Wasserman Schultz. Thank you so much, Mr. Chairman, for 
yielding, and I appreciate you agreeing to hold this important 
public witness hearing.
    Today's witnesses work tirelessly to assist our veterans 
daily as they navigate the--as I have been increasingly 
discovering--too often cumbersome VA system; the transition to 
civilian life; and the physical, emotional, psychological, and 
financial challenges that our veterans face upon returning 
home. To best identify the needs of our veterans it is 
important that we hear from them and partner with those who 
know them best, our VSOs.
    While the VA has made great strides in recent years, we 
know our work is far from done. This type of hearing is vital 
for us as appropriators and provides the opportunity to zero in 
on the issues the American public and the veterans community 
rely on this committee to address, particularly as we approach 
our process of marking up our bill.
    So thank you all for joining us today, and also thank you 
for joining us yesterday at Leader Pelosi's VSO roundtable. I 
look forward to participating in that going forward as well as 
hearing your testimony this morning.
    Thank you. Yield back.
    Mr. Dent. Thank you.
    Thank the gentlelady from Florida.
    At this time I would like to ask Mr. Blake to please take 
the seat. Mr. Blake is the associate executive government 
relations with the Paralyzed Veterans of America.
    Thank you for joining us, and you are recognized for 5 
minutes.
                              ----------                              --
--------

                                         Wednesday, March 29, 2017.

                     PARALYZED VETERANS OF AMERICA

                                WITNESS

CARL BLAKE, ASSOCIATE DIRECTOR OF GOVERNMENT RELATIONS
    Mr. Blake. Thank you, Mr. Chairman, Ranking Member 
Wasserman Schultz. I appreciate the opportunity to be here 
today.
    Let me first say that we are pleased to be able to have 
this opportunity once again. This used to be a regular 
occurrence with this subcommittee, having the VSOs come before 
you as outside witnesses, but that hasn't happened in a number 
of years and we are pleased to have that opportunity once 
again. We find this exchange very important.
    I am here on behalf of Paralyzed Veterans of America, as 
well as my partners in The Independent Budget, Disabled 
American Veterans, and Veterans of Foreign Wars, who will also 
be testifying before you this morning. We will be discussing 
various aspects of the Department of Veterans Affairs funding 
for fiscal year 2018, as well as advance appropriations for 
fiscal year 2019.
    This is our annual budget report that we have drafted. It 
outlines our recommendations in detail about all of the funding 
requirements of VA.
    With the chairman's indulgence, we would like to submit 
this into the official hearing record?
    [The information follows:]
    
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    Mr. Dent. Without objection, we will receive that.
    Mr. Blake. Thank you.
    You can also find this report at www.independentbudget.org, 
and it can be downloaded there, as well.
    Let me begin by saying that while we appreciate the 
administration has stated that it intends to recommend an 
increase in the Department of Veterans Affairs budget for 
2018--less clarity about fiscal year 2019 as it relates to 
advance appropriations--the fact is that the devil will be in 
the details. There are still many questions that remain about 
how the Administration will fund the priorities for the VA when 
the more detailed budget comes out later this spring.
    The fiscal year 2018 projections are of particular concern 
for us with the Independent Budget. The previous secretary of 
VA, Robert McDonald, actually testified last year that they 
knew that their fiscal year 2018 advance appropriations 
recommendations were not going to be sufficient to meet what 
they projected to be demand; yet, Congress acted upon that 
recommendation last year in the appropriations bill.
    It will be critically important for this subcommittee, for 
the full committee, for the House and the Senate to address 
what we know is a shortfall that the VA itself identified in 
continued funding for fiscal year 2018 that will come into play 
beginning in October of this year.
    We also believe it is necessary to consider the projected 
expenditures as it relates to the Choice program. Obviously the 
Choice program is a hot topic on the Hill, in the VA, and the 
VSO community.
    Last year in the VA's budget they projected as much as $5.7 
billion in remaining funds for Choice. That was a year ago.
    That number was revised to about $2.9 billion later through 
the course of the year. Currently the VA is projected to have 
as much as $1 billion remaining when the Choice program is set 
to expire in August.
    We support the legislation that has been moved by the House 
that will relieve the VA of its authority based on the date of 
expiration for the Choice program, but I would say that we 
don't believe that the Choice program, as currently 
constructed, is the optimal way forward. I don't think anybody 
actually disagrees with that notion. I think it obviously needs 
some changes, some improvements, or maybe something that is 
just better.
    But there are still a lot of questions remaining about how 
the Choice--or how that concept will look going forward and the 
funding associated with it.
    The current Choice program is covered under emergency 
designation as mandatory spending. What will that look like 
beginning after August or beginning in the next fiscal year? 
That is a serious question for us, a serious concern. Certainly 
it is a serious issue that you all will have to grapple with.
    As outlined in our budget, the I.B. recommends 
approximately $77 billion in total medical care funding for 
fiscal year 2018. Congress previously appropriated about $70 
billion; that takes into account collections, as well.
    I think the important thing to understand about how the 
Independent Budget makes its recommendations is we provide an 
overall snapshot of exactly what it costs to provide care from 
the VA, and that is a combination of things, from providing 
care as an inpatient or in the system of care of the VA, 
whether it be in the community, whether it be through Choice.
    Our view is the total view of what it actually requires to 
provide services to VA--or to veterans secondary to VA. That is 
outlined in greater detail in our budget report.
    There are a couple of issues I would like to highlight 
quickly that are included in our recommendations.
    One is continued funding and increased funding for women 
veterans programs. Obviously this has become a growing issue.
    This is a fast-growing population that VA is serving. We 
recommend about $110 million additional dollars in 2018, $120 
million in fiscal year 2019, and that is explained in detail.
    Another hot topic is reproductive services, assisted 
reproductive technology, that was included in the 
appropriations bill, which we thank you all for, last year. It 
carries us, as we understand it, through the end of fiscal year 
2018. It is critical that that program gets carried forward.
    And then lastly, the Staab ruling involving emergency care 
services. Everyone believes that the VA has interpreted the 
ruling--misinterpreted the legislation that was passed all the 
way back in 2009 about its obligation for meeting emergency 
care costs for veterans, and they now are on the hook for what 
may be as much as $10 billion over the long haul because of 
their decision to not pay for those services, as they are 
required by law.
    Lastly, we include a recommendation for medical and 
prosthetic research to the tune of about $713 million, along 
with additional money targeted at the Precision Medicine 
Initiative that the VA has designated. That would bring the 
total for research up to about $778 million. It cannot be 
overstated enough the importance of research as a part of the 
mission of VA.
    With that, Mr. Chairman, I thank you for the opportunity to 
testify. Be happy to answer any questions that you or the 
members of the subcommittee may have.
    [The information follows:]
    
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    Mr. Dent. Thank you very much for your testimony, Mr. 
Blake. We really appreciate it.
    We haven't seen a detailed budget yet for the VA, 
obviously, but we know from what the administration has 
provided in the skinny budget that your fiscal year 2018 
Independent Budget comes in at more than $9 billion above the 
President's request. Since the budget treats VA far better than 
any other domestic discretionary program or agency, I don't 
know how our subcommittee would be able to provide that kind of 
funding increase.

        PROGRAMS WITH THE MOST URGENT NEED FOR INCREASED FUNDING

    So I only have really one question: Realizing that we won't 
be able to handle your total request, which areas can you 
identify within the VA that have the most urgent need for 
increased funding?
    Mr. Blake. Well, I think there is no question but the 
medical care section, particularly under medical services, is 
the most critically important.
    To understand how the I.B. frames its recommendation, our 
medical services recommendation, if you were to line it up with 
what the VA recommends for its dollars, the VA's comparable 
recommendation would look like their medical services, plus 
their medical and community care account, plus their Choice 
program funding that they have planned.
    So that is how you align what we recommend. We don't break 
those out because truthfully, from our perspective it is a 
complicated proposition to figure out what community care 
spending might actually be.
    So medical care in particular is by and large the most 
important.
    I think where you see one of the big deviations in our 
recommendations from the administration is in the construction 
area. That has been the case for many, many years now. One of 
our long-running frustrations is particularly in the area of 
major construction, to a lesser degree minor construction.
    The VA has billions of dollars in projects that are setting 
in the queue, and my colleague from the VFW will talk about 
that so I won't steal his thunder in that respect. But that is 
a serious concern that we have because there hasn't been enough 
commitment.
    From the I.B.'s perspective we have considered in our 
policy agenda, you know, innovative ways to address the 
construction issue, recognizing that that part of VA is under 
scrutiny in places like Denver, New Orleans, Orlando--places 
where we are not satisfied with how that was handled; I know 
you all are not satisfied how--with how those things were 
handled.
    So construction remains a serious issue.
    I think in light of the VA's announcement about its plans 
for information technology, a star needs to be put next to that 
because it is going to be hard to rationalize the cost in I.T. 
with what the new secretary has stated as his desired goal, to 
move towards a commercial off-the-shelf, and how that might 
impact the funding.
    I.T. has increased year over year for a number of years 
now, but we don't know what impact that this decision might 
have on that decision by the VA moving forward.
    So I think I.T. is critical, as well.
    We try to take a view that a number of the administrative 
accounts are--we take a conservative approach to a lot of the 
administrative accounts. You see that in our recommendations 
for medical support and compliance, general administration, 
some of the areas where we believe there is probably too much 
bloat in the VA and that--we don't necessarily ascribe to the 
belief that those should just increase for the sake of 
increasing.
    So I think if you look at our recommendations you will see 
that we try to treat those fairly without going out of the 
bounds of what seems reasonable.
    So short answer to your question, medical services for 
sure, the construction areas for sure, I.T. for certain.
    I also will just sort of touch on the issue that my other 
colleague from the DAV will mention: funding for the Veterans 
Benefits Administration. The number of claims is not going 
down.
    We still also have to grapple with the issue of appeals 
modernization, the cost associated with that. And I think the 
subcommittee is going to have to figure out how to rationalize 
what the authorizers are trying to do, along with the VSO 
community and the VA, in appeals modernization and how that 
impacts the larger claims process, as well.
    Mr. Dent. Ms. Wasserman Schultz.
    Ms. Wasserman Schultz. Thank you, Mr. Chairman.

                    ASSISTED REPRODUCTIVE TECHNOLOGY

    First, thank you for your service and your testimony.
    On the assisted reproductive technology language, I was 
proud to join my colleague, Congresswoman Brownley, in making 
sure that that language was there, and we followed up with a 
letter to the VA to make sure that there was a clear 
understanding that the idea is that this is not just a 1-year 
policy and that we expect that they would permanently make sure 
that we can provide this assistance and coverage. So as someone 
whose--two of three children were conceived through in vitro 
fertilization, so I certainly know what it is like to struggle 
with the challenge of infertility no matter what its cost.

                        PARKING AT VA FACILITIES

    I do want to ask you on--about the challenges that your 
members might have with parking at VA facilities, because I, 
you know, represent the Miami area, and I--when I went to the 
University of Florida, I have never seen a parking problem like 
they have at the Miami VA--and that is saying something.
    So come to find out that it is actually against the law to 
shuttle employees of the VA, as opposed to shuttling veterans. 
So when a medical center comes up with a solution to park 
employees in an offsite lot and shuttle them, versus parking 
veterans at an offsite lot and shuttle them, or have veterans 
park at the further part of the--end of the parking lot and 
shuttle them versus employees, that seems to me to be somewhat 
backwards.
    So I am going to be filing legislation--likely along with 
Chairman Roe and hopefully Chairman Dent--and we are working 
with the secretary--to correct that. But I wanted to see--I 
would imagine that it is a unique and particular problem for 
the paralyzed veterans, so----
    Mr. Blake. Well, ma'am, I would say, being a regular user 
of the VA--and I go to the Richmond VA. I have been using that 
VA for 17 years now, and all I have seen is the parking lot 
grow to the point that they have knocked down towns around it 
to build out more parking lot. If you don't go there--if you 
have a 9 o'clock appointment and you are not there at 6:30 or 7 
o'clock you are not parking in the parking lot.
    I can make the argument that that is a reflection of the 
demand being placed on the system. Parking is sort of a 
microcosm of the larger demand for health care services.
    And that is the demand on a facility like Richmond. Many of 
the major VA hospitals are like that.
    I was not aware of the legal challenge you referenced 
there, but it seems kind of silly. I am sure there are some 
liability issues that make it more complicated than I would 
like to believe, but----
    Ms. Wasserman Schultz. Well, the secretary----
    Mr. Blake [continuing]. But there is no question but that 
parking is a serious problem. I mean, many of the facilities 
have brought in valet as an option. All that has done is 
squeeze, you know, drive-up-and-park parking. I mean, it is 
certainly a major issue.
    Ms. Wasserman Schultz. It is hard to imagine what member of 
Congress thought it would be a good idea to prohibit employees 
from being shuttled, but hopefully we are going to be able to 
correct that.

           PARALYZED VETERANS HAVING ACCESS TO CHOICE PROGRAM

    And then the other question I had was how are paralyzed 
veterans experiencing access inside and outside the VA to the 
Choice program?
    Mr. Blake. I would say that primarily our members don't use 
Choice because there is not a whole lot of comparable systems 
to the VA's SCI system of care outside of VA. You do have 14 
model systems of care around the country. The majority of those 
don't even meet CARF certification, which is one of the--sort 
of the overarching rehab certifications used for many of the VA 
SCI systems of care.
    We encourage our members to use VA's spinal cord injury 
system, particularly for annual physicals and preventive care. 
There are barriers and challenges to that.
    But by and large our members have not taken advantage of 
the Choice option. I do know that, much like many of the other 
veterans that have taken advantage, they have struggled when 
they have taken advantage of the opportunity.
    I think one of the common problems our members have seen is 
when taking advantage of the opportunity to use Choice, they 
find that waits are just as long in the community to receive 
care or that the service that they are trying to avail 
themselves of is not necessarily available in the community in 
which they live.
    So I think that in the event of our members using Choice, 
their experiences are not uniquely different necessarily than 
what the larger population that is taking advantage of it have 
experienced.
    Ms. Wasserman Schultz. Thank you.
    Yield back.
    Mr. Dent. Mr. Taylor.
    Mr. Taylor. Thank you, Mr. Chairman.
    Thank you for--appreciate your service, appreciate that you 
are in Virginia, and----

                     EMERGENCY CARE COURT DECISION

    Mr. Blake. Yes, sir. Thank you.
    Mr. Taylor [continuing]. And certainly appreciate your 
advocacy. So thank you very much.
    Just really quick, emergency care in the VA paying by law: 
Can you just expound upon that for people like me who are new 
here and haven't seen that?
    Mr. Blake. So in 2009 legislation was enacted--and I am not 
the subject matter expert, so I will freely admit that--
legislation was enacted that basically obligated VA to 
provide--to pay for your care when you have to get emergency 
care in the community.
    The VA, as I understand it, has interpreted that 
legislation so that they don't--they have not. This gentleman, 
Staab, sued the VA because he had an experience where he had 
had to take advantage of emergency care in the community and 
his bills were not paid. And the court at the federal level 
ruled in his favor.
    The VA is currently appealing a ruling that everyone knows 
they are going to lose. At every level that has already been 
determined.
    I think the secretary maybe understands this, but they 
continue to resist what is the inevitable. And because of their 
resistance, the bill is just continuing to build.
    And so the $10 billion cost is over I think a 10-year 
period, but the current-year cost for the reimbursement is like 
$1 billion. And it is sort of a trickle-up effect, but it stays 
in that realm.
    Bottom line is the VA is on the hook to pay for these 
emergency bills for well over $1 billion each fiscal year now, 
and they are not paying any of that.
    Mr. Taylor. Thank you.
    Thank you, Mr. Chair.
    Mr. Dent. Thank you, Mr. Taylor.
    At this time I recognize Mr. Bishop.
    Mr. Bishop. Thank you very much.
    And welcome, Mr. Blake.

                 CONSOLIDATING COMMUNITY CARE PROGRAMS

    As you are aware, in 2015 the VA delivered a plan to 
Congress outlining steps to consolidate community care 
programs. The plan would consolidate and streamline existing 
community care programs into an integrated care delivery system 
and enhance the way that VA partners with other federal health 
care providers, academic affiliates, and community providers.
    But the Choice and Community Care programs are currently 
funded from different accounts. There seems to be some problems 
with their being funded from two accounts--for example, with 
the Choice being funded from a subsidy-managed account at VA 
and Community Care being funded at the medical center level. 
That can present inconsistency of the implementation there, 
depending on what the local budget is at the community level, 
at the medical center level.
    Can you speak to that? Do you think that the provisions of 
Choice and Community Care programs should be funded from the 
same account, or you think that that would provide better 
services to our veterans?
    Mr. Blake. Well, Mr. Bishop, the I.B. organizations 
generally supported what the VA had laid out as a plan back in 
2015 for its consolidation. We believe that that is a 
reflection of the right way forward.
    Continuing to have clearly defined, separate programs, from 
Community Care over here in VA and Choice, is not the way 
forward. I think VA recognizes that.
    When the VA presented its plan in 2015 to the authorizers 
almost universally the committee supported it. Yet, we seem to 
have reached a point of collective amnesia that they might have 
actually supported that. But I think that is the right way 
forward, and I think the VA has been working towards that end 
for the last year-and-a-half.
    There are a number of legislative authorities that are 
still hanging in the balance that are required to effect those 
changes.
    At the end of the day, the I.B. has supported a singular 
Community Care program. Our policy agenda, which we released 
back at the end of January and can also be found on our Web 
site at www.independentbudget.org, explains our view of how 
that whole integration process should work, our own 
recommendations to affect the implementation of that, and how 
it should work.
    But I think it is not a good idea to continue forward 
indefinitely with Choice over here and Community Care over 
here. If nothing else, you run into the problem we had early 
last year, where the VA took advantage of its Community Care 
and over-obligated itself, and then they were forced to come to 
the Hill and say, ``Hey, we need to borrow money from 
ourselves, which is in the mandatory account of Choice over 
here, just to be able to pay the bills that we had obligated 
for care in the community.''
    So I think that that creates an obvious problem for the VA 
in managing its total Community Care----
    Mr. Bishop. Thank you very much.
    Mr. Dent. Thank you, Mr. Bishop.
    Mr. Blake, thank you so much for your testimony. We 
sincerely appreciate it, and we are going to take the rest of 
your remarks under advisement. So thank you, and----
    Mr. Blake. Yes, sir.
    Mr. Dent [continuing]. We appreciate your testimony before 
us today.
    Mr. Blake. Thank you very much.
    Mr. Dent. At this time I would like to recognize Mr. 
Varela--Paul Varela. Paul is the assistant national legislative 
director at the DAV, Disabled American Veterans.
    So, Mr. Varela, we are pleased to have you, and when you 
are settled and ready we will recognize you for 5 minutes. 
Again, thank you for joining us.
    Mr. Varela. Thank you, Mr. Chairman.
    Mr. Dent. You are recognized for 5 minutes.
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                                         Wednesday, March 29, 2017.

                       DISABLED AMERICAN VETERANS


                                WITNESS

PAUL VARELA, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR
    Mr. Varela. Chairman Dent, Ranking Member Wasserman 
Schultz, and members of the subcommittee, good morning. Thank 
you for providing DAV and our Independent Budget partners with 
an opportunity to discuss our recommendations for fiscal year 
2018 funding requirements essential to the Department of 
Veterans Affairs' ability to efficiently process and deliver 
benefits to veterans, their families, and survivors.
    As one of the co-authors of the Independent Budget, I will 
focus my comments on resource requirements for programs within 
the Veterans Benefits Administration--VBA, and the Board of 
Veterans Appeals.
    Compensation services is responsible for processing claims 
related to disabilities and other non-disability-related 
claims, such as those based on changes in dependency status and 
award adjustments based on veterans returning to active duty. 
Additionally, VBA is responsible for processing local-level 
appeals.
    For fiscal year 2018 the Independent Budget recommends 
increasing staff by 750 new FTEE. This staffing increase is 
needed to address the rising disability rating claims backlog, 
the appeals backlog, and backlog of non-rating-related claims.
    Today VBA is responsible for roughly 380,000 appeals at 
various stages in the appeals process. Of the 750 new FTEE 
request, we recommend that 1,000 FTEE be dedicated to driving 
down the appeals inventory. With this infusion of much-need 
manpower we estimate the appeals inventory could be reduced to 
a manageable level within the next 3 years.
    Next, vocational rehabilitation and employment services, 
VRE, provides critical counseling and other adjunct services 
necessary to enable service-disabled veterans to overcome 
barriers as they prepare for, find, and maintain gainful 
employment. For fiscal year 2018 the Independent Budget 
recommends increasing staff by 266 new FTEE.
    Over the past few years VRE program participation has 
increased steadily without commensurate staffing increases. 
Furthermore, as VBA continues to expand VRE eligibility to more 
service-connected veterans due to increased claims processing 
and changes in law, we project that total program participation 
for fiscal year 2018 will grow by at least 5 percent, for a 
total caseload of close to 155,000 participants. Therefore, 
commensurate staffing levels are critical to ensure VRE 
services are delivered in a timely and efficient manner to 
facilitate successful program participation.
    Finally, the Board of Veterans Appeals must be permitted to 
on-board the full complement of FTE that was authorized for 
fiscal year 2017. Congress authorized the Board of Veterans 
Appeals a total of 922 FTE for fiscal year 2017. To date, they 
have only been able to increase their FTE by roughly 880.
    The issue of timely and efficient appeals processing has 
received considerable attention and been the subject of much 
debate--rightfully so. On average, it can take close to 5 years 
to get a resolution on an appeal that is being considered by 
the Board of Veterans Appeals.
    As I am sure we can all agree, subjecting veterans to a 5-
year wait period in any capacity is simply unacceptable, and 
they are counting on us to correct this inequity.
    However, there is some good news. Congress, VA, the 
Independent Budget partners, and other stakeholders have been 
working diligently to reform the appeals process to make it 
less complicated and more efficient overall. This reform has 
often been referred to as ``the new framework.''
    Legislation has been introduced in both the House and 
Senate, and we are hopeful it will be enacted into law this 
year. We believe this will provide veterans with more timely 
and accurate decisions while protecting their rights.
    However, regardless if appeals reform legislation becomes 
law, an essential component going forward will be adequate 
resources for the Board of Veterans Appeals to process not just 
appeals within the new framework, but processing equitability 
for appeals within the current inventory in a timely and 
efficient manner.
    We must ensure that appeals languishing within the current 
system are not treated as a lesser priority in favor of a more 
expeditious appeals processing within a new system. Each and 
every veteran within the appeals process must be treated fairly 
and equally.
    Chairman Dent, Ranking Member Wasserman Schultz, and 
members of the subcommittee, thank you again for this 
opportunity to present the Independent Budget's resource 
recommendations for fiscal year 2018, and I look forward to 
your questions.
    [The information follows:]
    
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    Mr. Dent. Thank you, Mr. Varela.

    ADDING MORE VBA STAFF OR THE USE OF TECHNOLOGY

    And just wanted to ask one question: The Independent Budget 
includes a large fiscal year 2018 request for more VBA staff. 
Do you feel that additional staff are the ultimate answer to 
keeping the disability claims backlog down, rather than the use 
of technology?
    Mr. Varela. They are symbiotic. They are both interrelated.
    You are going to need--as we can see, VBMS has given the VA 
quite a lift in claims processing. They were able to keep 
processing record number of claims each year.
    But in addition to that, while they were making those 
strides they diverted a lot of their workforce from the appeals 
workforce to process those claims. So what that tells you is 
that yes, you have the I.T. component that is helpful, but you 
still need the manpower as well, and these two things are 
interrelated.
    Mr. Dent. Thanks.
    I would recognize the ranking member, Ms. Wasserman 
Schultz.

                  HIRING FREEZE AND PROCESSING CLAIMS

    Ms. Wasserman Schultz. Thank you, Mr. Chairman.
    Mr. Varela, given the administration's hiring freeze and 
your organization's position that staffing levels need to be 
addressed, how does the hiring freeze affect our ability to 
achieve that goal?
    Mr. Varela. It is my understanding that recently some 
positions within the Board of Veterans Appeals have been 
exempted so they can reach their full complement of 922 FTE. 
They probably won't get all of that, but they will get most of 
it.
    Without the bodies to do the work, every day that is 
delayed in hiring new personnel to do the work is an extra day 
of delay in the claims and appeals process.
    Ms. Wasserman Schultz. So is it your impression that the 
claims process is negatively impacted by the hiring freeze?
    Mr. Varela. Yes, it is.
    Ms. Wasserman Schultz. Thank you.
    Mr. Dent. Mr. Valadao.
    Mr. Valadao. Thank you very much for your service and for 
being here today.

       TRANSITIONING SOLDIERS TO OBTAIN LICENSES AND CREDENTIALS

    In the Independent Budget's agenda that you released this 
year you mentioned the need for Congress and the Department of 
Defense to work together to assist soldiers who are 
transitioning from civilian life to obtain occupational 
licenses and credentials. Recently the senior enlisted 
noncommissioned officers from each service testified before 
this committee and talked extensively about credentialing being 
one of their top priorities in helping prepare servicemen and 
women to transition to civilian careers.
    Now, I know some progress has been made in the Department 
of Defense, but to your knowledge, has the VA been working with 
the services to assist with this issue? And in your opinion, 
how can the VA work with the services and States to streamline 
the process for transitioning soldiers to obtain these licenses 
and credentials?
    Mr. Varela. I believe the VA has been very supportive of 
that cross-certification. What it really boils down to is the 
licensing and certification that you get in the service has to 
translate to what is acceptable within the States.
    So it is going to be a matter of not just what we can do 
here with the VA--which they are very supportive of that; DAV 
also has a resolution that calls for Congress to enact 
legislation to make that happen--but we have got to get that to 
trickle down to the States for them to say, ``Yes, that 
credentialing is acceptable,'' so that a nurse from the 
military can simply just come out of the military and be a 
nurse in any State.
    Mr. Valadao. And yes, you pointed out the States, but here 
at the federal level what do you think we can do to be of 
assistance to streamline that or--there is probably not a whole 
lot.
    Mr. Varela. Yes.
    Mr. Valadao. A lot of it falls on the State.
    Mr. Varela. Here at the federal level we have to ensure 
that Congress makes it a requirement for the DOD to say that, 
``You will outline your certifications to either match what is 
acceptable within the State or somehow establish those 
partnerships,'' you know, force them to say, ``We need you to 
set up a program that allows those skills and credentials to be 
translated directly into the community.''
    Mr. Valadao. Well, thank you.
    And I yield back.
    Mr. Dent. Thank you, Mr. Valadao.
    Recognize Mr. Bishop.
    Mr. Bishop. Thank you.
    Welcome, Mr. Varela.
    The chairman emphasized--and, of course, I am equally 
concerned about the overall rise in the disability claims and 
the growing appeals claims backlog. And, of course, I agree 
with you that the I.T. investments will supplement and augment 
addressing that.

          LIMITATIONS ON APPEALS WHILE THE RECORD IS SUBMITTED

    But one of the things that the VA has recommended and I 
think the authorizing committees have been considering, with 
which I have had some concern, is that they want to limit the 
appeals and the opportunity for veterans to supplement the 
record while it is pending, once it has been submitted, which 
is another opportunity for veterans to provide more current 
medical information to bolster their claim. And, of course, the 
department has said that that adds to the backlog and that it 
makes it more difficult for them to alleviate that backlog.
    So there is some tension there between making sure the 
veteran gets full consideration, and also expediting the 
appeals or the reconsideration. What is your view in terms of 
how to deal with that situation?
    I have always, and I think the VA has historically, wanted 
to resolve that in favor of the veteran by allowing the veteran 
to submit any information at any time which would allow the 
more favorable consideration of their claim. How do you feel 
about that and the legislation now that is moving forward that 
would limit the veteran's ability to do that?
    Mr. Varela. Okay. So there are two tracks there.
    One is the current environment and a veteran's ability to 
submit evidence. In the current environment that has to be 
maintained because you are dealing with crucial benefits that 
can be awarded, effective date issues. And as you mentioned, 
sometimes it is not easy for veterans to come up with the 
evidence at a particular juncture, so they need to have an 
opportunity to submit that.
    And we understand it is additional work for the VA, but it 
is work on behalf of disabled veterans. So that is where the 
efforts should be.
    In the new environment, in this proposed new framework, 
there are still opportunities to submit evidence, particularly 
if a veteran wanted to go to the Board of Veterans Appeals. It 
is limited. We are working out the finer details and what 
happens if you submit evidence after that, but we are very 
comfortable that we will still be able to preserve that 
effective date to that filing and allow that evidence to be 
considered either at the board or at the VBA level.
    Mr. Bishop. Yes. That is what the rub is, and I don't quite 
know how to resolve that because my caseworkers have been able 
to supplement the records many times with medical evidence that 
the veteran didn't initially have or didn't submit and end up 
with a positive outcome.
    But if they are cut off and shut out from being able to do 
that until after a decision is made then they have got to start 
all over again, which, again, is a protracted work for the VA 
as well as anxiety for the veteran.
    Mr. Varela. Yes.
    Mr. Dent. Thank you, Mr. Bishop.
    And, Mr. Varela, we appreciate your testimony and appearing 
before this subcommittee today. Thank you very much.
    Mr. Varela. Thank you, Mr. Chairman.
    Mr. Dent. At this time I would like to invite Carlos 
Fuentes, director, National Legislative Service for the 
Veterans of Foreign Wars, VFW. So we welcome Mr. Fuentes, 
Carlos Fuentes, before us today.
    And with that, you are recognized for 5 minutes.
                              ----------                              --
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                                         Wednesday, March 29, 2017.

                        VETERANS OF FOREIGN WARS


                                WITNESS

CARLOS FUENTES, DIRECTOR NATIONAL LEGISLATIVE SERVICE
    Mr. Fuentes. Chairman Dent, Ranking Member Wasserman 
Schultz, and members of the subcommittee, on behalf of the men 
and women of the VFW and our auxiliary, I do thank you for the 
opportunity to present our views on VA's budget.
    I would like to first start by thanking you for your hard 
work last year on fiscal year 2017 appropriations. And because 
of your hard work, the MILCON-VA appropriations bill was the 
only one to have completed regular order and, as a result, VA 
is the only department with full fiscal year 2017 
appropriations.
    Mr. Dent. Could you say that again? [Laughter.]
    Mr. Fuentes. And we have seen the impact on the number of 
departments who are operating on the continuing resolution, and 
no other sticks out more than DOD. And I am sure you are also 
tracking that part of the military construction aspect of the 
jurisdiction.
    Yet, those appropriations levels that were included in the 
conference report were more than $600 million short of the 
administration's request and significantly less than the 
Independent Budget recommendations. We know, however, that your 
ability to properly fund VA appropriations accounts are 
severely limited by outdated budget caps established by the 
Budget Control Act of 2011 and subsequent budget agreements.
    The threat of sequestration and draconian spending cap 
limits our Nation's ability to provide servicemembers, 
veterans, and their families the care benefits they have 
earned. The VFW calls on this subcommittee to join our campaign 
to finally end sequestration and do away with federal budget 
processes based on arbitrary spending caps.
    The VFW is glad to see President Trump has proposed a 6 
percent increase in VA's fiscal year 2018 budget. However, we 
feel that the proposal falls a bit short.
    And my colleague from PVA has described our recommendations 
for VA health care, and I would like to associate the VFW with 
those remarks.
    I would like to focus my testimony on VA's need for capital 
infrastructure. For more than a decade the I.B. VSOs have 
warned Congress and VA that perpetual underfunding will allow--
would allow VA infrastructure to erode while its capacity to 
meet demand has swelled from 81 percent in 2004 to as high as 
120 percent in 2010.
    The events of 2014 and subsequent access issues at VA 
health care facilities have illustrated how chronic 
underfunding of VA capital infrastructure and the lack of 
capacity to keep pace with demand has resulted in VA rationing 
care and veterans waiting too long for the care that they have 
earned.
    The I.B. VSOs are working with VA to reform its 
construction process so facilities can be delivered on time and 
on budget. Previous errors must be corrected to ensure the 
issues that occurred in Aurora, Colorado never occur again. 
However, this subcommittee must not punish veterans who are 
awaiting desperately needed health care facilities because of 
the incompetence of bureaucrats who no longer work at VA
    Currently, VA has 24 partially underfunded construction--
major construction projects, which need a clear path to 
completion, some of which have been in the works for more than 
12 years. VA's fiscal year 2017 priority list, which includes 
seismic corrections, cannot take a systemic pause while 
Congress and VA decides how to manage capital infrastructure 
long term.
    VA will need to invest more than $3.5 billion to complete 
all 24 partially funded projects. Of the top five projects, 
many of them are seismic deficiencies and part of VA's core 
missions, such as mental health and spinal cord injury centers.
    The I.B. VSOs recommend that Congress appropriate at least 
$1.5 billion for major construction in fiscal year 2018. This 
amount would ensure--will fund the next phase or fund through 
completion of the existing projects and begin advance planning 
and design development for VA's major construction projects.
    I would also like to quickly mention and thank the 
subcommittee, and especially Chairman Dent, for your leadership 
on expanding VA's fertility treatment options. VA, as we know, 
has announced that they will begin providing these treatments 
soon. However, the authority is limited and folks who--or 
veterans who aren't able to use assisted reproductive 
technology or adopt a child before the end of fiscal year 2018 
will be left to bear the full cost of starting a family.
    And these are severely disabled servicemembers who have 
lost their ability to reproduce due to their service, and we 
feel that that is unacceptable. We are working with the 
authorizing committees to make this authority permanent, but we 
ask that you continue to carry that authority into fiscal year 
2019 and 2018 so that these veterans aren't left behind and 
that they continue to have that opportunity.
    Mr. Chairman, thank you for the opportunity to testify. 
This concludes my remarks, and I am happy to answer any 
questions you or the members of the committee may have.
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    Mr. Dent. Thank you, Mr. Fuentes, for your testimony, and 
thank you, too, for your kind words about the in vitro 
fertilization, IVF, provision that was included. A lot of 
people were very interested in that--Mr. Larsen I know, Ms. 
Brownley, Mrs. Roby, and many others all, you know, were very 
strong advocates. So thank you for your good words on that.

   INFRASTRUCTURE NEEDS WHEN NON-VA CARE IS INCREASING

    Also, just wanted to highlight the enormous infrastructure 
needs of the VA and how it is struggling, given all the aging 
buildings and the shifting veteran population. We know that 
last year the VA calculated its infrastructure shortfall as 
being as high as about $50 billion. Setting aside the problem 
that we are unlikely to be able to provide the funding 
required, is it appropriate to continue to plan a massive VA 
infrastructure effort when VA is increasing its use of non-VA 
care that uses private facilities?
    Mr. Fuentes. What we want to make sure is not forgotten or 
ignored when discussing the Choice program and Community Care 
is VA's ability to provide direct care, right? We have 80 
percent of the VFW's membership relies on VA for their health 
care, and the community is part of the solution.
    As we increase VA's funding for Community Care we cannot 
ignore its medical services appropriation and the impact that 
construction has on VA's ability to meet the needs.
    The lack of funding for VA's capital infrastructure has 
really resulted in a lot of these wait-time issues because it 
takes way too long for VA to construct these facilities. We 
need to reform its capital infrastructure process, but we can't 
ignore that they need the funding to continue to expand.
    Mr. Dent. Ms. Wasserman Schultz.
    Ms. Wasserman Schultz. Thank you.

                         IN VITRO FERTILIZATION

    Just to underscore your point about in vitro fertilization 
and other assisted reproductive technologies, for those 
unfamiliar with the process--and I won't go into any of the 
details, but it often does not work the first time, 
particularly for individuals who have a service-related injury 
and whose infertility is caused by their service or their 
injuries.
    So leaving it in place just for one fiscal year and having 
it expire would be devastating to people who are in the midst 
of a fertility cycle because these are--this is a process that, 
as you go through it, is dependent on nature's timing, not our 
fiscal year calendar.
    So it is really important that we make sure that we don't 
cut off the access to procedures that our service-related 
injured veterans might be in the midst of, denying them the 
opportunity to start their families.
    So I don't have a question. I just want to make sure you 
know you have my support.
    Mr. Dent. Thank you.
    Mr. Taylor.
    Mr. Taylor. Thank you, Mr. Chairman.
    And thank you again for your service and your advocacy, and 
yours as well, too. Go Navy. And I am Post 392. Thank you. 
Lifetime member.

                MENTAL HEALTH CARE AWARENESS INITIATIVES

    Quick question. Two things. First, you were mentioning 
spinal cord injuries. I didn't hear you talk about TBI or PTSD. 
Can you just mention if there are any initiatives with VFW and 
what you are supporting for increased help in those arenas?
    Mr. Fuentes. Sure. My testimony, as a co-author of the 
I.B., focused on the infrastructure needs of VA, but we 
certainly have made mental health care awareness a priority for 
the VFW this year.
    Our national commander actually launched a campaign to 
really change the direction and the narrative around mental 
health because there is a stigma around mental health where 
veterans fear going to receive the mental health care that they 
need. And it is really just as any other type of health or any 
other body part, it needs to heal. You need treatment to get 
better.
    So we certainly support expanded mental health care 
services and also believe that there is this need for outreach 
in order to really de-stigmatize mental health.
    Mr. Taylor. Thank you.

                    USE OF VA VERSUS COMMUNITY CARE

    So with the understanding that there is a shortfall in the 
construction budget and construction plays a big impact, 
potentially, on wait times; also with the understanding that 
the VA, of course, is responsible for our veterans' care, does 
the VFW support more use of private care, whether it might be 
redundancies or duplication of primary care services, for 
example, where there are private facilities that are right 
there? Not, of course, the injuries that are unique to 
veterans, but other private care that is accessible and easily 
accessible. Do you guys support that or are you are saying no?
    Mr. Fuentes. Yes, we do.
    So just to be clear, VA needs to really conduct a manpower 
capacity analysis in each community. Health care is local--you 
know, there are areas in the country where it will take 6 
months in the private sector to receive a dermatology 
appointment. In other areas like San Diego it is more readily 
available.
    So VA needs to see what the demand is for veterans in each 
community and see what its capacity to meet that demand, but 
also incorporate the private sector, but other public health 
care facilities like DOD, Indian Health Services, and federally 
qualified health centers, so to take that integrated approach 
so you are not duplicating and you are leveraging the best 
capacities in that community.
    Each community is going to look different. So sometimes 
there may be more private primary care, and in other areas 
private primary care may not be readily available so VA will 
have to build that.
    Mr. Taylor. Thank you.
    Thank you, Mr. Chairman.
    Mr. Dent. Thank you, Mr. Taylor.
    Mr. Bishop.
    Mr. Bishop. Thank you very much.
    Again, welcome, to you, Mr. Fuentes.

                  CONSTRUCTION OF RESEARCH FACILITIES

    I am sure that Ms. Kelly will probably touch on this when 
she testifies, but I would like to know what the VFW's position 
is with regard to the construction of research facilities.
    In 2012, at the request of Congress, the department Office 
of Research and Development did an in-depth study and an 
analysis of the physical condition of the VA's aging research 
infrastructure, and they reported that the average VA building 
that houses research laboratories is over 50 years old.
    Of course, the American Psychological Association argues 
that VA lacks the state-of-the-art research facilities and that 
modern research can't be conducted in facilities that closely 
resemble a high school science lab.
    As a result, they are recommending $50 million for five 
major research facility construction projects and $175 million 
for minor construction maintenance projects. What is VFW's 
position on that? Do you support that analysis and that 
request, in light of the other request for major construction 
that is a lot more expensive?
    Mr. Fuentes. We fully support. Research is one of VA's four 
core missions, and you are absolutely right. I have also 
visited some of those research facilities that are out of date.
    You know, fortunately there are some that you see as an 
examples of what state-of-the-art research facilities should 
look like and, as a result, you see VA making a lot of progress 
and really leading the industry, in many respects, when it 
comes to research when they are given the proper tools. And 
that just speaks to, again, the lack of attention and, frankly, 
resources devoted to VA's capital infrastructure.
    Again, not ignoring the fact that we need to make sure that 
buildings are delivered on time and on budget, but the need for 
resources cannot be ignored.
    Mr. Dent. Thank you, Mr. Bishop.
    And, Mr. Fuentes, we thank you for your testimony. We 
really appreciate all that you are doing. Thank you very much.
    Mr. Fuentes. Thank you, Mr. Chairman.
    Mr. Dent. At this time I would like to call to the witness 
table Dr. Heather O'Beirne Kelly. She represents the American 
Psychological Association.
    Dr. Kelly. Good morning, Chairman Dent.
    Mr. Dent. Dr. Kelly, welcome, and you are recognized for 5 
minutes.
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                                         Wednesday, March 29, 2017.

                   AMERICAN PSYCHOLOGICAL ASSOCIATION


                                WITNESS

DR. HEATHER O'BEIRNE KELLY, DIRECTOR VETERANS AND MILITARY HEALTH 
    POLICY
    Dr. Kelly. Thank you.
    Chairman Dent, Ranking Member Wasserman Schultz and members 
of the subcommittee I am Dr. Heather Kelly, a psychologist and 
director of veterans and military health policy at the American 
Psychological Association. I also come from a family of career 
military officers and combat veterans, so I do care deeply 
about these issues of veterans care, both personally and 
professionally.
    As you may know, APA is our country's largest scientific 
and professional organization, with more than 115,000 
psychologists. And the Department of Veterans Affairs, or the 
VA, is the largest single employer of psychologists.
    VA's psychologists work both as research scientists and 
clinicians committed to improving the lives of our Nation's 
veterans. As the largest provider of training for 
psychologists, the VA also plays a vital role in equipping the 
mental health workforce to provide culturally competent and 
integrated mental health services to veterans and their 
families.
    I have provided more detail in APA's written testimony, so 
I would like to focus on three priority areas today and get to 
Congressman Bishop's question in particular, and I would like 
to also echo the priorities of my VSO colleagues who have gone 
before me. We agree on all of the same issues and, in fact, we 
were one of the members who co-wrote the research section of 
the I.B.
    So, Congressman Bishop, we thank you for mentioning our 
concerns about research facilities, and that is also echoed in 
the Independent Budget. You are not going to attract the 
highest-quality psychologists, particularly who are often both 
researchers and clinicians, to the VA unless they can do their 
research in facilities that at least have computers. We are not 
even talking about really high tech in some cases, but really 
that have desks and computers. So thank you for calling 
attention to that issue.
    So the three priority areas I would like to focus on are VA 
research, clinical care for veterans, and the scope of practice 
for VA psychologists.
    In terms of research, APA joins the Friends of VA Medical 
Care and Health Research coalition, or FOVA, in urging the 
subcommittee to provide $713 million in fiscal year 2018 for VA 
medical and prosthetic research. As my colleagues have 
mentioned, a strong VA psychological research program provides 
the scientific foundation for high-quality care within the VA 
system, which is absolutely vital for serving veterans 
suffering with post-traumatic stress disorder, PTSD; traumatic 
brain injury, or TBI; substance abuse; aging-related and other 
disorders requiring physical and psychosocial rehabilitation; 
and, of course, suicidal ideation.
    We have better treatments now for all of these issues 
because of your prior investments in VA intramural research, 
and we desperately need to further advance our knowledge of 
these signature wounds of war to alleviate veteran suffering--
and not only to alleviate suffering, but to help them regain 
lives of purpose and of joy.
    In terms of clinical care, APA echoes the many concerns and 
suggestions of the VSOs regarding VA mental health services 
outlined in their Independent Budget, as I have mentioned. We 
also share VA Secretary Shulkin's recently announced priorities 
related to enhanced suicide prevention efforts, extension of 
mental health care to veterans with other-than-honorable 
discharges, and expansion of caregiver benefits to include pre-
9/11 veterans' families.
    These were the initiatives, as you, I am sure, know must 
come with more resources to be implemented. If you open the 
doors wider, you need more money to serve those people whom you 
have invited in.
    We urge Congress to provide ample resources for VA mental 
health programs and the VA psychologists who serve veterans 
through increased hiring of VA psychologists--and I would ask 
that we finally make the move and move psychologists into the 
Title 38 hiring authority; by holding community partners and 
contractors to the high standards of quality assessment and 
care that exist in the VA; increasing support for primary care 
mental health integration models and telemental health 
services; and replacing the scheduling package in the 
electronic medical record. All of these are critical for 
improving patient experience and patient care within the VA.
    And finally, within the terms of the VA psychologists' 
scope of practice and improving mental health care access at 
the VA, I strongly urge you to direct the VA secretary to grant 
specially trained VA psychologists prescriptive authority 
analogous to that granted by the Department of Defense almost 
20 years ago. DOD has had zero adverse effects or complaints 
reported during that entire period, and if any of you are 
familiar with health care, zero adverse effects and zero 
complaints are unheard of.
    DOD psychologists--medically prescribing psychologists--
have served thousands and thousands of active duty military 
personnel. This is another safe, effective way to increase 
mental health care access, and the VA is behind in granting 
this authority to appropriately trained psychologists.
    I should mention, these are psychologists like me, who have 
master's degrees and Ph.D.s and then go out and get a separate 
master's in pharmacology on top of their existing M.A. and 
Ph.D. These are really well-trained psychologists and the only 
doctoral-level professionals in the VA who do not have 
prescribing authority.
    As I mentioned, VA is behind in granting this authority, 
and behind not only DOD but behind States like Louisiana, 
behind territories like Guam, and behind the tribal 
reservations of Indian country in granting this prescribing 
authority.
    A veteran in Pennsylvania, a veteran in Florida, a veteran 
in Georgia, a veteran in Virginia should have access to the 
same high-quality mental health care as a nonveteran in 
Louisiana or Guam.
    And remember that the power to prescribe is also the power 
to un-prescribe medication, which is a particularly important 
issue facing both civilian and veteran populations across the 
country.
    So I urge you to direct the secretary at the very least to 
begin with a pilot program in VA, particularly in VA medical 
centers with the most dire mental health care access needs, and 
those tend to be the rural areas.
    In conclusion, the VA, in the face of increasing demand for 
mental health care and recognized access difficulties in rural 
areas in particular, must remain a pioneer in the health care 
arena by allowing specially trained and certified psychologists 
to work at the full scope of their practice and to serve 
veterans with the expertise and dedication they already employ.
    Thank you for the opportunity to testify, and I am happy to 
answer questions.
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            PREVENTING VETERAN SUICIDES

    Mr. Dent. Thank you, Dr. Kelly, for your testimony. We very 
much appreciate your being here.
    I only have one quick question. In our hearing last week 
with the VA inspector general we heard about the problems with 
the VA suicide hotline.
    Dr. Kelly. Yes.
    Mr. Dent. More generally, I guess, how does your 
association think the VA is doing in its efforts to prevent 
veteran suicide?
    Dr. Kelly. In general, VA mental health care is superior to 
any other mental health care anywhere in the world. I have 
veterans in my family, and if they had mental health issues I 
would send them immediately to the VA.
    So in general, superior care. All the reports coming out of 
RAND and other reports you have seen, VA mental health care is 
either equal to or superior to that you can get often in the 
civilian sector.
    Suicide prevention is as important as it is difficult. It 
is a very low base rate behavior that we desperately want to 
prevent, and I would say that VA has made remarkable strides 
into lowering the rates of veterans who come to the VA for 
their mental health care. The suicide rate for veterans who get 
care outside of the VA is much higher, so we want them to come 
to the VA for their care.
    There are issues with the suicide hotline that need to be 
resolved. There are issues with access more than with the 
quality of VA mental health care, so if we can increase 
access--and there are a variety of ways to do that; pulling 
apart the VA's integrated system is not one of them.
    We are watching very carefully the hotline in particular. I 
think most of the issues have actually been with the civilians 
who call the prevention line and are more often put on hold 
than the veterans.
    So we have issues with the suicide hotline in general, but 
are watching it very carefully. And I think they are being 
taken very seriously by the VA.
    Thanks.
    Mr. Dent. Thank you, Dr. Kelly.
    Ms. Wasserman Schultz.

                      TRAINING FOR CRISIS HOTLINE

    Ms. Wasserman Schultz. Thank you, Mr. Chairman.
    Just to follow up on the chairman's line of questioning, we 
did extensively ask the I.G. questions about problems with the 
crisis hotline, and training appears to be one of the 
significant obstacles that they have.
    Have you given them any guidance on how they can improve 
their training? What it appears is that there is very 
inconsistent training from the national hotline to the local 
crisis lines that are housed at each medical center.
    Dr. Kelly. And that is a classic issue, frankly, and there 
are a couple things I would like to say about that. One is it 
may seem unrelated, but some of the restrictions on federal 
employee conference attendance and travel have actually 
affected VA training rather substantially, and so anything you 
all can do to get rid of the restrictions on federal employees 
of all kinds, but VA federal employees, traveling--there were 
things in Florida happening where a number of psychologists 
were hired a couple of years ago by the VA and weren't allowed 
to travel six miles down the road in their own car for the 
mandatory new mental health training.
    So there are some really crazy ramifications of some of 
those rules, so I am not surprised that training is an issue.
    Part of what you all need to know we are all struggling 
with is that VA has always provided community care, and this is 
an issue of care when more people in the communities are 
staffing those hotlines. It is very important that all 
community partners be trained and held to the same standards of 
assessment and care as VA staff and mental health professionals 
are, and right now that is not the case.
    And so I echo your concern about training and maintaining 
and assessing quality of care.

        TRAINING THAT VA PROVIDES VERSUS PRIVATE SECTOR TRAINING

    Ms. Wasserman Schultz. And speaking of training, that was 
actually my next question in terms of the difference in 
training that the VA provides versus the private sector 
training.
    Are they comparable? You alluded now that they are not. 
Where would you think there need to be improvements on the VA 
side of training, or is the VA already superior, not just on 
the crisis line, but across the board?
    Dr. Kelly. Thank you. It is a great question and one that 
we are really involved in trying to tackle, because obviously 
at the American Psychological Association, I am in charge of 
the side that deals with military and veteran populations, but 
we certainly care very much about our civilian providers.
    This civilian-military divide--this is one of the places 
where it shows. And so we have been very involved with partners 
like PsychArmor, the VA itself, who have a number of modules of 
training in military culture and veteran cultures, thorough, 
that have been developed and vetted and provided for free to 
civilian providers. PsychArmor now has MOUs with all of the 
major health care providers--civilian health care providers and 
offers corporations, staff, counseling centers at colleges 
training in military culture and veterans culture for that 
exact reason, is to begin to bring some of the civilian 
providers at least some more competence in that area, which is 
completely separate from some of the things you have seen, 
again, in some of the RAND reports.
    ``Ready to Serve'' is the most important recent report 
showing that even on some of the evidence-based 
psychotherapies, which APA obviously recommends for treatment, 
in particular with PTSD and depression and anxiety, civilian 
providers are behind VA providers in their provision of 
evidence-based mental health care. And so when we talk about 
moving veterans into getting more community care, I have very 
deep concerns about the quality of the care that they would 
receive there.
    And so we are working very hard to make sure that any 
relationship that the VA has with community providers must 
entail training and assessing and constant monitoring of that 
care in the community to make sure that our veterans are 
getting the quality of care that they deserve.
    Ms. Wasserman Schultz. Thank you.
    Mr. Dent. Mr. Taylor.
    Mr. Taylor. Thank you, Mr. Chairman.
    Thank you for what you do and all those degrees that you 
got. [Laughter.]
    Thanks a lot. We really appreciate it.

           LACK OF UNIFORMITY IN SUICIDE PREVENTION POLICIES

    Quick question along the lines of the suicide hotline. That 
is something that has been talked about, but one of the other 
things that we talked to the I.G. with, that my office actually 
has requested a report on is not just the suicide hotline but 
the physical walkups, people come to the facilities and say, 
``Look, I am suicidal,'' or they exhibit those tendencies or 
something like that, and the non-uniform-type policy with the 
VA. One of the things that the I.G. said was that there is 
decentralized across the whole VA spectrum.
    Has APA helped with that in terms of trying to create a 
uniform policy for the VA across everywhere that says anyone 
who comes in, that they are not turned away and the unfortunate 
thing happens, potentially?
    Dr. Kelly. Yes. I have been very vocal--Dr. Shulkin will 
tell you--with him personally and with his staff for many years 
on this issue in his previous role and now in his current role. 
My understanding is that any veteran who calls or appears at a 
VA medical center with urgent self-harm or harm-to-others 
concerns will be seen immediately.
    There are some metrics there that we are watching very 
carefully--that is supposed to be true of all VA medical 
centers. I am not sure if they have reached that at this point. 
But same-day urgent care absolutely is the standard that VA is 
looking to meet.
    And I think sometimes the issue--two things: One, that is 
precisely why you also want the primary care mental health 
integration. You want someone who is much more likely to walk 
up into an E.R. or to come through primary care to get 
automatic assessment.
    You know, a lot of these people are not going to tell you--
some will, but some won't tell you and a really quick but 
really careful diagnostic assessment of anyone that comes in--
frankly, we find out about suicidal behavior much more often by 
asking about sleep issues and some other concerns. I mean, it 
is the gateway into a lot of health care problems for veterans 
in particular.
    So we want psychologists in most VA facilities--in all of 
the big ones, and we are trying to make sure it goes all 
throughout the VA. There are psychologists embedded in primary 
care for those reasons of stigma that you have heard about. You 
know, someone doesn't have to walk to another floor with a door 
that says ``mental health'' above it, but literally gets a warm 
handoff to a physician or a psychologist standing right there 
to talk about those issues.
    So same-day access is vital, and I think it is certainly a 
VA standard.
    What is often the issue is the second appointment, so how 
quickly can that veteran then be seen, depending on what the 
diagnostic assessment is, for the next kind of care--if it is 
outpatient, for the next level of outpatient care? There are 
never enough inpatient beds anywhere in the entire U.S. health 
care system, but in the VA also we need more inpatient beds for 
psychiatric issues.
    But certainly same-day access, and this is an issue I work 
on every day with the VA and the VA psychologists in 
particular.
    Mr. Taylor. Thank you very much.
    And just we would love to speak with you offline about the 
pilot program. So thanks. Thanks a lot.
    Dr. Kelly. Thank you.
    Mr. Dent. Thank you, Mr. Taylor.
    Mr. Bishop.
    Mr. Bishop. Thank you very much.
    And, Dr. Kelly, thank you so much, and we appreciate your 
insights as well as your level of training, particularly in 
pharmacology.
    Dr. Kelly. Well, I didn't go get the extra one in 
pharmacology. My colleagues have, but I can talk to you but I 
can't give you any medication.
    Mr. Bishop. Okay. That level of training and becoming a 
pharmacologist is probably unique among the VA psychologists--
--
    Dr. Kelly. Yes.
    Mr. Bishop. We, at the committee, have to deal with the 
tension between scope of practice issues, the professional 
associations and the VA, that often has difficulty getting the 
high-level professionals in the specific disciplines. And so 
the prescribing authority that you recommended sometimes brings 
us into conflict with the professional associations, the M.D.s, 
the medical doctors who say that, ``No, no, they don't need to 
have that.''
    And so we get in the middle between what is the best care 
for veterans and what will protect veterans, versus what is 
most convenient and most economical for the VA. So that is 
something that we need your help in dealing with.

                    CARE FOR SEXUAL ASSAULT VICTIMS

    But I wanted to explore another issue with you, 
particularly as a psychologist. We are now experiencing the 
first generation of women who have served in combat roles, and 
many of them will return home with the same psychological scars 
as men.
    But according to the Department of Veterans Affairs, women 
have a higher risk of exposure to sexual harassment and sexual 
assault than men, which may lead to trauma. Furthermore, many 
of the women will be in their teens and their early 20s when 
this happens.
    In your opinion, is the VA adequately postured to ensure 
that there is adequate access to quality care for women 
veterans to deal with these myriad of issues that they will be 
experiencing in escalating numbers going forward?
    Dr. Kelly. Let me touch on your first question and then 
your second.
    In terms of the first question and the turf issues between 
medicine and other disciplines for whom prescribing authority 
is appropriate and the fullest extent of our practice, I will 
tell you what I told a young staffer who was trying to work 
with me on this issue: Regardless of what you may hear from the 
medical societies, many of whom have been supportive of our 
prescribing authority in the States, in Illinois in particular, 
I refuse to do turf battles over people who have served in 
actual battles.
    So that is something that people in associations need to 
get over and deal with, and I care about what care the veterans 
get. And if you have a psychologist in the Department of 
Defense who can prescribe medication and other kinds of 
therapy--which are always going to be the first attempt for us; 
we are never going to go to medication first, and that is 
something I think that is incredibly valuable--they can walk 
across the hall in El Paso from seeing a DOD psychologist and 
can't see a VA psychologist once that member is now a veteran 
who can provide the same service. That doesn't make any sense 
to me.
    But the turf battles are purely that, and we need to get 
over that.
    In terms of the second question, much more serious question 
of sexual assault and sexual harassment in the military for 
both men and women, but because women are increasing in numbers 
and increasing percentage of the services and now the veteran 
population, it is a massive problem and we are very concerned 
about it.
    In terms of the VA's capacity to handle, I have seen great 
strides in terms of their establishment of the women's office. 
They have women's research programs going that are just 
exquisitely set up. So I am very impressed with what I see.
    Certainly, you know, women veterans' suicide rates are much 
higher than the cohort of women in the civilian population, 
which should not be a surprise to us. Most people who die by 
suicide die with guns, and women civilians don't tend to have 
guns or be as accurate with guns, and women veterans are 
because that is the nature of their work.
    So we have our work cut out for us to address the issue of 
guns and suicide in the veteran population very directly 
without being shy about it. I think that the VA is making some 
strides in that area as well, but women veterans need more 
access, just like any other issue, be it fertility-related or 
mental health-related. Those are often interrelated.
    There need to be enough mental health professionals within 
the VA to see them, and so it always comes back to just the 
staffing level.
    Mr. Bishop. Thank you.
    Dr. Kelly. Thank you.
    Mr. Fortenberry [presiding]. Thank you, Dr. Kelly.
    I am Congressman Fortenberry from Nebraska and I am pinch-
hitting for the chairman for a moment, but I have a question, 
as well. Before I enter it in mind, you said sexual assault is 
a massive problem. Would you unpack that a little bit more, 
please?
    Dr. Kelly. So in the civilian population and the veteran 
population, certainly rates of sexual harassment are quite high 
and sexual assault I think is on the minds of many of us, in 
particular in relation to the military with some of the issues 
going on on the online issues that we are facing.
    Mr. Fortenberry. With the appropriate attentiveness to this 
problem and the growing awareness, and the creation of 
infrastructure and policy to deal with this more directly, do 
you think that this is declining or is it still in a phase 
where we do not have appropriate management of this grave 
problem?
    Dr. Kelly. So as a good scientist I am loath to go beyond 
the data. I would say I don't see it declining. I think you see 
more----
    Mr. Fortenberry. Why is that?
    Dr. Kelly. I think there are multiple reasons for that, one 
of which is it is hard to detangle sometimes whether the actual 
incidence is increasing or whether people are reporting and 
feeling more comfortable reporting. It is hard to untangle 
that.
    Mr. Fortenberry. That actually could be progress, even 
though it shows as a statistically higher increase, the 
progress that this is----
    Dr. Kelly. It could be. It could be. And we have ways of 
addressing that.
    Mr. Fortenberry [continuing]. The culture is creating 
mechanisms for reporting and decreasing inhibitions.
    Dr. Kelly. I hope that that is the case. I hope that it is 
solely an increase in reporting. I would not stake my expertise 
on that.
    I think it is a particular issue, and I think that women 
veterans that, anecdotally with whom I talk--and male veterans 
who are sexually assaulted--this is a population that is hardy 
and tough and they want to keep doing their jobs.
    I come from a military family. I understand the hierarchy; 
I understand the need for it. All of those issues provide a 
context in which coming forward is very, very difficult, and 
the more we can do to set up infrastructure such that 
commanders deal with that appropriately, the more that I think 
we will see it dealt with appropriately.
    Mr. Fortenberry. In this regard, you mentioned that women 
veterans suicide rates are higher than nonveteran populations. 
Are their suicide rates higher than male veteran populations?
    Dr. Kelly. I would have to look at the data on that and by 
age, because suicide has sort of a bimodal activity, more 
likely in the young and more likely in the old. I would have to 
look and see for women veterans if their rate is higher than 
their male veteran counterparts.
    I do know that it is significantly different from women 
civilians of their same age.
    Mr. Fortenberry. And then the correlation to a culture 
that, as you are saying, as we know, has had difficulties with 
the issue of sexual assault, there has got to be a variable 
there that is significant, I would think.
    Regarding sleep, I was interested to hear you say that. I 
was talking with--actually, there is a psychologist here in the 
House who is a member of the military and he has counseled 
commanders who have sometimes, in terms of punishment, 
increased the duty and assignments on young people that create 
a cycle of a lack of sleep and then suddenly we are into deeper 
problems. And his first recommendation is, ``Go to bed.''
    Dr. Kelly. Yes.
    Mr. Fortenberry. ``Talk to you in 2 days.''
    Dr. Kelly. Yes.
    Mr. Fortenberry. I thought that was very insightful, and I 
think that even medical school training is shifting in this 
regard.
    Dr. Kelly. I was just going to say the analogy between 
training physicians in particular--you know, my dad was a 
nuclear submariner, and one of Rickover's boys, and the lack of 
sleep standing duty on subs is just immense, but we do the same 
thing to our physicians. And the results are life-or-death 
sometimes.
    Mr. Fortenberry. Maybe we should make note of that here in 
Congress, as well.
    Dr. Kelly. Yes.
    Mr. Fortenberry. Adequate rest.
    Finally, I have been working with an outside entity that 
really has a fascinating project. There is a pilot project 
going on. Their outcomes are measurable in terms of the 
increase in wellness, the reductions in mental health stress, 
plus harder-to-define outcomes such as feeling a sense of 
belonging to your community for wounded veterans, disabled 
veterans participating in group recreational programs. This one 
is bicycling.
    So apparently the new secretary is considering authorizing 
VA medical center directors to support this particular 
activity.
    I think this is very smart. I mean, we have got 
demonstrable outcomes in one area, and if VA directors locally 
are empowered with community volunteers and outside entities 
that will actually create these programs that have continuity 
but are embedded inside the VA.
    Dr. Kelly. Yes. I would love it.
    Mr. Fortenberry. It is not--as opposed to outside things, 
which are, of course, excellent and good, but bring embedded 
with the VA creates mechanisms of continuity that aren't always 
there.
    Dr. Kelly. I couldn't agree more. You know, at the Warrior 
Games--and I was at Invictus this past year when it came to 
America--the physical activity and all of the equine groups, 
the Team Rubicon, the Red White and Blue, all of these groups, 
many of which have the physical component, I agree.
    These are young men and women who are at the height of 
their athleticism. There is a reason why they still enjoy doing 
those activities when they come home.
    And at the same time, what we often--again, anecdotally--
talk to veterans about is the--and what a lot of civilians 
don't understand when they say they miss being in the military 
at a time when we are at war--is they miss the sense of 
belonging and belonging to a group that has purpose.
    So those kinds of programs serve all of those, and we are 
very much in favor of them.
    Mr. Fortenberry. Great. Thank you for your testimony.
    Dr. Kelly. Thank you.
    Mr. Dent [presiding]. Thank you, Dr. Kelly.
    And at this time I would like to invite our final witness 
to the desk. It is Mr. Fred Sganga.
    Fred, we appreciate your being here with us today, and I 
know you are a legislative officer at the National Association 
of State Veterans Homes. We appreciate your participation this 
morning and we look forward to receiving your testimony. You 
are recognized for 5 minutes.
                              ----------                              

                                         Wednesday, March 29, 2017.

              NATIONAL ASSOCIATION OF STATE VETERANS HOMES


                                WITNESS

FRED SGANGA, LEGISLATIVE OFFICER
    Mr. Sganga. Thank you, Chairman Dent, Ranking Member 
Wasserman Schultz, members of the subcommittee. On behalf of 
the National State of Veterans Homes, thank you for the 
opportunity to provide testimony recommending $300 million for 
the Grants for State Extended Care Facilities program, commonly 
referred to as the State Home Construction Grant program, for 
fiscal year 2018.
    As you know, for more than 125 years state homes have been 
in partnership with the Federal Government to provide long-term 
care services to honorably discharged veterans. There are 
currently 153 state veterans homes located in all 50 States and 
the Commonwealth of Puerto Rico.
    The National Association of State Veterans Homes, which 
represents the homes, was established in 1952 to promote strong 
federal policies and share experience and knowledge among state 
home licensed nursing home administrators to allow us to care 
for our Nation's heroes with the dignity and the respect they 
deserve.
    With over 30,000 beds, the State Veterans Home program is 
the largest provider of long-term care for our Nation's 
veterans, offering skilled nursing care, domiciliary care, and 
adult day health care. The Department of Veterans Affairs 
provides state homes with per diem payments for these purposes, 
which covers about one-third of the daily cost of care to these 
veterans.
    VA also provides construction grants to build, renovate, 
and maintain the state veterans homes, with the States required 
to provide at least 35 percent of the cost for such projects in 
a matching fund program. The State Veterans Home program allows 
the VA to leverage federal resources to expand long-term 
services and support for veterans through partnerships with all 
50 States.
    Federal State Home Construction Grants are awarded based 
upon when a grant is received, where it falls among the 
statutory priority groups, and when state matching funds are 
certified as available. Projects that have been certified state 
matching funds are included in the VA's priority group one 
projects list, which includes critical life and safety projects 
as well as the new construction of state homes in states that 
will have a great need, as defined in the statute.
    Grant requests that do not yet have state matching funds 
secured are placed in VA priority group two through eight on a 
list according to when they are submitted and according to 
their specific priority status.
    Over the past several years VA has requested, and Congress 
has provided, between approximately $85 million and $90 million 
annually, which was barely enough to keep up with the new grant 
requests from States and failed to make any significant headway 
with the existing backlog of priority one projects awaiting 
federal funding.
    The most recent VA State Home Construction Grants priority 
list for fiscal year 2017, released in January, includes 99 
requests; 57 are in priority group one, with a total federal 
cost share of approximately $639 million, an increase of $89 
million to the backlog compared to fiscal year 2016.
    There are also additional 42 grant requests among priority 
two groups through eight. Once those projects have been 
certified with state matching funding, they will, too, move to 
priority list one.
    Overall, there are more than $1 billion of State Home 
Construction Grant requests that have been submitted to the VA.
    With just $90 million for fiscal year 2017, VA will only be 
able to provide funding for the first 10 projects on the list, 
leaving 47 priority one projects awaiting a future year's 
funding.
    For each of the past three fiscal years--fiscal year 2015 
through fiscal year 2017--NASVH has recommended to Congress--to 
the VA and Congress that $200 million be allocated for the 
State Home Construction Grant program, a sum that was also 
recommended by the Independent Budget organizations.
    For fiscal year 2018 NASVH recommends that $300 million be 
provided to the State Home Construction Grant program, which 
would provide sufficient funding to cover approximately half of 
the pending priority one projects. The I.B. also supports the 
recommendation of $300 million for fiscal year 2018 funding.
    At this time it is not clear what level of funding the 
administration will request for fiscal year 2018. However, if 
the same inadequate amount of $90 million were to be 
appropriated for fiscal year 2018 it would support just the 
next seven priority one projects.
    Given the recent trends of state matching funding, it is 
likely that this will result in little or no net decrease in 
the existing backlog of $639 million priority one projects. 
Among these projects that would not be funded at that level are 
two in Pennsylvania, two in Florida, two in California, and two 
in Ohio. All of those and 17 others, however, would receive 
funding next year if the $300 million were appropriated for 
fiscal year 2018.
    As the veteran population continues to age and federal 
budgets continue to get tighter, there is no better investment 
of federal long-term care dollars than the State Home program, 
and we urge the subcommittee to significantly increase the 
funding for next year.
    Mr. Chairman, I would also like to bring to the 
subcommittee's attention another issue that is beginning to 
have a significant impact on the level of funding required to 
sustain the state veterans home system: the VA's new Community 
Living Center, or CLC, design and construction guidelines. 
These new guidelines call for the state homes to use what is 
called the small house design when constructing new or 
renovating existing homes.
    The small house design model is based on housing veterans 
in small group homes, or pods, each with their own kitchen, 
cleaning, and other basic facilities, along with separately 
assigned staff for each small group home. The homes are 
physically connected through common areas for social, medical, 
and other purposes.
    However, compared to the economies of scale that are 
achieved in traditional state veterans homes, the small house 
design has proven to be between 30 to 40 percent more expensive 
both to construct and to operate, imposing new financial 
burdens on the States. While some States have favored the small 
house design, others have found that many of the veterans 
prefer more traditional, larger state home model.
    NASVH is recommending that the VA modify the Community 
Living Center design and construction guidelines to allow 
States sufficient flexibility in using the small house design 
so they can better meet the different needs of their respective 
veteran populations in a financially responsible manner.
    Without such flexibility, Congress will need to 
significantly increase the level of funding for State Home 
Construction Grants to make up for the increased per capita 
costs as well as per diem rates to cover the higher operating 
costs.
    Mr. Chairman, that concludes my testimony. Thank you for 
the opportunity to be here today before the subcommittee, and I 
would like to answer any questions you might have.
    [The information follows:]
    
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    Mr. Dent. Thank you, Mr. Sganga, for your comments.
    I also appreciate the work your folks are doing in our 
State, with six state veterans homes.

     MISMATCH BETWEEN LOCATION OF VETERANS AND STATE HOMES

    Mr. Sganga. Thank you.
    Mr. Dent. Just one question: Given that veterans as a 
group, are moving away from many of the areas in the Northeast 
and Midwest where state veterans homes are located, would it be 
better to contract out for long-term care rather than to 
continue to build or repair facilities in areas with declining 
veteran populations?
    Mr. Sganga. In my experience as a licensed nursing home 
administrator for over a 30-year period I do find, Mr. 
Chairman, that you will have Northeastern retirees that will go 
to other parts of the country for retirement, but I will tell 
you a significant amount of those veterans and their spouses 
return back to their original place of residence in order to 
receive long-term care services.
    Mr. Dent. Are you saying my constituents are heading down 
to Ms. Wasserman Schultz's district? Is that what you are 
telling me?
    Mr. Sganga. Yes.
    But they come back to die back in Pennsylvania. I mean, 
that is what happens.
    Mr. Dent. On that point, there are statistics showing that 
if you are born in Pennsylvania you are likely to die in 
Pennsylvania.
    Mr. Sganga. Right. I have seen that. And spend 20 years in 
Florida.
    Mr. Dent. People in Pennsylvania do like to spend time in 
Florida. Maybe not 20 years, though.
    Mr. Sganga. But I think that answers the question. The 
whole notion of long-term care, the trend that we are seeing is 
a lot more of our veterans are coming to homes much older.
    Typically in my home--I am the executive director of the 
Long Island State Veterans Home in Stony Brook, New York--it is 
not unusual for a World War II veteran to be entering in their 
early 90s to the home.
    Mr. Dent. Thank you.
    Ms. Wasserman Schultz.
    Ms. Wasserman Schultz. Well, from a Long Island girl to a 
Long Island boy----
    Mr. Sganga. There you go.
    Actually, I was born in Queens.
    Ms. Wasserman Schultz. Me too--Forest Hills. Long Island, 
Jewish, just like most of my constituents.
    Which is why, Mr. Chairman, I always say that you should 
care about two people who represent you, particularly when I am 
up north: the person who represents you now--say, Mr. Dent--and 
me, because I am going to represent you when you retire and 
move to my district in about 20 years.

                  ALTERNATIVE TO LONG TERM FACILITIES

    That having been said, Mr. Sganga, I do share the interest 
of the chairman in answering the question, particularly because 
people always prefer to age in place if they can, that not only 
should we explore long-term care options in other places, but--
besides just the Northeast, where I guess more of the homes are 
located and being constructed. I mean, we do have state nursing 
homes in Florida, and hopefully we will continue to build more 
of them because there is a real shortage of beds.
    But I would think that your organization would be 
interested in trying to make sure that we could provide 
services to veterans where they would like to age, not 
necessarily in a particular home or facility. So have you ever 
explored broadening your mission?
    Mr. Sganga. That is a great question. Actually, three of 
our homes--Stony Brook, New York; Hilo, Hawaii; and 
Minneapolis, Minnesota--provide medical model adult day health 
care services, so that is one way that we do that. We would 
like to expand that.
    I would like the subcommittee to know that we have been 
waiting 8 years for the VA to have the adult day health care 
regulations revised. We think as an association this is a 
disgrace, in terms of the time that it is taking to revise 
those regulations.
    We have about 16 to 20 States who are on standby now to 
provide medical model adult day home care--health care to 
veterans and their spouses and widows, as well as gold-star 
parents, but they are not moving forward until they see 
publication of those regulations.
    Ms. Wasserman Schultz. Eight years?
    Mr. Sganga. That is correct.
    Ms. Wasserman Schultz. It has taken 8 years for them to----
    Mr. Sganga. We don't have them yet, so----
    Ms. Wasserman Schultz. Why?
    Mr. Sganga. You will have to ask the VA.
    Ms. Wasserman Schultz. I will.
    Mr. Sganga. Okay. Thank you.
    Ms. Wasserman Schultz. Thank you, Mr. Chairman.
    Mr. Dent. Thank you, Ms. Wasserman Schultz.
    I would like to recognize at this time the vice chairman of 
the subcommittee, Mr. Fortenberry.
    Mr. Fortenberry. Thank you, sir, for appearing.
    The veterans homes approximate to my district seem to be 
very happy places, to be honest with you.
    Mr. Sganga. That is correct.

                     VETERANS ORAL HISTORY PROJECT

    Mr. Fortenberry. And the decided focus on the particular 
needs of the veteran but also the celebration of the lives of 
the veteran and an inclusion of families is a dynamic that I 
have witnessed that, frankly, I am very proud of, so thank you 
for your work.
    One thing I would encourage you to do if you haven't 
already is there is a veterans history project coordinated 
through the Library of Congress, and we have made several 
offerings to veterans in our community--one at the vets home, 
which we actually facilitate the recording of the veterans' 
stories. And I remember one time a woman veteran, World War II 
veteran, told me, ``Well, I didn't really have anything great 
to say about my service in the war. I mean, I joined after my 
five brothers joined.''
    I said, ``What? There were six of you from one family?'' 
``Oh, yes.''
    And I said, ``Well, tell me''--in other words, this person, 
her own greatness, her own willingness to sacrifice, her own 
understanding of what she did as simply dutiful and not 
extraordinary was a reason itself that it was so extraordinary 
and a reason to capture that memory.
    So one of the things I just wanted to suggest to you is if 
it is not already a part of the culture that for veterans who 
are in your homes to get those stories recorded and be 
permanently here in our nation's archives. And I think it has a 
lot of meaning to them, particularly the older veterans for 
whom, as you are quite aware, there wasn't a culture in which 
people talked about their service or what they saw.
    In fact, we did one of these recordings with a veteran--a 
World War II veteran; I believe he was about 90 at the time--
who, through that interview, we actually were able to determine 
that there was post-traumatic stress disorder that had never 
been caught, diagnosed. And now he is receiving some treatment 
at a very old age.
    Nonetheless, it is a great way to continue this celebration 
of vet services, and you, as a platform, a home for so many 
veterans, I think the more we can do to capture those stories, 
it is not only beneficial for the Nation but it is a great 
service to the individual.
    Mr. Sganga. Mr. Vice Chairman, thank you for recognizing 
the special culture that does exist at any state veterans home.
    I can tell you that a typical nursing home in the United 
States of America is probably 75 percent women, 25 percent men. 
In Stony Brook where I am, and a lot of my colleagues, we are 
about 90 percent men and 10 percent women. So that does create 
a little bit of a different atmosphere. If we were to return in 
50 years I am sure it would be a lot different.
    But as a licensed nursing home administrator in a state 
veterans home, we are constantly looking out for the needs of 
both men and women whose service provided the freedoms we enjoy 
today.
    And I want to let you know that, indeed, a good portion of 
our state veterans home program participates in the Veterans 
Oral History Project.
    Mr. Fortenberry. Great. Good. Thank you.
    Thank you, Mr. Chair.
    Mr. Dent. Mr. Bishop.
    Mr. Bishop. Thank you, Mr. Chairman.
    Mr. Sganga, thank you so much for your service, and thank 
you for supporting the grants for state extended care 
facilities programs.
    All of our States have stressed budgets and, of course, 
that program would certainly supplement what the States are 
able to do, and so I thank you for that.
    I don't have any questions for you.
    I yield back, Mr. Chairman.
    Mr. Dent. Thank you, Mr. Bishop.
    And before we adjourn I just want to make a few comments.
    First, the Capitol Police advise us that Independence 
Avenue is still blocked due to an ongoing investigation or an 
incident, actually. For your safety we would ask that our 
witnesses and guests use the first-floor exit for the Rayburn 
Building, which is open to South Capitol Street. You will be 
directed to walk east away from the mall. So we just wanted you 
to be aware of that.
    I would also like to mention to the group that today's 
hearing is being webcast. It will be available on the 
committee's Web site, Facebook page, and YouTube link, so I 
wanted you to be aware of that, as well.
    And finally, I just wanted to say thanks to all of our 
witnesses today and to your organizations for the very 
important work that you are doing on behalf of our Nation's 
veterans. Your advocacy and your dedication and commitment are 
deeply appreciated, and we just want to say thank you for that.
    So with that, this hearing will be adjourned. Our next 
hearing is on Wednesday, May 3, with the secretary of the VA.
    Thank you all. Have a good day.

                                      Wednesday, November 15, 2017.

               VETERANS AFFAIRS ELECTRONIC HEALTH RECORD

                               WITNESSES

HON. DAVID J. SHULKIN, SECRETARY, DEPARTMENT OF VETERANS AFFAIRS
JOHN H. WINDOM, PROGRAM EXECUTIVE, ELECTRONIC HEALTH RECORD 
    MODERNIZATION
SCOTT R. BLACKBURN, EXECUTIVE IN CHARGE, OFFICE OF INFORMATION AND 
    TECHNOLOGY

                    Opening Statement Chairman Dent

    Mr. Dent. Good morning. Well, thank you all for coming out.
    We have convened this hearing with the Secretary of the VA 
to discuss a very important and expensive issue that was first 
presented to us last week--VA's plan to sign a contract with 
Cerner Corporation for an electronic health record. The record 
will use the same platform the DOD has purchased from Cerner 
for its health record.
    Since this need developed after the fiscal year 2018 budget 
was submitted and before we received the fiscal year 2019 
budget, the VA proposes to begin funding it through a 
reprogramming request.
    We understand that you have not completed negotiations with 
Cerner, so there are some total cost issues you are not able to 
discuss in open session out of concern about generating bid 
protests. We intend to pursue those issues in a closed session 
that will follow this one. However, we are confident we can 
discuss the major elements of the contract in public.
    For veteran members of the committee like Chairman 
Frelinghuysen and Ranking Member Lowey, the creation of a 
electronic health record has become a tired refrain. They have 
been hearing about it since the mid-1990s. VA Secretaries have 
come and gone, promising that their records were achieving 
interoperability or that they were developing the same record 
as DOD or that they had decided to have two different systems 
that would talk to each other.
    Now the pendulum has swung back once again to creating one 
record to be used by both departments, the position this 
committee has argued for from the start. The number of years 
and dollars that have been wasted reaching this point is 
extremely troubling.
    Mr. Secretary, we know that we cannot lay this past history 
at your feet, but you will forgive us for being a little 
skeptical that, at this late date, the VA has now found the 
answer to its electronic health record conundrum. We know you 
are anxious to sign the contract with Cerner, but the committee 
will need more information before it is comfortable with 
approving this first step down a long and expensive road.
    Before we ask you to give a statement, I would like to 
inquire if Ranking Member Wasserman Schultz has any comments.
    Ms. Wasserman Schultz. I do. Thank you, Mr. Chairman.
    Mr. Dent. You are recognized.

           Opening Statement Ranking Member Wasserman Schultz

    Ms. Wasserman Schultz. And welcome, Secretary Shulkin.
    Thank you, Mr. Chairman.
    And we do appreciate you being here on fairly short notice 
so that we can discuss the VA's efforts to modernize its 
electronic health records platform.
    But I really think, especially because we have some new 
members, including a relatively new member, myself, that we 
walk everyone through the EHR timeline thus far and the 
unbelievably lengthy process that this has been, even for 
government.
    Mr. Chairman, as you know, in 1998, during the Clinton 
administration, a Presidential review directive acknowledged 
that DOD and VA systems were not compatible and that actions 
should be taken to identify data exchange systems.
    In 2003, President Bush established a task force to improve 
healthcare delivery for veterans, and it recommended that the 
Departments develop an interoperable record.
    In 2007, the President's Commission on Care for America's 
Returning Wounded Warriors also supported interoperability, the 
genuine ability of these two systems to seamlessly exchange and 
make use of the other's information.
    Then, in 2009, President Obama announced that DOD and VA 
would be working together to build a seamless system of 
integration.
    Fast-forward to 2011, when VA Secretary Shinseki and DOD 
Secretary Gates announced plans to create a single electronic 
record.
    However, just 2 years later, in 2013, the two Departments 
announced that they would no longer create a single, common 
health record and, instead, solely focus on interoperability. 
The VA chose to modernize its existing VistA health record in-
house, while DOD announced it would contract a commercially 
produced health record.
    In response to that problematic announcement, the House-
reported fiscal year 2014 MILCON-VA bill directed the VA and 
DOD to develop a single electronic health record. I stress: 
directed the VA and DOD to develop a single electronic health 
record.
    Unfortunately, the committee was forced to remove that 
requirement after discussions with the House Armed Services 
Committee. The final appropriations language permitted either a 
single system or two interoperable records.
    After that battle was lost, DOD went on to award a $9 
billion contract to Cerner to develop the DOD health record, 
while, at the same time, VA efforts to modernize VistA 
underwent further review.
    Mr. Chairman, I believe we can agree this would not have 
led to genuine interoperability, and the patchwork of the Joint 
Legacy Viewer has left much to be desired.
    Finally, earlier this summer, the VA announced its 
intention to award a single-source contract to Cerner to 
provide VA the same electronic health record DOD is developing, 
as well as follow the same rollout cycle being operated by DOD.
    So, Mr. Chairman, this issue could have and should have 
been resolved years ago. It is no wonder that our constituents 
get incredibly frustrated with the insanity of the bureaucracy 
of many Federal agencies, and this is a textbook case. When I 
think about the time and resources that have been wasted over 
the years on this endeavor, it is easy to see why members have 
such strong feelings and such frustration concerning this 
issue.
    And I share the chairman's recognition that it is certainly 
not at your feet, but it is at your predecessors' feet and 
people who have been working on this for probably all of those 
years.
    And while I am pleased that the VA is moving in the 
direction of creating an integrated health record system, 
finally, with DOD, like we thought should happen years ago, I 
was not thrilled about getting a $782 million reprogramming at 
the end of October that needed to be acted on by November with 
no real details.
    I am also concerned about how this new system will work 
with the private-sector providers. And that is a question that 
I hope you are going to address in your testimony. If not, I 
will ask you. With veterans taking advantage of community care 
in significant numbers, we need to ensure that the new EHR 
system will be able to seamlessly exchange data between the 
private sector and the VA.
    Years down the road, I hope to not be at a hearing where we 
are discussing our frustration over the less-than-complete 
interoperability and ability to seamlessly move electronic 
health records from DOD and military service all the way 
through, including to the private sector. So I look forward to 
the opportunity to hear your thoughts and share my concerns.
    And I yield back.
    Mr. Dent. I thank the ranking member.
    At this time, I would like to recognize the chairman of the 
full committee, Mr. Frelinghuysen.

       Opening Statement of Full Committee Chairman Frelinghuysen

    The Chairman. Great. I want to thank you, Chairman Dent and 
Ranking Member Wasserman Schultz, for scheduling this hearing.
    And I want to thank everybody for being here today.
    Dr. Shulkin, it is good to be with you and your colleagues.
    We are here today because of your reprogramming request for 
additional resources for your electronic health records 
project. As all of us are painfully aware, the VA and DOD 
electronic health record compatibility, as has been mentioned, 
has been an issue for over 20 years.
    In fact, 4 years ago, your predecessor, Rick Shinseki, and 
Department of Defense Secretary Chuck Hagel met with Mrs. Lowey 
and with my predecessor, Hal Rogers, and made a fairly public 
commitment to get the damn job done. And some sort of a 
solution was supposed to be reached within a year. It was never 
done. DOD went one way; VA went another way.
    Despite those decisions, Congress has supported in a 
bipartisan way, the joint effort by providing billions of 
dollars over the years for these different projects. So when 
the committee was asked on short notice to approve a 
reprogramming to get yet another proposed project started and 
one that would require many billions of dollars over a long 
period of time, it was clear we needed some answers.
    Today, we need answers: True cost? What can be salvaged 
from the old system? And when it is all said and done, will the 
systems be seamless? And will this investment take away from 
dollars needed to replace existing old IT systems in the many 
veterans hospitals we have around the country? We have dozens 
of them, old systems.
    And will it take away from meeting the challenges of the 
new Choice Program and, may I say, a constant irritant to me, 
the embarrassing backlog of cases? I mean, some of these men 
and women are in their eighties and they are waiting for some 
sort of adjudication of their cases. Totally inexcusable.
    I know the focus here is on electronic medical records. Two 
priorities for the entire Appropriations Committee, not just 
this subcommittee, which Chairman Dent runs well, is that we 
ensure that we are providing the best medical care for our 
veterans and that we are setting out a fiscally responsible 
course to meet their needs. All of us want to hear in detail 
and for the record how that is going to be done.
    Thank you, Mr. Chairman.
    Mr. Dent. Thank you, Chairman Frelinghuysen.
    At this point, I would like to ask the Secretary to 
introduce his panel and then proceed with your testimony.
    Thank you, Mr. Chairman.
    Thank you, Mr. Secretary. You are recognized.

                  Secretary Shulkin Opening Statement

    Secretary Shulkin. Well, Chairman Frelinghuysen, Chairman 
Dent, Ranking Member Wasserman Schultz, and all the members of 
the committee, thank you for being here. And our intent is to 
be candid and answer all your questions this morning.
    I have with me, to the right, Scott Blackburn, who is the 
executive in charge of information and technology, and, to my 
left, John Windom, the executive for the electronic health 
record modernization.
    And, as you know, VA and DOD have been working on trying to 
get interoperable electronic medical records for quite some 
time. I was only able to trace the history for 17 years, but I 
am going to defer to the ranking member, who I think did a much 
better historical record of this than I did, so we are going to 
use her timeline. It has been quite a while.
    And, Chairman Dent, I think skepticism is appropriate. I 
don't know any other way to interpret history than to say that 
this has taken way too long, and there have been many false 
starts along the way. So I am right with you.
    I think that there is enough blame on both sides here, with 
DOD and VA. So I am not going to spend a lot of time on the 
history. I will tell you, right now--because that is really my 
best chance to sort of assess the situation--I have never seen 
better cooperation between DOD and VA. And I have to give a lot 
of credit to Secretary Mattis and Deputy Secretary Shanahan for 
leading this and saying we are going to get this done. So I 
think everyone is in agreement, this has taken too long.
    Even besides the fact that we don't have interoperable 
systems, VistA by itself is not a system. It is 130 different 
instances of an electronic medical record. That is insane, but 
that is the system that we have today.
    So we could continue down the same path that we are right 
now, without DOD and VA being interoperable, with VA having 130 
different electronic medical records. But we could, 
alternatively, go for a commercial, off-the-shelf system that 
is going to provide a single system with DOD and give veterans 
seamless care and this integration with community providers 
that the ranking member mentioned.
    From my perspective, maintaining the status quo is just not 
acceptable. The health and safety of our veterans is our 
Nation's highest priorities--among our highest priorities. On 
that, I know that everyone here agrees in a bipartisan way.
    Critical to meeting that priority is a complete and 
accurate veterans health record in a single common EHR system. 
Adopting the same EHR as DOD will vastly improve VA services 
and significantly enhance the coordination of care for 
veterans, not only at VA facilities but also at the Department 
of Defense and with community providers.
    Continuing to pursue VistA EHR interoperability would fall 
short in providing veterans the quality healthcare that we can 
give while throwing good money after bad. So, on June 5th of 
this year, after carefully looking at the data, I announced my 
decision to adopt the same electronic health record as the 
Department of Defense.
    And I am convinced adopting the same EHR system that DOD 
uses is the best solution. It will allow VA to keep pace with 
health information technology and cybersecurity improvements 
that VistA simply cannot achieve. Veterans' health information 
will reside in a single common system, providing seamless care 
between the Department of Defense and VA. We will be able to 
share veterans' health information with our community partners. 
And for those transitioning servicemembers, veterans' medical 
records will be at VA on day one.
    In working hand-in-hand with DOD on the same system, we are 
going to gain the advantage of their lessons learned, while 
making sure we fully achieve interoperability objectives. We 
are also committed to working with other EHR vendors besides 
Cerner and leading technology companies to create 
interoperability with our academic and community partners 
within the communities where our veterans live.
    This is the best decision for veterans in the short term 
and long term, and it is the best decision for taxpayers. 
Upgrading and maintaining VistA to industry standards will cost 
approximately $19 billion over 10 years--that is an independent 
study that was done by Grant Thornton--and we will still not 
achieve the necessary VA-DOD interoperability that the new EHR 
system that we are proposing will provide.
    The new EHR system over 10 years will be billions less than 
the $19 billion required for our current system. We are going 
to discuss the specifics in closed session, as you suggested, 
Mr. Chairman.
    And by moving from over 130 instances of VistA to a single 
instance of the new EHR, we will save billions more in 
efficiencies and quality improvements. I look forward to 
discussing those details, as well, in the closed session. But 
what I can say here is that we are achieving substantial 
discounts, choosing the same system as DOD and aligning our 
system deployment with theirs.
    Mr. Chairman, we want to work with Congress to find a 
common solution to funding this EHR modernization plan in 
fiscal year 2018. We prefer to fund the plan as part of the 
enacted 2018 appropriations bill, as I think you do too; 
however, we have to do this quickly.
    We have achieved substantial discounts by aligning our EHR 
deployment and implementation with the Department of Defense's.
    Absent an appropriation bill by the end of the calendar 
year funding the plan, we ask Congress to consider approving 
our transfer request so we can promptly award the contract. 
This contingency enables VA to avoid cost increases and allows 
us to move forward with IT infrastructure modifications and 
expanding our program management office to provide the 
necessary oversight and manage implementation.
    I do ask you consider establishing a new, separate 
appropriation account for EHR modernization costs. That way, we 
can capture everything in one place for the sake of full 
transparency and accountability, from our initial operating 
capacity to full deployment and other important decision points 
along the way.
    Mr. Chairman, the electronic health record modernization 
plan is right for veterans' healthcare, and it is right for 
taxpayers. It will significantly improve VA services and 
enhance the coordination of care at VA, DOD, and in the 
community.
    Thank you for the partnership in helping us improve how we 
care for our Nation's veterans.
    [The information follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
    
    
    Mr. Dent. Thank you, Mr. Secretary.
    Would you introduce your panel that's with you today, 
please?
    Secretary Shulkin. Yes. Mr. Scott Blackburn, the executive 
in charge of information and technology, and Captain John 
Windom, who is in charge of our EHR modernization.
    Mr. Dent. Thank you.
    At this time, let's go right to questions.

           DESCRIPTION OF PROPOSED EHR SYSTEM

    Mr. Secretary, could you please start by laying out for us 
the type of records system you are contracting for, what 
capabilities VA needs, the timeframe and geographic rollout you 
plan nationwide, and the impact it will have both financially 
and in terms of patient healthcare?
    Secretary Shulkin. Well, we have been working very hard to 
answer all those questions. And we do have a very specific 
timeline/project plan objectives. And in order to do this in 
the most succinct and accurate way, I am going to ask Captain 
Windom to respond to that.
    Mr. Windom. Retired, sir.
    Secretary Shulkin. Okay.
    Mr. Windom. I appreciate the opportunity, and thank you, 
Mr. Chairman.
    Because we have a closed session forthcoming, I can speak 
in greater detail in a closed session. But, overall, we intend 
to award a 10-year contract. Within that 10 years, we 
anticipate deploying to the full enterprise the full breadth of 
the 1,600-plus facilities and community providers that support 
those respective facilities. We believe that within that 10-
year timeframe that is very much achievable.
    And following the signing of the D & F back on June 5 by 
Secretary Shulkin, we entered into immediate and direct 
negotiations with Cerner Corporation such that, as part of an 
alpha contracting process, we are able to communicate across 
the table to fully assess not only their concerns for 
deployment but to offer them full understanding of the 
environment that they are going to be deploying to. And, 
therefore, we are very comfortable with a plan that deploys 
across the enterprise in less than 10 years.
    We intend to align our efforts to those of DOD today. I was 
fortunate enough to lead the program office for DOD that 
successfully acquired Cerner through a competitive acquisition. 
So very comfortable that I have seen both sides of the fence.
    I am also very comfortable that we are leveraging the 
lessons learned that DOD has in their associated deployment 
challenges. But that alignment, that critical alignment early 
in the process allows us to move out more aggressively in our 
approach, to be more efficient in our approach, and, again, to 
maintain the requisite configuration management over both 
sides, DOD and VA, that will support seamless information 
exchange well into the future.
    So hopefully I answered your question, but subject to your 
additional questions, I will pause.

         ROLLING OUT SYSTEM GEOGRAPHICALLY

    Mr. Dent. Yes. Mr. Windom, you said you were going to roll 
this out across the whole system. Geographically, in what areas 
are you going to start?
    Mr. Windom. So, presently, DOD is in the Pacific Northwest. 
They just went live in Madigan Hospital, and they have gone 
live at three other facilities. So it is our intent to deploy 
also to the Pacific Northwest.
    It is inherent economies of scale gained by labor 
efficiencies. I can't speak for Cerner Corporation, and I won't 
delve overly into the specifics of the negotiation, but there 
is clearly--by us deploying into the same geographical area, we 
will be able to leverage the resources that are already in that 
area. If we deployed east, clearly they would have to stand up 
a full-team that would have to, again, support our deployment 
on the opposite part of the country that DOD is in fact 
deploying.
    So we believe and have seen as part of the negotiation 
process substantial efficiencies in that area and in that 
strategy.
    Mr. Dent. Back to Secretary Shulkin, your reprogramming 
proposes to move funding in two ways, from medical services and 
medical support and compliance, to jump-start the program, with 
appropriated funding first assumed for fiscal year 2019.
    The first wave of transfers is $324 million from medical 
services and $50 million from headquarters staff hiring. We 
understand the hiring freeze has generated the $50 million, but 
the $324 million from medical services will be a hard sell to 
outside organizations, some of whom are probably represented 
here today.
    I know you say it is for medical equipment purchases that 
can be recouped at the end of the year, but your fiscal year 
2018 budget already starts out with a $245 million cut to 
medical equipment. So merely getting back to the original cut 
level isn't particularly reassuring.
    How are you going to characterize this publicly?
    Secretary Shulkin. Well, first of all, we would prefer to 
take the strategy that I believe that you would also support, 
which is not to do this transfer but to get the 2018 
appropriations done before the end of the calendar year.
    We are in somewhat of a time crunch, in that, in order for 
us to achieve the efficiencies that Mr. Windom just talked 
about, we do need to align closely with the DOD implementation. 
And so we are trying to do the best thing for taxpayers here.
    What we have proposed is an alternative if we are not able 
to get the 2018 appropriations bill done, where we would use 
some money that was from carryover from 2017 as a stopgap to be 
able to start this project, and then we would refund it, we 
would replenish that money so we do not believe that this will 
end up delaying or hurting veterans' healthcare. But it is not 
our preferred strategy.
    Mr. Dent. Thank you.
    I have additional questions, but we have a lot of members 
here, so I want to go right to their questions.
    Ranking Member Wasserman Schultz is recognized for 5 
minutes.
    Ms. Wasserman Schultz. Thank you, Mr. Chairman.

                   CATCHING UP TO DOD EHR DEPLOYMENT

    The frustrating thing here is that the VA--and I say VA, 
not you--but the VA's foot-dragging and missteps have become 
our emergency.
    Because DOD has jumped ahead and gone forward with what we 
should have been doing in parallel. You know, as an 
appropriator for a long time, that is not really the fiscally 
responsible way to deal with things. So I just will express 
that frustration out loud.
    To follow up on the chairman's question, I was going to ask 
this in closed session, but since you were able to answer it in 
the open, I will ask it. At the locations where the VA missed 
the opportunity to piggyback on DOD, are you going to deploy at 
those sites last? Or is a second Cerner team going to have to 
go to those sites?
    Secretary Shulkin. Well, we don't think we have missed any 
yet. They are just now implementing in the Pacific Northwest. I 
think they had their opening 2 weeks ago or a recognition of 
that. Today, maybe, is their official.
    So that is why we are trying to do this quickly. And we 
recognize you have been extraordinarily responsive in trying to 
keep up with that timeline. But we haven't missed any sites 
yet, and so we don't want to be in the position of having to go 
back and correct for that.

                 TIMEFRAME TO DEPLOY THE CERNER SYSTEM

    Ms. Wasserman Schultz. On the timeframe to fully deploy the 
Cerner system, theirs is a 15-month deployment schedule per 
location. Is that a timeframe that is set in stone, or are you 
going to be able to shorten it as you learn best practices?
    Secretary Shulkin. Yes. Working with DOD and the fact that 
they have been so generous in sharing their lessons and their 
implementation plans, we can clearly shorten this.
    The DOD healthcare system is one-third the size of VA. So 
let's just, from the start, say ours is a much more complex and 
larger implementation. But we believe that if the contract is 
signed that we will be implementing our first site within 18 
months. And then it will be this 7- to 8-year rollout that will 
get you to the full 10-year period.
    But we have to implement much faster and more aggressively 
than DOD, just because the number of facilities that we have 
are two-thirds more than what they have.
    Ms. Wasserman Schultz. When I got on the Appropriations 
Committee, I inherited, as the then-chair of the Leg Branch 
Subcommittee, helping to bring in for a landing the really 
unbelievably blown timeline and cost of the CVC. So, at a 
certain point, we had to bring in GAO to manage the completion 
of it so that we could stop the bleeding.

                     IS THE TIMELINE TOO AGGRESSIVE

    So I have a little experience in oversight of something 
this significant, which concerns me--just to use an example of 
the question I am going to ask you, my husband for years--I am 
almost always late. My husband will be early to his funeral. 
And in our 27-year marriage, he has told me, ``Debbie, it is 
just better to tell me the real time you are going to be here 
than to give me a time that is a lot sooner than you really 
likely are going to arrive.''
    So that begs the question, it took DOD 26 months from 
generation until contract award, and you have a faster timeline 
than DOD and a larger system, so is there any concern that your 
timeline is too aggressive?
    Secretary Shulkin. Well, first of all, I think your example 
is a very good example we can all understand. But there is no 
doubt that we are being aggressive with this. But we are also 
doing business differently, and we are trying to do business 
differently. Now, that doesn't assure that we are going to be 
100-percent successful at this, but I think the right thing to 
do in this situation is to act with urgency and to be 
aggressive and to establish sharp timelines.
    The major difference that we are going to do in 
implementing this versus other VA IT projects, which does not 
have a great history of on-time, on-cost----
    Ms. Wasserman Schultz. No.
    Secretary Shulkin [continuing]. And we understand that--is 
we, first of all, have given up on the idea that we are going 
to be doing software development ourselves. That was the 
initial plan, which is that we are going to buy commercial, 
off-the-shelf systems and we are going to rely upon industry 
partners who have good track records.
    Secondly, we are going to do the governance of this project 
and the oversight of this project directly out of the 
Secretary's office. That has not been done before. Part of the 
root cause of some of our problems at VA has been the silos 
between IT and the health system. And so this is going to 
report directly to the Deputy Secretary, who will have 
oversight. And there will be a new governance committee 
established that will have VHA and IT working as part of that 
governance structure.
    Third is we are using the lessons from DOD. If they weren't 
talking to us and sharing this, I would be much more concerned. 
But they are so fully committed to our success that I believe 
that saves a lot of time and a lot of money for taxpayers.
    And, fourth, we are taking advantage of the private-sector 
CIOs. Mr. Blackburn is going to be on a call with five of the 
leading CIOs in the country getting their advice, asking what 
mistakes are likely to happen, and essentially using private-
sector input.
    I have been a private-sector CEO. I have done EHR 
implementations. It doesn't mean I have done anything like this 
or this complicated. Nobody has. But I think we are committed 
to working with the private sector and DOD in ways that VA 
before just hasn't been willing to do.
    Ms. Wasserman Schultz. Mr. Chairman, Mr. Secretary, I look 
forward to being surprised. Thank you.
    I yield back.
    Mr. Dent. At this time, I would like to recognize the 
chairman of the full committee, Mr. Frelinghuysen, for 5 
minutes.
    The Chairman. We are admiring of the work you are doing and 
the fact that you are putting your shoulder to the wheel.
    Just let's say for the record, the House did all of its 12 
appropriations bills. We are waiting on the Senate. And the 
first bill out of the hopper was this bill.
    Secretary Shulkin. Yes.
    The Chairman. And may I say for the record, no 
disagreement, we forward-funded the VA. No one else gets that, 
and we do it for a reason.
    The issue here is that we are about to approve a 
reprogramming of a certain amount, which commits us to a long-
term obligation. And that is why we are here, is just to have 
some assurances that we know where we are going here. That is 
really why we are having this hearing here.

                    ELEMENTS TRANSFERABLE FROM VISTA

    For me, just a couple of comments. Is there anything 
salvageable from what we have already invested in? Which I have 
indications there is.
    And we have other financial systems in a variety of VA 
facilities that are subpar, ancient, all different.
    And I assume you feel that those are systems that need to 
be replaced, rejuvenated, and whatever.
    But, you know, the issue here is we sign on the dotted line 
with this reprogramming. We are committing this Congress and 
future Congresses to the implementation of this plan.
    We want to get it headed in the right direction.
    Secretary Shulkin. Right.
    I think that, Mr. Chairman, you were absolutely correct in 
all of your comments here and your perspective on this. VA has 
always shared the goal of getting interoperability and has 
shared the goal of getting interoperability and has shared the 
goal of getting to one instance instead of 130 of our EMR. It 
is just that we thought we would build this ourselves. And so 
we have been trying to be a software development company. And 
we have literally spent billions of taxpayer dollars and lots 
of years and haven't gotten there.
    And what we are saying now is that we are going to go to 
commercial, off-the-shelf technology. But what we have worked 
on isn't completely wasted. We have a lot that we have achieved 
that we are going to use in this implementation. Part of why it 
gives us a little bit more confidence that we will get there 
and that we can make up on some of these timelines. Because a 
lot of the work that we have done in process mapping of getting 
towards a single instance, which we had called VistA Evolution, 
is not going to be wasted, and we are going to need that.
    We are also going to be running our VistA system in 
parallel while we bring up Cerner, because we cannot afford to 
let any veterans' healthcare fall down.
    Mr. Dent. I would now like to recognize the gentleman from 
Georgia, Mr. Bishop, for 5 minutes.
    Mr. Bishop. Thank you very much.
    Let me welcome you, Mr. Secretary, Mr. Blackburn, Mr. 
Windom.

                   CONNECTION TO COMMUNITY PROVIDERS

    Let me get right to the point. As you know, the issue of 
creating a fully interoperable health record for our veterans 
has been a concern of Congress for a long, long time. It is my 
understanding that the proposal from Cerner is focused on DOD-
VA interoperability but that the strategy to connect community 
physicians who provide care for veterans is not yet defined.
    Given the growth of the Choice and the Community Care 
program, this challenge is something that really needs to be 
addressed immediately, particularly in rural areas. I, for one, 
would be much greater reassured if we knew that you had plans 
to address the interoperability with the community providers, 
as well as to ensure that all veterans can benefit from the 
interoperability.
    As such, what provisions are in the Cerner contract that 
will develop interoperability solutions to improve connectivity 
between the providers and the community? And by that, I don't 
mean a Joint Legacy Viewer.
    Secretary Shulkin. Yes. Your question is absolutely the 
critical question that we have set forth to achieve.
    So, first of all, we will achieve DOD interoperability. 
That is one piece of it. We will achieve better 
interoperability among the 130 different instances because I 
practice in the VA; I have to leave my system that I use to go 
into one across the country. So it is not, even in the VA 
system, true, easy interoperability.
    VA already has several hundred health information exchanges 
with community providers. So we are doing interoperability with 
our community providers in the network. As you know, one-third 
of our care is now out in the community.
    Mr. Bishop. Right.
    Secretary Shulkin. So we are going to already have that.
    Cerner, itself, has an interoperability tool that connects 
with thousands of additional providers with standards that are 
common. So we will have that.
    But we absolutely need to engage other IT vendors, other 
EHR vendors, besides Cerner, in order to achieve the objective 
that you have laid out, and that is a program that we have just 
put out an RFI for to industry to ask how we can best do this 
and work with them to achieve the goal you have stated.
    We call it the digital health platform. It is a central 
component of achieving the goal that we need for our veterans, 
which is interoperability with community partners. And we are 
going to be working with industry to get that done.

                        CYBERSECURITY CHALLENGES

    Mr. Bishop. One of the real challenges, particularly in 
this day and time, is going to be the cybersecurity aspects of 
the Community/Choice program connectivity, as well as the DOD-
VA interoperability.
    Secretary Shulkin. Yes.
    Mr. Bishop. So that is going to be a real challenge, and we 
will be very interested to know how you are going to make that 
happen.

                     EHR PROGRAM MANAGEMENT OFFICE

    You mentioned that the electronic health record program 
will be run out of your office. Will you set up a new sub-
office? Will we see this in the fiscal year 2019 request? Or 
are you going to try to do it----
    Secretary Shulkin. Yes. This is all part of the overall 
program cost.
    And, Scott, you may want to talk about the PMO and how we 
are going to do this.
    Mr. Blackburn. Absolutely.
    So there will be a separate office. That is currently being 
led by Mr. Windom. So it will be a program management office 
that will be made up of both clinicians from VHA as well as 
technologists from OI&T. We feel it is incredibly important to 
put them together in one team, one integrated team that is 
working together, with a joint governance structure over that 
that includes the CIO, that includes the Under Secretary of 
Health and the Deputy Secretary.

                           PROJECT GOVERNANCE

    Mr. Bishop. Quickly, let me ask you, where you have these 
CIOs working together, for key decision points that might 
impact both departments, who will serve as the responsible 
personnel that is accountable? DOD? VA? Who is going to be 
ultimately responsible for making those decisions?
    Mr. Blackburn. I will defer to Mr. Windom on the joint 
governance structure.
    Mr. Windom. We believe that governance is a critical part. 
We want to stay on converging paths to seamless care, not 
diverging paths. So governance has been something we have been 
working on hand-in-hand with our DOD counterparts, and we have 
created an interagency governance board. That interagency 
governance board is chaired at the highest levels. We would 
like to think that much of the decisionmaking and results 
will----
    Mr. Bishop. Who will chair that?
    Mr. Windom. Well, it will be chaired at the DepSec level 
for us, and it is at the AT&L level for DOD.
    And so that board, there will be technical and functional 
governance elements under those levels that, hopefully, most 
problems will be resolved in.
    There will be participation by Cerner Corporation, as a 
nonvoting member, because they are the developer of the 
software. DOD, as you know, has Leidos as a prime contractor, 
so they will be a participant.
    So it is important that we all stay in tune to the changes 
that each side is making or desires to make, DOD-VA, with a 
clear understanding that we will manage, you know, in a 
configuration management schema, those changes. Because, 
typically, most changes are good for both sides of the 
enterprise, not for a single side.
    So, sir, that construct under that interagency platform is 
going to be how we are going to ensure that we stay aligned in 
our methodologies and moving forward.
    Mr. Dent. I would like to recognize Mr. Jenkins for 5 
minutes.
    Mr. Jenkins. Thank you, Mr. Chairman.
    And, folks, thanks for being with us.
    Two areas of inquiry.

                             OPIOID CRISIS

    One, we are amidst, nationally and certainly at ground 
zero, an opioid crisis. And I appreciate the work that the VA 
is doing trying to address this within our veteran population.
    We obviously have a patchwork of prescription drug 
monitoring programs at the State level around the country. We 
have had issues about trying to make sure the VA is sharing 
information for these PDMPs and also that the healthcare 
providers at the VA have full access to the appropriate medical 
history for best prescribing practices.
    Can you reassure me about the interoperability of this 
system being able to integrate the information from State PDMPs 
and what the status is on the VA sharing information the other 
direction, with State PDMPs, about prescribing issues?
    Secretary Shulkin. Yes.
    Well, first of all, as you know, the VA is fully committed 
to complying with the State regulations and the State laws, and 
we do. That is our current policy, that we use the PDMPs. And 
it is part of our multifaceted approach to reducing opioid use 
and one of the reasons why we have a 36-percent reduction in 
opioid use among veterans since 2010.
    We are concerned about data that shows that when veterans 
leave the VA out into the community that there are actually 
higher rates of opioid abuse happening out in the community. So 
this is one of the reasons why this interoperability with 
community providers is absolutely key to us.
    But Cerner Corporation, in this contract, is committed to 
complying with the State regulations. And that is something 
that we just won't see any misstep from in the transition.
    Mr. Jenkins. Thank you.
    The second, I am a big believer that you have to be able to 
walk before you run. And I know what you are describing here is 
running with an integrated system, working with community 
partners, but I still remain very concerned about the existing 
system and the breakdowns.

                        PAYMENT SYSTEMS PROBLEMS

    Let me just give you an example. I was in my hometown, at 
Cabell Huntington Hospital, one of the largest hospitals in the 
State. Many veterans get care there, coupled also with our 
wonderful VA medical center in Huntington.
    But in my meeting with Cabell Huntington Hospital, they 
were sending claims for the direct VA care to Mountain Home VA 
Health Center in Tennessee. And they were having a 40-percent 
rejection rate just because the folks at Mountain Home VA 
Health Center, as I understand it, generally, maybe not in 
every case, was sending them to the wrong VA center.
    So Cabell Huntington Hospital has to start stamping each 
claim that they submit to say where Mountain Home needs to send 
it. And they have improved. They are at the 25- or 30-percent 
level.
    And then, when Cabell Huntington tries to call, very often, 
nobody answers; there is no ability to leave a message.
    So, fundamentally, I still think we have serious, serious 
payment system problems. We have an administrative challenge, 
to be polite about it. Because this is to the tune, for a 
community of 50,000 people, a hospital, they have accounts 
receivable to the tune of $7-million-plus waiting for payment. 
That impacts healthcare delivery for our veterans.
    So what assurances can you provide that, while we are 
thinking visionarily about this new integrated EMR-EHR system, 
we are still making a commitment to getting the payments done 
in a timely, accurate fashion and addressing the flaws in the 
existing system?
    Secretary Shulkin. Yes. You know, I come from the world of 
running hospitals, and I fundamentally believe that if you 
deliver a service, you need to be paid for that. And the VA, in 
too many cases, as you are saying, is falling short on that.
    There is, again, enough blame for this to go around. We 
have had problems with our third-party administrators in some 
cases, our contractors and payments. But, clearly, a lot of the 
responsibility is also on the VA.
    We are working very hard to improve those areas of 
communication, that what you are describing is unacceptable. We 
are trying to build timely payment standards into new Choice 
legislation that we hope that you will soon have an opportunity 
to consider. And we are trying to simplify the payment systems, 
which right now require 100-percent adjudication, which is not 
an industry standard. You wouldn't find that in the private 
sector.
    So I think that we are trying to move much more to where 
the private sector has gotten to on timely payments, and we 
need to do that. And I would be glad to look into your 
particular situation there so that we can get that corrected, 
as well.
    Mr. Jenkins. Thank you, Mr. Secretary.
    Mr. Dent. I would like to recognize the gentlelady from 
California, Ms. Lee.
    Ms. Lee. Thank you, Mr. Chairman.

       PROBLEMS FINDING MINORITY & SMALL BUSINESS SUB-CONTRACTORS

    Welcome, all of you. Thank you for being here.
    Of course, this is a sole-source contract, 10 years. You 
have been very aggressive, in response to Congresswoman 
Wasserman Schultz, in terms of getting this done.
    Now, Small Business Administration negotiates prime and 
subcontracting goals with each Federal agency. So, given this 
contract, given that it has been pending, as we know--I mean, 
this work has been pending for many, many years, let me ask you 
a couple of questions just about this in terms of the VA.
    Now, I know the VA got a passing grade of B on the prime 
subcontracting goals of 30 percent of small-business-eligible 
contracts. That is the VA. Now, your newly negotiated goal for 
fiscal 2017, actually, that has been downgraded--I don't know 
why--to only 28 percent.
    Now, the VA notes in your report that providing timely 
patient care requires that we continue to rely on national and 
regional contracts for procuring healthcare outside the VA 
system but that the VA will seek subcontracting opportunities 
for small business.
    Now, the VA did exceed its general small-business 
subcontracting goal of 70 percent, but you failed in all these 
other categories that are in statute. Let me give them to you.
    Okay. You are required 5 percent of all prime 
subcontracting goals. You reached 2.2 percent for women.
    For small, disadvantaged businesses, 5 percent of all prime 
and subcontracting awards. You got to 1.4 percent. And let me 
remind you, this is where the minority-owned businesses are, 
okay? African American, Latino, Asian, Pacific American, 1.4 
percent total. That is outrageous.
    Service-disabled veteran-owned businesses, 3 percent of all 
prime and subcontract. You got to 0.3 percent.
    And for HUBZones, you have a requirement of 3 percent. You 
got to 0.5.
    Now, given the enormous amount of money Cerner is going to 
make off of taxpayers in this VA contract, let me ask you what 
you have required of them to comply with Federal law to meet 
all of these goals. Because what you are doing, you are going 
backwards now, in terms of most of these businesses that you 
should be requiring the subcontracting goals--contractors to 
reach.
    So let me hear your thinking on that and what you are doing 
about this Cerner Corporation subcontracting goals.
    Secretary Shulkin. Yes. So you are asking about what 
requirements will we put on Cerner to subcontract with small 
business and some of the particular----
    Ms. Lee. Yeah. In compliance with the law.
    Mr. Windom. Ma'am, within the terms and conditions of the 
contract, the VA small-business goals are fully captured. I 
can't site those for you directly. I can get back to you with 
those numbers, but I could tell you exactly what percentages 
are going to whom. What----
    Ms. Lee. For Cerner. You are talking about now, for this 
contract.
    Mr. Windom. For this contract.
    Ms. Lee. Yeah. Okay. For small business. Okay.
    Mr. Windom. Cerner is fully on board with those--they have 
to provide as part of the process a small-business plan on how 
they are going to achieve those goals.
    Ms. Lee. Right.
    Mr. Windom. It is really the enforcement of those terms and 
conditions that are important.
    Ms. Lee. Yes.
    Mr. Windom. My program management office will be enforcing 
those goals rigidly. I can't speak for the other elements of 
the VA. That is all new information to me. But I can assure you 
that, in overseeing the Cerner contract, those small-business 
objectives will be of the foremost importance to us to achieve.
    Ms. Lee. But, Mr. Windom----
    Mr. Windom. Yes, ma'am.
    Ms. Lee [continuing]. Small-business goals are one. You are 
not aware of minority-owned-business goals?
    Mr. Windom. I am absolutely aware of minority-owned-
business goals.
    Ms. Lee. Then what are they and what have you required of 
Cerner for women-owned businesses and minority-owned businesses 
in this contract?
    Mr. Windom. Ma'am, the way the contract is broken down, 
there are--again, I can't site the specific percentages, but 
each one of those categories have a percentage of the total 
contract value that they are entitled to be awarded as part of 
contracted work subcontracted to Cerner.
    Ms. Lee. Does anybody have those requirements here?
    Mr. Windom. I can get back to you. Ma'am, I don't want to 
cite inaccurate--but I can give you those percentages, broken 
out by categories, as you requested. That is no problem. As a 
matter of fact, I may even be able to get it in time during the 
closed session.
    [The information follows:]
    
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
    
    
    Ms. Lee. Thank you.
    And, Mr. Secretary, let me just ask you, just overall, 
generally, what is going on over there? I mean, you know, we 
are trying to ensure parity and equal opportunity and 
nondiscrimination, and here you have 1.4 percent this year for 
minority-owned companies?
    Secretary Shulkin. Well, first of all, we are committed to 
this. Those are numbers that are different numbers than I have, 
so I would like the opportunity to be able to sit down with you 
and----
    Ms. Lee. This was from the Department of Veterans Affairs, 
your procurement division.
    Secretary Shulkin. In what time period?
    Ms. Lee. This is February--we requested it for February 
2017. Subcontracting data as of March 14, 2017, for fiscal 
2016.
    Secretary Shulkin. Yes. As I said, those are different 
numbers than I have seen.
    As you know, the Kingdomware decision has completely 
changed the approach that the Department of Veterans Affairs is 
doing for contracting with small businesses. And we have had a 
strategic pause and have relaunched to be able to meet these 
objectives.
    This is a goal that we share, we take seriously. As you 
said, our overall goals are always above our targets here. And 
if we are falling short in some areas, I want to make sure that 
you and I have the same information, but I can tell you we are 
going to be committed to improvements. If the data that I have 
is different than what you have, then I want you to have that 
information as well too.
    Ms. Lee. Okay. Thank you. And I look forward to getting the 
specifics on Cerner. Thank you.
    Mr. Windom. Absolutely, ma'am.
    Mr. Dent. Okay. Mr. Taylor is recognized for 5 minutes.
    Mr. Taylor. Thank you, Mr. Chairman.
    And, Mr. Secretary, thanks for being here.
    Let me first say, number one, let me echo some of my 
colleagues' comments in talking about how long it has taken. 
And I just appreciate that you are a hard charger, that you are 
aggressively moving to get the damn thing done. Because it is 
inexcusable, in my opinion, how it has been before you and I 
both got here.
    But I appreciate that you are doing that, but we do have 
some questions, of course, on some of the cost savings and 
timeline issues.
    But I do want to address one thing that I just heard that I 
think is important. Sure, you know, it is extremely important 
for the VA to meet statute, to meet goals, in terms of service-
disabled veterans and minority- and women-owned businesses and 
stuff like that. I am curious what Cerner's own goals are. But, 
at the same time, I don't want forced equality on unequal 
things, in terms of understanding that those statutes and goals 
are overall in the VA Department, so if there is a specific 
contract that there aren't qualified folks that can do the 
work, if we force that to happen, then you are hurting 
veterans.
    So I definitely want to say that for the record. That is 
not something that I want to see happen. But I do, of course, 
you know, like my colleagues, want you guys to meet your goals 
and statute.
    That being said, a couple quick things. Let's see.

               IMPACT OF FAILURE TO RECEIVE REPROGRAMING

    Let's say you aren't able to get this reprogram, these 
moneys, how will that affect you? What would the timeline be? 
What would the cost be? Would it be a complete stop for your 
efforts?
    Secretary Shulkin. Yes, we think it will add--and, Mr. 
Windom, please correct me if I am not being as accurate, 
because we want to be as fully transparent as we can in open 
session. We think it will add at least 5 percent to the total 
project cost if we miss that alignment with the Department of 
Defense.
    Mr. Taylor. So, on the alignment--so it would seem that 
they are actually getting the best efficiency, the DOD, as 
opposed to your guys, because you are much bigger and you are 
more complex, which is fine. That is great. We want to make 
sure you guys are there.
    In terms of if you didn't have the DOD in this, what would 
that also be in terms of cost and timeline?
    Secretary Shulkin. Well, it would be a longer timeline and 
more expensive.
    Mr. Taylor. No question. No question.
    Secretary Shulkin. I mean, in closed session, Congressman, 
we would be glad to share with you what we believe we have been 
able to negotiate in terms of efficiencies.
    I do believe we have achieved substantial savings and 
efficiencies and timelines because of DOD's experience here. 
And we have also learned from them what they would do if they 
could do it over again so that we are not making the same 
mistakes, which are costly, to make mistakes.
    Mr. Taylor. When you are speaking about your community 
partners--which, in my area, I know that you guys do have that, 
you do have some exchange in information there.
    Secretary Shulkin. Uh-huh.

            ADDITIONAL FUNDING TO COMMUNITY INTEROPERABILITY

    Mr. Taylor. Is that going to be another appropriation to 
make sure--obviously, Cerner has 27,000 facilities that use 
their information. Is that an easy fix, to be able to talk to 
community partners and everything? Or is that something that 
you will come back to us and ask for more money for?
    Secretary Shulkin. Yes, we can absolutely take advantage of 
the health information exchanges that already exist within VA. 
We have 700 of them. And it is built into the contract to take 
advantage of Cerner's interoperability with community partners.
    This Digital Veterans Platform, which is to seek outside 
industry to help us create the true interoperability that, 
frankly, everybody in healthcare is looking for--this isn't 
just a VA issue. We think VA and DOD can lead this for the 
country. That digital veteran platform, right now we are just 
going out and asking an RFI, request for information, that will 
turn into an RFP for outside industry help.
    And so we don't anticipate--we are not asking for an 
appropriation for that for several reasons: We don't anticipate 
that happening in these next couple fiscal years, and the work 
that does happen will be funded internally at VA. But, also, 
healthcare technology is changing so rapidly and there are so 
many new advances that we don't exactly know what that is going 
to look like.
    Mr. Taylor. Will this system allow for you to be--you know, 
that we are not building on legacy systems and MS-DOS and all 
that stuff but----
    Secretary Shulkin. It automatically includes the new 
advances, the new updates----
    Mr. Taylor. With software that just changes----
    Secretary Shulkin. Absolutely. That is part of this 
contract negotiation.

                 100 PERCENT INTEROPERABILITY GUARANTEE

    Mr. Taylor. Can you guarantee 100 percent after this 
change, if we, you know, reprogram these funds, that you will 
speak to DOD--or that the interoperability will be 100 percent, 
DOD and VA?
    Secretary Shulkin. I don't think I have ever guaranteed 
anything 100 percent. But Mr. Windom is willing to.
    Mr. Windom. I mean----
    Secretary Shulkin. Yes.
    Mr. Taylor. He has been shaking his head over there.
    Mr. Windom. I am willing to say that, because we will be on 
the same Cerner Millennium platform. We will be hosting our 
data in the same hosting facility. We will communicate 
seamlessly across the respective DOD and VA environments 
because of those reasons. So I expect it to be 100 percent. And 
I am a veteran, so I am banking on it.
    Mr. Taylor. All right.
    Thank you, Mr. Secretary.
    Thank you, Mr. Chairman.
    Mr. Dent. At this time, I would like to recognize the 
gentleman from Ohio, Mr. Ryan, for 5 minutes.
    Mr. Ryan. Thank you, Mr. Chairman. I appreciate it.
    Thank you, Mr. Secretary. Thank you for your service.
    Gentlemen, we appreciate you and all the work that you do.

               ALTERNATIVE MEDICINE FOR OPIOID ADDICTION

    I come from Ohio, and we have, as you know, an opiate 
epidemic that is of immense proportions for us. In 2016, we 
lost 4,000 of our fellow citizens in the State of Ohio to 
overdose, primarily from opiates. As you know, in 2016, we lost 
over 60,000 people across the country to overdose deaths, more 
than we lost in the Vietnam War.
    So this is something that we continue to struggle to deal 
with. And I know, Mr. Secretary, that we have talked about this 
before.
    Last month, I noticed that another substantiated report was 
released by the VA Office of Inspector General following a 
confidential complaint that the VA clinic in Baltimore, 
Maryland, was failing to provide appropriate quality control 
through the opioid treatment program.
    A 2014 investigation revealed a disturbing lack of 
attention on opioid management. Only 6.4 percent of new 
patients were prescribed opioids in accordance with the 
clinical practice guidelines. For our highest-risk veterans, 
those with active substance use diseases prescribed opioids for 
more than 90 days, less than 19 percent received appropriate 
testing and therapy, with some clinics providing no testing and 
therapy at all. The death rate from opiate overdose among the 
VA is almost double the national average. And issues span many, 
many facilities.
    Further complicating the opioid overprescription problem is 
a lack of appropriate software in our clinics. As we discuss 
electronic records and electronic health record management, now 
is the right time to also address including appropriate 
software to provide opioid oversight.
    What is the VA doing nationwide and in communities like 
mine in Ohio to implement technology solutions to assist 
clinicians in delivering improved and preventative patient care 
so that opioid prescriptions and other medication are properly 
prescribed?
    Secretary Shulkin. Well, we share, Congressman, your 
absolute concern and believe that, although we have begun to 
really focus on opioid safety in 2010, that we need to do much 
more on this. And so I have personally participated in the 
President's commission for opioid reduction and addiction, and 
we are going to redouble all of our efforts. So, when we find 
situations like the IG did in Baltimore in 2014, that was 
really a call to doing more in terms of oversight and action.
    In terms of technology, we have something called the Opioid 
Safety Initiative that has a dashboard. We can track opioid 
prescribing not only by facility, by clinic, by provider. And 
that triggers for us the ability to go in and intervene with 
the provider, using academic detailing, which is education by 
our pharmacists and by other subject-matter experts; by 
developing alternatives to prescribing medication. We adhere to 
the stepped-care management approach, the DOD-VA guidelines 
that do not go first to opioids but look for alternatives. We 
are investing heavily in complementary or integrative medicine 
approaches as alternatives in pain management.
    But, as you know, 50 percent of the people we care for in 
the VA system complain of chronic pain. So this is a very tough 
population to get their pain level correctly, and simply not 
prescribing is not always the best answer either.
    So we are working on this. We are using technology. It is 
going to be built in to the work that we have done, built in to 
a new electronic health record. And we are going to stick at 
this and actually, I hope, be one of the leaders in this in the 
country to try to solve this problem.
    Mr. Ryan. So are you seeing steps in the right direction? I 
mean, you are looking at, you know, only 19 percent received 
the appropriate testing and therapy.
    These are high-risk populations, as you know. And they are 
in a lot of pain. So----
    Secretary Shulkin. Right. Those are referring to urine 
tests for concomitant benzodiazepine use--again, something that 
we think is a risk, when you put a patient on both an opioid 
and a benzodiazepine. And being able to track those urine tests 
to make sure that there are not other drugs being used, that is 
part of the State prescription data monitoring program, as 
well.
    So this is really a very multifaceted program. Nineteen 
percent, of course, is not anywhere near what is acceptable. If 
you went back to Baltimore today--that was 3 years ago--you 
would find much higher rates. And we do have the ability to 
track this now. That is how the IG was able to find those 
rates.
    I have recently been to facilities in Cleveland. We 
actually brought the entire commission, Governor Christie and 
Congressman Kennedy and others, there to Cleveland because they 
are one of the leaders in the country in the lowest rates of 
opioid prescribing. So we are taking those best practices from 
Ohio and spreading them throughout the country.
    Mr. Ryan. You talked about the stepped-care management 
approach. Can you just walk us through for 30 seconds--if you 
can indulge me, Mr. Chairman--of what those steps are? Because 
I think that is an important point that we kind of ignore. The 
default position, give the scripts. There are these other 
approaches. Can you talk to us a little bit about what those 
are?
    Secretary Shulkin. Sure.
    First of all, all of our stepped-care protocols and our VA-
DOD guidelines for pain management are all publicly available. 
So we share these freely with anybody who wants to, because we 
think they are very good work.
    But what it basically says, as a prescribing doctor--and, 
as you know, I am a practicing physician--you do not start with 
reaching for your prescription pad or, now, your computer mouse 
and prescribing opioids, that you take people through what 
would be a reasonable approach for pain management and starting 
with the least addictive options and, often, nonpharmacologic 
options, if that is appropriate.
    One of the recommendations that has come out nationally--
and you have seen CVS actually take a lead in this--is not 
prescribing a month's worth of drug but really seven days' 
worth of drug. Part of the problem of addiction is not even to 
the person you are prescribing, but it is that they put the 
remaining drugs in their medicine cabinets and their kids get 
them or somebody else in the family gets them.
    So there are so many things that we can do with this 
stepped-care approach of how you adequately get to a point 
where you would prescribe opioids.
    Mr. Ryan. Using acupuncture? What are the----
    Secretary Shulkin. Absolutely.
    Mr. Ryan. Are we going to have another round, Mr. Chairman?
    Mr. Dent. Yes. We are going to go into closed session.
    Mr. Ryan. Okay. I will get you next time. Thanks.
    Mr. Dent. Mr. Womack is recognized for 5 minutes.
    Mr. Womack. Thank you.

                     LENGTH OF TIME TO DEVELOP EHR

    Mr. Secretary, gentlemen, thank you for being here.
    I am from Arkansas, and I know sometimes we are 
stereotypically slow. We have been doing this--in your 
testimony, you talked about how we have been in this discussion 
now for 17 years, how we have been trying to address this 
issue--not you guys, because you haven't been doing it that 
long. And I commend you for the decision to go to the platform. 
It just would seem to me that that was a decision that should 
have been made a long time ago.
    And I make this observation not because of the money that 
we have spent and the difficulty getting this interoperability, 
as we call it, but because it just makes absolute sense to me 
that if you are going to want to talk to DOD, if VA and DOD are 
going to talk together, they should be on the same platform.
    Am I missing something as to why we have been in this rut 
now for 17 years?
    Secretary Shulkin. I think it is important to understand 
why this has happened, because what it says is it is at risk of 
happening again.
    In 2011, on March 5, 2011, Secretary Shinseki and Secretary 
Gates, I believe it was, committed, probably in a hearing room 
like this, that they were going to do it. And I believe that 
they meant that. I believe that they meant that. And then what 
happened is Secretaries change and Congress changes, and all of 
a sudden people say, no, we are going to go a different 
direction.
    So I think what is important is, if we get your support in 
moving forward, that we do not allow that to happen, that we 
stay--because this is the right decision. This is the right 
thing for veterans. And so we have to stick at this.
    And it is going to be hard, and there are going to be 
stumbles. That is why I never say 100 percent. But this is 
something that we have to get done for the country. And, 
frankly, the fact that we are following DOD on this gives me 
greater assurance that we can get this done.

                  TRANSITIONING FROM THE VISTA SYSTEM

    Mr. Womack. The only experience I have in anything along 
this line, on a much, obviously, smaller scale, was I was a 
mayor once upon a time, and our court system had a bad computer 
system, and they went to a new system, which was fine, but they 
made one real major error, and that is they scrapped the old 
when they transitioned.
    Secretary Shulkin. Right.
    Mr. Womack. It wasn't much of a transition, but they just 
scrapped the old.
    So, in your testimony, you talked about keeping the VistA 
system alive. What does that mean? And how long can we expect 
that we have two systems kind of running simultaneously?
    Secretary Shulkin. Right. So we have 130 VistA systems. 
Part of what we are planning on doing is we will shut them down 
one at a time. When we have a successful Cerner implementation 
and we are confident, we can shut that one down, start to save 
some money. But by the time we get to the very last medical 
center at the end of this full 8-year implementation after we 
start, that will be when we can finally turn off the system.
    And, by the way, even then, I think there are 37 subsystems 
that we haven't figured out yet how to transition off of VistA. 
Now, we are working on that.
    But we are planning on running a dual system for the 
foreseeable future because we don't want to have what happened 
to your court system. I mean, we can't afford to put veterans' 
health at risk.
    Mr. Womack. Absolutely.

                BEST PRIVATE SECTOR MANAGEMENT PRACTICES

    And then, finally, Mr. Secretary, you have been to my 
district, and you know how interested I am in seeing that our 
Federal bureaucracy learn best management practices from the 
private sector.
    Secretary Shulkin. Yes.
    Mr. Womack. You have personally been to my district to 
witness that, talk with people.
    In the testimony earlier--and I think it was Mr. Blackburn 
that talked about, I kind of look at it as third-party 
validation. You have some kind of a CIO board, people from 
outside the universe, that are going to be looking at the 
process that we are implementing, this Cerner platform.
    Are you at liberty to say who these people are? Do they 
have a connection to Cerner? Is there any potential, you know, 
for a conflict of interest in that regard?
    Mr. Blackburn. From what I have seen, I think the whole 
American medical community that I have spoken to wants to see 
us succeed.
    So, as an example, this afternoon, I will spend 2 hours on 
the phone with the CIO of the Mayo Clinic, the CIO of Partners 
HealthCare, the CIO of Johns Hopkins and Kaiser Permanente. And 
they will be providing feedback, you know, on--they are 
reviewing the contract, they are taking a look and saying, hey, 
you know, here are some of the things that we would do 
differently, providing us feedback and helping coach us.
    As I have reached out to various academic, medical, and 
healthcare providers, everybody is rooting for us. This is 
going to be a game-changer for American healthcare. They are 
providing input. We are even talking about borrowing talents 
that have gone and done these implementations.
    But I would say the support that we have gotten from the 
healthcare community is fantastic.
    Mr. Womack. Very good.
    I yield back.
    Mr. Dent. Thank you, Mr. Womack.
    At this time, I would like to recognize the gentleman from 
California for 5 minutes, Mr. Valadao.
    Mr. Valadao. Thank you, Mr. Chairman.
    Thank you, gentlemen, for appearing today.

                   PORTABLE ACCESSIBILITY TO THE EHR

    I personally would like to applaud your decision to adopt 
the same electronic healthcare system as the DOD. Obviously, 
for nearly two decades, the VA has been seeking to achieve this 
interoperability between VA's VistA and the DOD system. It 
makes much more sense to me if both DOD and VA utilize the same 
system.
    There has been some debate recently about a veteran's lack 
of ability to access their personal healthcare information. Do 
you foresee in the transition the establishment of a secure, 
patient-centered, portable medical records system, that a 
veteran can access their own comprehensive medical records?
    This is something that has been available to the private 
sector for quite some time, so it is only natural we afford the 
same ability to our veterans as well.
    Secretary Shulkin. Yes. Well, I may ask one of my 
colleagues just to chime in with the details. But our system 
now, My HealtheVet, is used by millions of veterans. It is a 
portable system where they are able to access and message with 
their providers. Used probably more extensively than any other 
system in the country. So we believe in that. We think that is 
important.
    The transition of that over to Cerner, maybe I would ask 
Mr. Windom to talk about that.
    Mr. Windom. And I will defer to Mr. Blackburn, but I can 
say simply, yes, mobility, the ability to access your record 
via your phone, via web-based access, definitely at the 
forefront of the terms and conditions of our contract and that 
we are pursuing all of the state-of-the-art technology that the 
commercial environment can produce.
    So, Mr. Blackburn, I will pass to you.
    Mr. Blackburn. I agree. And, you know, as an example, I 
think I am personally a good example. I am a veteran, an Army 
veteran. The DOD has a part of my healthcare record. I got out 
of service, moved back to my hometown of Boston, where Partners 
HealthCare had part of my healthcare record--I then moved to 
Cleveland. Cleveland Clinic has part of my healthcare. When I 
came to the VA 3 years ago, I enrolled in VA healthcare and get 
my care right now at the Washington VAMC Orange Clinic. I also 
get care in the community.
    Every single one--and I think I just named about five 
different entities that have different pieces of my medical 
record that, right now, are not shared well. I had to print out 
my Cleveland Clinic records and give them to my VA doctor so 
that he had them. My VA doctor does use the Joint Legacy 
Viewer, but I got out in 2003, so not much is in there. My 
records were destroyed in a flood.
    So, with that, the ability for a veteran or a citizen to be 
able to get those pieces and put them together is something 
that is coming. And we are very excited that this will begin to 
facilitate that process by linking DOD and VA, with the Digital 
Veterans Platform beginning to link in all these other systems 
as well.
    It will take a little bit of time to get to where we are 
going to be in 10 years, where you are going to have this all 
together on your iPhone, but we are taking the first steps to 
get there.
    Mr. Valadao. All right.

         PROTECTION OF VETERANS' PERSONAL IDENTITY INFORMATION

    And then I am going to go in the opposite direction, 
because, obviously, access means there is an issue with 
security.
    So, Mr. Secretary, one of the issues I have focused on in 
my career and my actual first piece of legislation I ever 
signed into law had to do with securing someone's ID and their 
personal information. Government agencies have to take steps to 
protect people's personal information.
    Can you speak to the cybersecurity enhancements the VA is 
undertaking in this transition? This system will obviously 
contain the very sensitive personal information of millions of 
veterans. What is the Department doing to ensure the safety of 
that information?
    Secretary Shulkin. Yes.
    Mr. Windom, do you want to talk about the cybersecurity 
requirements in the contract?
    Mr. Windom. I will touch on--and then I will defer to Mr. 
Blackburn again.
    I come from the DOD side of the house. And, you know, the 
OI&T efforts right now are leveraging fully the security 
posture of DOD. And I can assure you the level 2, 3, 4, 5 
certifications that exist within the framework of DOD's 
security posture are being adopted fully. We just had a session 
with DOD to highlight the importance of the reciprocity 
agreements that would be necessary between VA and DOD in order 
to leverage their posture fully. Those are being consummated as 
we speak.
    So there is not going to be this separate VA security 
posture, separate DOD. There is going to be a joint security 
posture that is going to support the transition of a soldier, 
sailor, airman, marine from the Active Duty environment to the 
veteran environment. So that is of the utmost importance to us.
    Mr. Blackburn.
    Mr. Blackburn. Yes. I share your concerns on cybersecurity. 
The VA does not have a great track record. I think we have been 
on the GAO high-risk report as a material weakness for 16 
consecutive years, which is a streak that we are not proud of. 
But I am proud that we have made great strides over the last 2 
or 3 years, and we have gotten good feedback from GAO and OIG 
on that.
    I think one of the reasons we have been so vulnerable is 
having these 130 instances on an antiquated system, so this 
will help that out. But, in the future, we will be looking, you 
know, at new emerging technologies, whether it is blockchain or 
whatever it might be, to get that even more secure.
    Mr. Valadao. I just feel that the transition period is 
something we need to be very careful with.
    So my time is up, and thank you very much.
    Mr. Dent. At this time, I would like to recognize the 
gentleman from Nebraska for 5 minutes, Mr. Fortenberry.
    Mr. Fortenberry. Gentlemen, good morning.
    Mr. Secretary, nice to see you.

             ALTERNATIVE WAYS TO ACHIEVE INTEROPERABLE EHR

    You have an extensive background in healthcare management, 
running facilities, being an entrepreneur. If someone told you 
this was going to take you 10 years before an implementation of 
an interoperable system in one of your hospitals, you would 
find that absolutely unacceptable.
    Now, this is a big, massive project that a lot of the 
difficulties, or, put more succinctly, mess, you have 
inherited, I get that, but this has been going on for a very 
long time.
    So let me just try to simplify this so that I can 
understand and perhaps we can unpack a lot of this technical 
language. But I have about four things I want to get to, 
including some issues of late in Nebraska.
    You have a system now where you are on one screen, you can 
show DOD records and your records, right? That is 
interoperability at the moment. This is going to be combined so 
that one button pulls up everything from a former 
servicemember's life, right?
    Secretary Shulkin. Yes.
    Mr. Fortenberry. Okay. Why 10 years?
    I very much appreciate what you are saying, that we are 
getting out of the software business, because why would we 
build out the expertise in that area when that is not our 
expertise? You want to deliver care. I get that.
    Why 10 years? What do you expect the outcome to be? Are 
there progress measures along the way so that in another year 
the system is not going to say, ``We have another significant 
delay, and it is 2 more years.''
    Let me throw everything out on the table----
    Secretary Shulkin. Sure. Absolutely.
    Mr. Fortenberry [continuing]. First, and then I would like 
you to get to it.
    We have some information that the VA has always worked with 
the Indian Health Service to help them with their electronic 
medical records, but there is some indication that you may 
desire to move away from that. I would like your comment on 
that. Because that is some slippage that may cause significant 
difficulty for another part of government that we would not 
like to see.
    Secretary Shulkin. Sure.
    Mr. Fortenberry. Finally, there is a glitch in the 
outpatient clinic contract in Lincoln. Give me your assessment 
of that situation. And explain the criteria for site selection, 
because I think there is some murkiness there that has caused 
some possible confusion.
    Then I have, hopefully, an answer to all of your problems, 
if we have enough time.
    Secretary Shulkin. Okay. I would like to hear the answer. 
Are you sure you don't want to start with the answer?
    Look, I think the implementation is, frankly, 18 months. 
From the time we sign the contract till we get our first site 
up is 18 months, which is consistent with a private-sector 
practice in terms of from contract to full implementation.
    We will begin to, after that first implementation, start 
shutting down what will be 130 successive implementations after 
that. So, by the time we reach all of our facilities across the 
country, which are around 1,600, but 130 different systems 
control those 1,600, it will be around 8 years after the first 
18-month implementation.
    Mr. Fortenberry. So, after 18 months, what percent of 
systems will have successful interoperability?
    Secretary Shulkin. Well, we will start with one, and then--
--
    Mr. Fortenberry. But what percent of veterans does that 
represent?
    Secretary Shulkin. Oh. Well, that would be a very small 
percent of veterans. But what we have is a detailed project 
implementation timeline, which we would be glad to show you, 
how we get from one system in 18 months all the way through.
    Mr. Fortenberry. That is not really necessary. You 
understand the nature of the question. Obviously, you are going 
to try something to make sure it works. But the larger number 
of veterans that is going to actually be served as a priority 
would seem to me to be a prudent way forward.
    Secretary Shulkin. Yes. The longer we take to implement 
this, the more costly it is and the greater we think that the 
risk is to veterans. So we are trying to do this as 
aggressively as we possibly can.
    Mr. Fortenberry. Okay.

                       INDIAN HEALTH SERVICE EHR

    My time is running short. I am sorry. Can you, in 30 
seconds, address the Indian Health Service question?
    Secretary Shulkin. Yes. The Indian Health Service does use 
our VistA system. That will remain available. This is an open-
source system. We won't withdraw that from them. They may have 
to look at alternative systems, just as we are, and we would be 
glad to work with them on that. We have no desire to hold----
    Mr. Fortenberry. We don't want to put them in a situation 
where they are having to go out on their own and redesign an 
entire system.
    Secretary Shulkin. Right. Exactly.
    Mr. Fortenberry. So anything they can leverage from your 
experience would be most helpful.
    Mr. Windom. Can I touch on this?
    Secretary Shulkin. Yes.
    Mr. Windom. So we have been in communication with Indian 
Health Services. And we are firmly committed to supporting 
them----
    Mr. Fortenberry. Great. Thank you. I am sorry to interrupt. 
Time is ticking.

                        LINCOLN, NEBRASKA CLINIC

    Secretary Shulkin. Okay. And Lincoln, Nebraska, we will get 
back to you on that. But that was a small-business issue, in 
terms of the award, where we have had to go now back out for 
contract. We are committed to that contract. It is off-schedule 
because of small-business issue, but we can get back----
    Mr. Fortenberry. As we have discussed before, a lot of very 
creative public-private-public partnerships are on the line 
here that will provide additional housing and additional 
development opportunities on a beautiful historic site.
    Secretary Shulkin. Right.
    Mr. Fortenberry. We just need for this to move, and move 
quickly, because there is a lot on hold.
    Secretary Shulkin. Yes. I will follow up with you on that.
    [The information follows:]

    In fiscal year 2014, Congress passed the Veterans Access, 
Choice, and Accountability Act, which authorized VA to procure 
27 Major leases, one of which was an Outpatient Clinic (OPC) in 
Lincoln, Nebraska. This project will support the VA Nebraska-
Western Iowa Health Care System's Omaha VA Medical Center 
(VAMC). Clinical services currently housed on the existing 60-
acre Lincoln campus will be moved to this proposed OPC.
    On October 18, 2017, the Department of Veterans Affairs 
(VA) announced it will start a new, competitive lease 
procurement process for the Lincoln, Nebraska Outpatient 
Clinic, which will be initiated in fall 2017.
    This decision follows an August 2017 bid protest that an 
interested party filed with the U.S. Government Accountability 
Office, regarding VA's prior competitive procurement action.
    In that action, the U.S. Small Business Administration 
determined that the proposed awardee no longer qualified as a 
small business. Accordingly, VA excluded the protestor from the 
competition, reviewed the remaining offers, and ultimately 
determined it was best for VA to cancel that procurement. VA 
now plans to revise its solicitation to update and adjust its 
actual leasing requirements. This will bring the project more 
in line with industry standards, reduce costs proportionately, 
and provide stronger value to the Government and taxpayers.
    VA anticipates release of the new Lincoln Request for Lease 
Proposals in Spring 2018, with a potential award in CY 2018. VA 
is committed to delivering a long-term clinical solution that 
meets the needs of Veterans and their families in the Lincoln, 
Nebraska area. VA will continue to provide care at the current 
Lincoln VA clinic during this process.

    Mr. Fortenberry. Thank you so much.
    Mr. Dent. Thank you, Mr. Fortenberry.
    Before we move into the closed session, which will happen 
in moments and members can ask additional questions, I did have 
two questions that I felt needed to be asked in open session to 
the Secretary.

                       ADMINISTRATION COMMITMENT

    One is, what is OMB's commitment to this entire project? We 
noticed that OMB has not submitted a fiscal year 2018 budget 
amendment as it did for the Department of Defense. I think that 
is very important we establish in the open session.
    Secretary Shulkin. Yes. As you know, we have been working 
very closely with OMB, just like we have come to you and asked 
for your assistance, and they are both aware and supportive of 
this initiative.
    Mr. Dent. And there is one final question.

                 EHR VULNERABILITY TO POLITICAL CHANGES

    Mr. Secretary, you and I have joked that neither of us will 
be in the jobs we currently hold in 10 years. But, in a serious 
vein, I am concerned that, without consistent leadership, this 
expensive project could be derailed or reconfigured, given the 
long implementation time. We have seen the electronic health 
record whipsaw back and forth every time a new Secretary of VA 
or DOD comes to the scene.
    Is it a fair concern for the committee that this health 
record won't be able to withstand changes in political 
leadership or budgetary shortfalls?
    Secretary Shulkin. Well, first of all, if you commit to 
stay, then I will consider that too.
    But, no, I think that it would be--once we step in this 
direction--and I think as all of you have really reflected, 
this is the right thing to do. This is the right thing; it 
should have been done years ago. I do not believe this is going 
to be subject to political back-and-forths.
    And we are going to set this up in a way that, when we 
start this, there is the full commitment. And, while anything 
could happen, I don't believe that this is likely to be 
derailed.
    Mr. Dent. Thank you.
    I was going to ask Ms. Lee to ask a question in open 
session. And then members will have a next round in closed 
session, so anything you want to ask, you can ask in there.
    Ms. Lee.
    Ms. Lee. Okay. Thank you very much.

                   FATE OF EMPLOYEES TRAINED ON VISTA

    I just want to find out who is going to maintain this 
system once the new system is rolled out and fully implemented. 
And what is going to happen to VA employees maintaining VistA 
once the Cerner system is rolled out, and will they move over 
to the new Cerner system?
    Secretary Shulkin. Yes. The basic upkeep and modernization 
of the new system is going to be done by the Cerner 
Corporation. That is the whole point of us getting out of the 
software development system.
    Our current employees, we need every one of them. It is 
very rare to find software engineers who know MUMPS, which is 
our system, which started back in 1977. But they will--we want 
them to stay, we need them to stay over this implementation 
period. And any staff, once we shut down the VistA system, will 
be utilized as part of our current IT software--part of our 
infrastructure needs.
    Ms. Lee. So no job loss.
    Secretary Shulkin. We do not believe this will be a job 
loss.
    Ms. Lee. Okay.
    Thank you, Mr. Chairman, very much.
    Mr. Dent. Thank you, Ms. Lee.
    At this time, I think our members have had a good 
opportunity to ask questions about the electronic health record 
in the public setting. We will now adjourn and move to closed 
session so that members may discuss with the Secretary issues 
that could compromise contract negotiations if discussed 
publicly.
    We ask members of the public to leave the room at this 
time. Associate staff members, committee staff, VA staff, and 
our court reporter, of course, may stay.
    So, with that, we will adjourn and go into closed session.




                               I N D E X

                              ----------                              

                 Department of Veterans Affairs Budget
                              May 3, 2017
                                Witness

                                                                   Page

Shulkin, Hon. David J.,..........................................     5

    Prepared statement...........................................     9


Chairman, Statement of...........................................     1

Ranking Member, Opening Statement of.............................     2

Full Committee Chairman, Opening Statement of....................     3

Full Committee Ranking Member, Opening Statement of..............     4


Access and Quality Web site......................................    42

Accountability and Whistleblower Protection......................    42

Agency Reform Plans..............................................    62

Appeals Modernization............................................    55

Blue Water Navy Veterans Act.....................................    40

Caregivers Program...............................................    50

Choice and Complementary Medicine................................    54

Choice Program Future Funding....................................    49

Choice Provider Payments.........................................    53

Correspondence Policy............................................    43

Disability Claims and Appeals Backlog............................    64

Disability Claims Backlog........................................    61

Facility Realignment.............................................    33

Focus on Core Competencies.......................................    33

Fraud, Waste, and Abuse..........................................    59

Future Demand on VA..............................................    65

Health Disparities among Minority Veterans.......................    35

Interoperability with Department of Defense......................    27

Joint Legacy Viewer (JLV)........................................    28

Lincoln, Nebraska Clinic.........................................    49

Military Sexual Trauma...........................................    51

MyVA Initiative and VISN Realignment.............................    32

New Therapies for PTSD...........................................    41

Oakland Regional Office..........................................    35

Office of American Innovation....................................62, 64

Opioid Abuse Prevention..........................................    61

Other-Than-Honorable Discharges..................................    49

Patient-Centered Care............................................    45

Predicting Future Demand.........................................    34

Provider Payments................................................    42

Public-Private Partnerships......................................47, 48

Recreational Therapy.............................................48, 49

Scheduling System................................................    51

Senate-Confirmed Position Vacancies..............................    52

Suicide Prevention Training......................................44, 65

The Future of Community Care.....................................    22

Third-Party Billing..............................................    29

Transitioning Care Between VA facilities.........................    27

Vacant and Underutilized Buildings...............................65, 67

Veterans Choice Program..........................................24, 45

Veterans Crisis Line.............................................    63

Vista Electronic Health Records..................................    21

Workforce and Facility Infrastructure Needs......................    24

                              ----------                              

      Department of Veterans Affairs--Office of Inspector General
                             March 22, 2017
                                Witness

Missal, Hon. Michael J., Inspector General, Department of 
  Veterans Affairs opening statement.............................   142
    Prepared statement...........................................   145

Chairman, Opening Statement of...................................   141

Ranking Member, Opening Statement of.............................   141


Actions against Prescription Drug Theft..........................   183

Air Quality Environmental Concerns...............................   177

Allocation of Funding Increase...................................   192

Challenges of Veterans Crisis Line Rollover Calls................   176

Choice Program...................................................   177

Choice Program Meeting Required Spending Targets.................   188

Collecting Data Based on Race and Ethnicity......................   191

Collecting Race and Ethnicity Data...............................   180

Data Reporting by Race and Ethnicity.............................   197

Disability Claims Backlogs.......................................   186

Discrepancies in Wait Time Data..................................   187

Efficiency in Processing Claims..................................   191

Electronic Health Records........................................   185

For-profit Schools Using the Post 9/11 GI Bill...................   186

GAO High Risk Report.............................................   186

GI Bill Backlog and Processing Delays............................   194

Hiring Freeze Exemptions.........................................   196

Hiring Freeze Impact.............................................   190

Improvements in Scheduling Delays................................   174

Nursing Pay Scales...............................................   198

Opioids Treatment Management.....................................   182

Oversight for Opioid Prescriptions...............................   182

Patient Wait Times...............................................   181

Possible Violation of Appropriations Law.........................   174

Proactive OIG Auditing...........................................   189

Problems with Suicide Hotline....................................   174

Progress in Reducing Time Between Reports........................   187

Procurement Deficiencies.........................................   180

Retiring Legacy Systems..........................................   183

Risk of Purchase of Commercial IT Systems........................   175

Rollout of Online Scheduling.....................................   181

Shift to Commercial IT Software..................................   175

State Prescription Drug Monitoring Programs......................   178

Timeline in Responding to Complaints.............................   193

Treatment of Ineligible Veterans.................................   194

Uniform Treatment Protocols for Suicidal Veterans................   184

Unmet Funding Needs..............................................   195

VA Animal Research...............................................   199

VA IG Staff Expansion............................................   185

VA Information Systems Vulnerabilities...........................   179

VA OIG Resources Needs...........................................   188

VA's Antiquated Financial Management System......................   175
                              ----------                              

                        Public Witnesses Hearing
                             March 29, 2017

Blake, Carl, associate executive director of government 
  relations, Paralyzed Veterans of America.......................   236
    Prepared statement...........................................   261
Fuentes, Carlos, director national legislative service, Veterans 
  of Foreign Wars................................................   281
    Prepared statement...........................................   284
Kelly O'Beirne, Heather, director, Veterans and Military Health 
  Policy, American Psychological Association.....................   292
    Prepared statement...........................................   296
Sganga, Fred, legislative officer, National Association of State 
  Veterans Homes.................................................   308
    Prepared statement...........................................   311
Varela, Paul, assistant national legislative director, Disabled 
  American Veterans..............................................   271
    Prepared statement...........................................   273

Chairman, Opening Statement of...................................   235

Ranking Member, Opening Statement of.............................   235


Adding More VBA Staff or the Use of Technology...................   279

Alternatives to Long Term Facilities.............................   317

Assisted Reproductive Technology.................................   267

Care for Sexual Assault Victims..................................   304

Consolidating Community Care Programs............................   269

Construction of Research Facilities..............................    00

Emergency Care Court Decision....................................   269

Hiring Freeze and Processing Claims..............................   279

In Vitro Fertilization...........................................   290

Infrastructure Needs When Non-VA Care is increasing..............   290

Lack of Uniformity in Suicide Prevention Policies................   303

Limitations on Appeals While the Record is Submitted.............   280

Mental Health Care Awareness Initiatives.........................   291

Mismatch Between Location of Veterans and State Homes............   317

Paralyzed Veterans Having Access to Choice Program...............   268

Parking at VA Facilities.........................................   267

Preventing Veteran Suicides......................................   301

Programs With the Most Urgent need for Increased Funding.........   266

Training for Crisis Hotline......................................   301

Training that VA Provides Versus Private Sector Training.........   302

Transitioning Soldiers to Obtain Licenses and Credentials........   279

Use of VA Versus Community Care..................................   291

Veterans Oral History Project....................................   318
                              ----------                              

               Veterans Affairs Electronic Health Record
                           November 15, 2017
                                Witness

Shulkin, Hon. David J............................................   324
    Prepared statement...........................................   327

Chairman, Statement of...........................................   321

Ranking Member, Opening Statement of.............................   322

Full Committee Chairman, Opening Statement of....................   323


Additional Funding to Community Interoperability.................   361

Administration Commitment........................................   371

Alternative Medicine for Opioid Addiction........................   362

Alternative Ways to Achieve Interoperable EHR....................   368

Best Private Sector Management Practices.........................   366

Catching Up to DOD EHR Deployment................................   337

Connection to Community Providers................................   339

Cybersecurity Challenges.........................................   340

Description of Proposed EHR System...............................   335

EHR Program Management Office....................................   340

EHR Vulnerability to Political Changes...........................   371

Elements Transferable from VistA.................................   339

Fate of Employees Trained on VistA...............................   372

Impact of Failure to Receive Reprogramming.......................   361

Indian Health Service EHR........................................   370

Is the Timeline Too Aggressive?..................................   337

Length of Time to Develop EHR....................................   364

Lincoln, Nebraska Clinic.........................................   370

100 Percent Interoperability Guarantee...........................   362

Opioid Crisis....................................................   342

Payment Systems Problems.........................................   342

Portable Accessibility to the EHR................................   366

Problems Finding Minority and Small Business Subcontractors......   343

Project Governance...............................................   341

Projection of Veterans' Personal Identity Information............   367

Rolling Out System Geographically................................   336

Timeframe to Deploy the Cerner System............................   337

Transitioning From the VistA System..............................   365