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


        CARE WHERE IT COUNTS: ASSESSING VA'S CAPITAL ASSET NEEDS

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

                                HEARING

                               BEFORE THE

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

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        WEDNESDAY, JULY 12, 2017

                               __________

                           Serial No. 115-22

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
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                     COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BRAD R. WENSTRUP, Ohio               JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   KILILI SABLAN, Northern Mariana 
JODEY ARRINGTON, Texas                   Islands
JOHN RUTHERFORD, Florida             ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

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

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                        Wednesday, July 12, 2017

                                                                   Page

Care Where It Counts: Assessing VA's Capital Asset Needs.........     1

                           OPENING STATEMENTS

Honorable David P. Roe, Chairman.................................     1
Honorable Timothy J. Walz, Ranking Member........................     2

                               WITNESSES

The Honorable Anthony Principi, Former Secretary , U.S. 
  Department of Veterans Affairs.................................     4
    Prepared Statement...........................................    35
Roscoe G. Butler, Deputy Director for Health Care, Veterans 
  Affairs and Rehabilitation Division, The American Legion.......     6
    Prepared Statement...........................................    36
Debra Draper, Director, Health Care Team, Government 
  Accountability Office..........................................     7
    Prepared Statement...........................................    38
James M. Sullivan, Director, Office of Asset Enterprise 
  Management, U.S. Department of Veterans Affairs................     9
    Prepared Statement...........................................    44

        Accompanied by:

    Regan Crump MSN, DrPH, Assistant Deputy Under Secretary for 
        Health, Policy, and Planning, Veterans Health 
        Administration, U.S. Department of Veterans Affairs

 
        CARE WHERE IT COUNTS: ASSESSING VA'S CAPITAL ASSET NEEDS

                              ----------                              


                        Wednesday, July 12, 2017

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. David P. Roe 
[Chairman of the Committee] presiding.
    Present: Representatives Roe, Coffman, Wenstrup, Poliquin, 
Higgins, Bergman, Banks, Gonzalez-Colon, Walz, Takano, 
Brownley, Kuster, O'Rourke, Rice, and Correa.

          OPENING STATEMENT OF DAVID P. ROE, CHAIRMAN

    The Chairman. Good morning, and the Committee will come to 
order. Welcome and thank you all for joining us at today's 
hearing entitled, Care where it Counts: Assessing the 
Department of Veterans Affairs' Capital Asset Needs.
    Though this morning's hearing is ostensibly about VA's 
management of its extensive capital asset portfolio, it is 
actually about something else altogether: patient care. VA is 
one of the Federal government's largest property holding 
entities with a capital asset portfolio that includes thousands 
of medical facilities spanning hundreds of millions of square 
feet in both owned and leased space across the country. 
Managing and maintaining those properties and aligning them to 
meet the ever changing shifts in patient population and in 
healthcare demand and delivery is increasingly complex and 
costly. And I might add that the private sector is doing the 
same thing with bricks and mortar because of how medicine's 
practice today is changing.
    The average VA medical facility building is five times 
older than the average building in a not for profit hospital 
system in this country and was designed and built to meet very 
different healthcare needs and delivery models than we see 
today. The consequences of this have been well documented in 
recent years by entities including the independent assessment, 
the Commission on Care, and the Government Accountability 
Office. All too often current facilities, including those that 
have been well maintained, are not equipped to support the 
provisions of modern high quality care and are not well suited 
to providing care in the current VA healthcare system. VA does 
not consistently allocated capital to projects that address the 
greatest areas of veteran needs in the most cost effective and 
timely manner. There is a wide and growing gap between VA's 
capital need and the antiquated and anticipated resources. And 
previous efforts to align and realign VA capital assets have 
failed.
    What is more, due to shifts in the veteran population VA 
spends millions of dollars, taxpayer dollars, every year 
maintaining buildings that are empty or largely so. That led 
the Commission on Care to include this startling statement in 
their final report last year, and I quote, ``VHA's principal 
mission is to provide healthcare to veterans, yet over time has 
acquire an ancillary mission, caretaker of an extensive 
portfolio of vacant buildings.'' That is an extraordinary 
statement. VA's primary mission is caring for veterans and it 
is those veterans, those veteran patients, who bear the brunt 
of the consequences of VA's lack of physical infrastructure.
    We can no longer continue to allow VA's outdated, 
inflexible, and ill-suited capital asset program to compromise 
the department's core mission and the care provided to millions 
of our veterans. That is why I am calling this morning a top to 
bottom review of all VA Health Administration capital assets. 
This is not something for the VA or her champions to fear. As 
one of our witnesses, former VA Secretary Anthony Principi will 
testify this morning, quotes, ``VA will fail to honor our 
Nation's commitment to its veterans if VA's medical systems do 
no evolve with the times.''
    Rather than continuing to invest valuable resources on 
infrastructure in many cases long past its prime, we need to 
take an objective view of all VA medical facilities and smartly 
plan for where and how we can divest of buildings and property 
that are no longer needed, and more importantly for where and 
how we can grow to ensure that VA medical facilities maintain 
strong assets in communities across the country and are 
equipped to provide the care and services veterans need.
    As the veteran population continues to shift, care 
continues to evolve. VA's infrastructure continues to age and 
veteran demand for care in the community continues to grow. A 
capital asset review and realignment free of political 
influence is critical to ensuring that the VA healthcare system 
remains strong and sustainable for veterans today and tomorrow.
    I will now yield to Ranking Member Walz for any opening 
statements that he may have.

      OPENING STATEMENT OF TIMOTHY J. WALZ, RANKING MEMBER

    Mr. Walz. Well I thank the Chairman, and I want to thank 
our distinguished panel. And Secretary Principi, it is great to 
have you back and I think it is worth noting there is probably 
no one else in America knows the very issue we are going to 
talk about today more than you. And we are grateful you would 
find the time to come and help us with this.
    I would also like to thank the Chairman. I know it goes 
against my Minnesota Lutheran roots to, if you do a good deed 
and talk about it, it does not count, is the way we see these 
things. But I am going to talk about it. I think it has become 
obvious in the short time of this new Congress that this 
Committee is committed to tackling the big issues, to finding 
bipartisan issues, and to getting them done. And I am certainly 
glad that this is one the Chairman decided to take on also. It 
is important.
    It is a complex and vast issue plaguing VA's ability to 
effectively manage its incredibly large capital asset portfolio 
are daunting. I do think it is worth noting the numbers even 
for those of us up here. VA owns over 6,000 buildings 
encompassing over 151 million square feet. If we were as a 
Committee to go visit each one of these buildings and spend an 
hour getting there and going between each one and we did that 
eight hours a day, seven days a week, 365 days of the year, we 
would finish in three years getting through them. This is a 
massive undertaking and it is one that we need to get our minds 
wrapped around.
    VA and Congress has been very aware of this issue since the 
late 1990s when the CARES Commission was established under the 
direction of Secretary Principi. However, GAO's recent report 
shows little progress has been made in improving the capital 
management. The effective management of VA's vast and aging 
capital asset portfolio is intimidating, yet it is incredibly 
important and one I hope that we are willing to get done.
    Recently GAO has found that VA has neither the process nor 
the data necessary to make a long term decision regarding the 
alignment of its facilities to the needs of veterans. Today GAO 
is going to testify that both the VAIP and the SCIP are 
ineffective and significantly flawed. The VAIP process is meant 
to determine veteran needs, simply put, while the SCIP process 
is meant to produce a long term plan to align VA capital assets 
with that need. These processes are absolutely crucial to VA's 
ability to strategically determine gaps in VA capacity to meet 
veterans' need and then to produce a long term plan to cover 
the gaps. But buildings do not deliver care and benefits. VA 
staff inside those buildings do. However, VA is unable to 
determine the amount of care its staff yields or has the 
potential to yield. Therefore, VA is unable to ensure existing 
structures are fully utilized by a highly productive staff and 
how that translates into veterans' care. In an age of billion 
dollar medical facilities, this determination is absolutely 
imperative and it is unacceptable we do not have it.
    Tomorrow GAO is going to testify in front of the Health 
Subcommittee that VHA also lacks the ability to accurately 
determine the level of clinical productivity and efficiency of 
its healthcare providers. How can VA determine a building is 
necessary to meet a veteran's need when VA at this time cannot 
determine how much need is being met using the existing 
building? Complex problems demand complex solutions.
    The failure of the CARES Commission to execute its 
recommendation proves that a commission is not enough. The cost 
of VA capital asset maintenance proves time is not on our side. 
I hope we, along with VA, are able to thoroughly consider 
pragmatic and timely solutions to the many costly issues 
impacting VA's ability to manage its care. And as the Secretary 
said, this is going to take courage. It is going to transcend 
politics. If it is not done now, we can no longer kick this can 
down the road. Because if we do, the ability to deliver that 
care and the capacity to deliver that care will be diminished. 
And all of us here have a commitment to making sure that does 
not happen.
    So Mr. Chairman, I once again thank you for tackling the 
tough problems and I look forward to hearing from our 
witnesses.
    The Chairman. Thank you, Mr. Walz. And joining us on our 
first and only panel this morning is the Honorable Anthony 
Principi, former Secretary of the U.S. Department of Veterans 
Affairs. And welcome, Mr. Secretary. Mr. Roscoe Butler has been 
here many times, the Deputy Director of Healthcare for the 
Veterans Affairs and Rehabilitation Division of the American 
Legion. Thank you for being here. Debra Draper, the Director of 
the Health Care Team for the Government Accountability Office. 
Again, many times here. And Jim Sullivan, the Executive 
Director of the Office of Asset Enterprise Management for the 
Department of Veterans Affairs, who is accompanied by Dr. Regan 
Crump, the Assistant Deputy Under Secretary for Health Policy 
and Planning at the Veterans Administration, and welcome. Thank 
you all for being here. And Secretary Principi, we will begin 
with you and you are now recognized for five minutes.

                 STATEMENT OF ANTHONY PRINCIPI

    Mr. Principi. Thank you, Mr. Chairman and Ranking Member 
Walz, Members of the Committee, it is certainly an honor to be 
back before you this morning. And I just commend you for the 
working relationship that all Members have. And veterans should 
be reassured that you are tackling the tough issues. So thank 
you very, very much.
    Medical care is a key component of the benefits and 
services enacted by Congress in recognition of the sacrifices 
of the men and women whose service in uniform preserved and 
protected our Nation's freedoms. Neither medical science nor 
the veteran population is static and unchanging and VA must 
always provide veterans with modern, high tech facilities to 
offer them high quality healthcare. The department will fail to 
honor our Nation's commitment to its veterans if VA's medical 
system does not evolve with the times.
    VA is a proud organization with a great history. The 
department has made enormous contributions to American 
healthcare across the spectrum of care, research, 
rehabilitation, and has been a lifeline for tens of millions of 
veterans returning to our shores. But many VA medical centers 
were designed and built in an era in which medical care was 
synonymous with hospital care and long term psychiatric care, 
facilities built in the twenties and thirties, 1,700 beds, 
still in existence today, with an average daily census of maybe 
166 patients. American medicine and VA healthcare has 
transformed itself from hospital centered to patient centered 
treatment. Most veterans, like most Americans, see their 
physicians on an outpatient basis and much treatment is 
provided by prescription drugs.
    However, while the practice of VA medicine has evolved, VA 
medical infrastructure has not kept pace. VA facilities are out 
of step with changes in the practice of medicine and with the 
statutory changes in VA's healthcare benefits package. In 
addition millions of veterans following the population 
migration patterns of the Nation have moved to different parts 
of the country. And as GAO noted in its recent report on VA 
real property, the new Choice program has also reduced the need 
for some VA facilities and services VA offers. If VA does not 
realign itself, the current decline in the veteran population 
will make many VA medical centers museums of the past, not the 
guideposts for the future they should be to care for our 
Nation's veterans.
    When I became Secretary in 2001, President George Bush 
reminded me that every dollar my agency spends is a dollar 
taken out of someone else's hard-earned pay. It is not how much 
money you are given in your budge, he told me that is 
important. He said it is whether you spend the money wisely. We 
are stewards of the public trust, he reminded me, and we must 
never forget that. I had an opportunity to recall his words a 
short time later when I was stuck in traffic in New York City. 
As my car idled in front of VA's Manhattan Hospital, I looked 
up at the hospital's enormous bed tower. Among the hundreds of 
windows looking out on First Avenue, only a handful were lit. I 
did not know what to make of it.
    I learned a short time later when I returned to Washington 
that the hospital was one of many built in the 1940s and 
fifties to handle the influx of ill and injured World War II 
and Korean War veterans. It once held 800 veterans, as did 
nearby hospitals in the Bronx and Brooklyn. I was told that the 
three hospitals that night were caring for only 283 veteran 
patient's altogether. All the other beds were empty and there 
were tens of thousands of empty beds throughout VA's system.
    Accordingly I commissioned a comprehensive assessment of 
VA's capital infrastructure and the demand for VA healthcare. 
The process was called Capital Asset Realignment for Enhanced 
Services, CARES, and was modeled on DoD's infrastructure review 
process. The CARES Commission offered sound recommendations for 
realignment and reallocation of the department's capital assets 
to meet demand of VA's services over the next 20 years.
    Unfortunately the CARES and DoD processes differed in one 
way. Under CARES there was no requirement for Congress to adopt 
or reject the commission's final recommendations as a package. 
As a result, recommendations for some needed new hospitals and 
outpatient clinics were accepted. Most of those to change, 
realign, or maybe close the mission of other facilities were 
rejected.
    I know that the difficulties of agreeing to such a 
procedure for Members of Congress cannot be overstated. Having 
served as the Chairman of the 2005 Defense Base Closure and 
Realignment Commission, BRAC, I know firsthand from visiting 
many of the military installations slated for closure or 
realignment now trying this process can be for you and your 
states. The closure and realignment are easy to write on paper 
but they have profound effects on communities and the people 
who bring those communities to life. But VA is simply spending 
too much money on bricks and mortar rather than doctors and 
nurses.
    VA's current budget request is $186.5 billion. In my last 
year as Secretary, in 2005, that figure was $69.4 billion, a 
268 percent increase. We are doing a disservice to the veterans 
VA is charged to serve and to the American people if those 
resources are not used wisely and well. Our Nation simply 
cannot afford to maintain a vast infrastructure built for a 
different time and healthcare delivery that was to care for 
tens of millions of veterans as they returned from World War 
II, Korea, and Vietnam, and even from earlier conflicts.
    One other area in which there is an opportunity for both 
enhancing and using taxpayer dollars more wisely is for VA and 
DoD to more widely share facilities and services at local 
levels. There are many DoD hospitals that have very low 
inpatient census as well. This is one of the CARES Commission's 
recommendations and more can be done in this area.
    A full review of VA's infrastructure, Members of the 
Committee, is the right thing to do. A review that is open, 
transparent, and apolitical. Those impacted by the decisions 
deserve no less. Thank you very much.

    [The prepared statement of Anthony Principi appears in the 
Appendix]

    The Chairman. Thank you, Mr. Secretary. Mr. Butler, you are 
recognized for five minutes.

                 STATEMENT OF ROSCOE G. BUTLER

    Mr. Butler. Thank you, Mr. Chairman. Each year since 2003 
the American Legion System Worth Saving Program has conducted 
site visits to VA healthcare facilities across the country. One 
thing we find in common is that VA has enormous amounts of 
aging buildings that are either underutilized or vacant. VA has 
a large inventory of buildings that are over a half century 
old, resulting in significant costs for upgrades and needed 
replacements of many parts of the facilities' aging 
infrastructures.
    As I mention in my written statement, GAO has been 
reporting on this issue dating back to 1991, or probably even 
earlier. GAO published a report title, VA Struggling to Respond 
to Asset Realignment Challenges. It has been 26 years since the 
1991 GAO report was issued and we are here again today to have 
an open and candid discussion on how to address VA's capital 
asset needs.
    Good morning, Chairman Roe, Ranking Member Walz, and 
Members of the Committee. On behalf of our National Commander 
Charles E. Schmidt, and the over three million voting members 
of our largest wartime veterans service organization, we want 
to say thank you for conducting this hearing that addresses 
VA's capital asset needs.
    Today the Veterans Health Administration is the largest 
integrated healthcare system in the United States, providing 
care at over 1,233 healthcare facilities, including 168 medical 
centers, and 1,065 outpatient sites of care of varying 
complexities serving more than 8.9 million veterans. In spite 
of the exceptional healthcare VA provides, its aging 
infrastructure with a number of buildings being underutilized 
or vacant, creates problems for VA to maximize the use of its 
capital assets.
    According to information provided by VA in fiscal year 
2016, VA had 403 vacant buildings at an annual operating cost 
of $6,674,227 and 784 underutilized buildings at an annual 
operating cost of $20,266,271. VA defines an underutilized 
building as an individual building that is occupied and in use, 
but the functions housed there do not require the full amount 
of space in the building to operate.
    If there was unlimited funding the easy answer would be to 
dispose of all of VA's vacant buildings and build new modern 
facilities. But the reality is that funding is not unlimited 
and there are no easy answers to these questions. Which is why 
everyone is here today to have an open and candid discussion to 
address VA's aging capital asset portfolio.
    In 2016 the American Legion renewed Resolution 136, 
Strategic Capital Investment Planning Program, which urges 
Congress to provide increased appropriations annually to 
address Department of Veterans Affairs construction 
deficiencies and gaps identified by VA's strategic capital 
investment planning program. VA includes activation costs in 
their future SCIP cost projections and allocations so that VA's 
budget will not have to offset this lack of funding and VA 
continues to be transparent about SCIP's progress by publicly 
posting information about projects and costs on an annual 
basis.
    Based on the American Legion's review, addressing VA's 
capital asset need is not a new phenomenon. There have been 
numerous government reports over the last 26 years addressing 
the same topics. However, countries around the world have 
placed high value in their historic properties, such as 
historic capitals, and the United States visitors frequently 
visit Washington's monuments and the Lincoln Memorial for its 
historic contributions to this Nation's historic value. In the 
past, our System Worth Saving team has visited the Hot Springs, 
South Dakota medical facility, which was designated as a 
historic national property. Subsequently, VA was pursuing to 
close that facility until Dr. Shulkin overturned the former 
administration's decision. The American Legion calls on 
Congress and VA to place high value on VA's historic national 
properties.
    The American Legion is concerned that VA has not routinely, 
actively engaged veterans service organizations in the 
discussion about their plans to address VA's capital asset 
needs. VA must do better involving VSOs in these discussions.
    Twenty-six years later, we are still trying to find 
solutions to VA's capital asset needs. The American Legion 
hopes it does not take another 26 years to find solutions to 
VA's capital asset needs.
    The American Legion thanks this Committee for this 
opportunity to explain the position of the over three million 
voting members of the American Legion. Thank you.

    [The prepared statement of Roscoe G. Butler appears in the 
Appendix]

    The Chairman. Mr. Butler, thank you. And full disclosure, I 
just mailed my 2018 dues in before I came back.
    Mr. Butler. Thank you, sir.
    The Chairman. Ms. Draper, you are recognized for five 
minutes.

                   STATEMENT OF DEBRA DRAPER

    Ms. Draper. Chairman Roe, Ranking Member Walz, and Members 
of the Committee, thank you for the opportunity to be here 
today to discuss VA's capital asset program, including our 
recently issued report that examined VA's efforts to align its 
medical facilities with veterans' needs.
    VA is one of the largest property holding agencies in the 
Federal government. In 2014 VA reported that its inventory 
included more than 6,000 owned and 1,500 leased buildings, 
together covering approximately 170 million square feet of 
space. Many of these facilities are underutilized and outdated, 
creating a variety of challenges for alignment.
    As we discussed in our recent report, there are a number of 
factors that affect the department's alignment efforts. First, 
VA projects a 14 percent decrease in the veteran population by 
2024. And as the map on the screen shows, up on the board, it 
also expects a continued migration of veterans from the 
Northeast and Midwest areas of the country to areas in the 
South and West, a trend that also mirrors that of the general 
population.
    Second, similar to trends in the healthcare industry 
overall, VA's model of care continues to shift away from 
inpatient to outpatient settings of care, the latter of which 
VA generally houses in converted inpatient space or in a 
growing number of outpatient clinics. The photo is of a closed 
inpatient wing at the Brooklyn facility.
    Third, although VA has traditionally provided care 
primarily through its own facilities, it is increasingly 
relying on care provided in the community.
    Fourth, an aging infrastructure affects facility alignment 
because many VA facilities are not well suited to provide care 
in the current environment, as the photo of an outdated double 
occupancy room at the Manhattan facility shows. The average age 
of a VA medical facility is 60 years, which is five times older 
than that of an average not for profit hospital building.
    Facility planning officials told us that it is often too 
difficult and costly to modernize, renovate, and retrofit older 
facilities. Photos from the Waco facility illustrate these 
challenges.
    And finally, the historic status of some VA properties adds 
to the complexity of alignment. VA has approximately 3,000 
historic buildings, structures, and land parcels, the third 
most in the Federal government. In some instances renovations 
may be more expensive but demolition and rebuilding may not be 
an option given the historic designation. These photos of 
buildings, of structures designated as historic from the 
Kerrville, Chillicothe, and Waco facilities provide good 
examples.
    VA has recognized the need to improve planning and 
budgeting for modernizing its aging infrastructure and aligning 
its facilities with veterans' needs. A previous effort at doing 
this, known as CARES, was never fully implemented and was 
halted about eight years ago. VA has more current efforts to 
align its facilities with veterans' needs, including the SCIP 
process and the integrating planning process. However, both of 
these have limitations.
    VA relies on the SCIP process to plan and prioritize its 
capital projects. But limitations, such as subjective 
narratives, long timeframes, and restricted access to 
information underlie VA's ability to achieve its goals. For 
example, the time between when facility planning officials 
begin developing the SCIP narratives and when they are notified 
that a project is funded has taken between 17 and 23 months 
over the past six fiscal years' SCIP submissions. While some of 
the budget timing is outside of VA's control, delays in 
reporting of the SCIP results has made it difficult for local 
officials to understand the likelihood that their projects 
would be funded.
    The integrated planning process also has limitations. Among 
other goals, it is intended to produce facility master plans 
for every VA medical center at a total cost of more than $100 
million when complete. A significant limitation to this process 
is that it assumes that all future growth in services will be 
provided directly through VA facilities, an inaccurate 
assumption given the increasing role of care in the community. 
Some local VA officials told us that they bypass the integrated 
planning process and instead contract for their own facility 
master plans.
    Additionally, VA has faced stakeholder challenges to its 
facility alignment actions, including from veterans, state, 
local, and Federal officials, employees, historic preservation 
groups, and others. We found that VA has not consistently 
followed best practices for effectively engaging stakeholders 
in these decisions or evaluated the effectiveness of their 
stakeholder communication strategies.
    In conclusion we have made several recommendations that if 
implemented could improve VA's ability to plan for and 
facilitate its alignment efforts. Specifically we recommended 
that VA improve the SCIP process; discontinue or improve the 
utility of the integrated planning process; and improve 
communications with stakeholders.
    Mr. Chairman, this concludes my opening remarks. I am happy 
to answer any questions.

    [The prepared statement of Debra Draper appears in the 
Appendix]

    The Chairman. Thank you, Ms. Draper. Thanks very much. And 
Mr. Sullivan, you are now recognized for five minutes.

                 STATEMENT OF JAMES M. SULLIVAN

    Mr. Sullivan. Good morning, Chairman Roe, Ranking Member 
Walz, and Members of the Committee. I am joined by my 
colleague, Dr. Regan Crump, and we are here today to discuss 
VA's capital asset needs, and we acknowledge the many 
challenges that face us as we attempt to modernize the VA 
healthcare system.
    VA's mission is distinct compared to other agencies. We 
operate the largest integrated healthcare system in the Nation, 
with 135 national cemeteries, 1,700 hospitals, clinics, and 
facilities used to provide benefits and services to our 
veterans. Our portfolio consists of approximately 180 million 
square feet, 86 percent of which is owned, and in many cases 
the average age of a facility exceeds 60 years.
    Most of our infrastructure is in need of repair and 
replacement and requires considerable investment. VA has more 
than $50 billion in capital needs to upgrade existing 
facilities or replace existing facilities to meet modern 
healthcare standards.
    Secretary Shulkin has made it one of his top five 
priorities to modernize the VA system. We are supporting his 
priority by getting rid of buildings that are no longer needed 
to provide services to veterans. We have identified 430 
individual vacant buildings, totaling six million square feet 
across the country. It costs VA an average of $7 million a year 
to operate these buildings and we want to redirect these 
resources to services.
    We are initializing disposal and reuse actions for these 
430 vacant buildings over the next two years. VA will begin 
performing due diligence, ensuring compliance with applicable 
laws and regulations, and initiate disposal or reuse 
transactions. In the last 30 days alone, we commenced the 
process for 71 vacant buildings through an enhanced use lease 
for repurposing buildings at Perry Point, Maryland, 54 
buildings, and we completed the excessing process to GSA of the 
hospital in Pittsburgh, Pennsylvania, which was 17 buildings.
    While we are working with an aggressive timeline to address 
our vacant buildings, we anticipate hurdles that may slow us 
down. Some challenges that can impact our timeline include the 
lengthy processes associated with the National Historic 
Preservation Act, the National Environmental Policy Act, and 
the location and condition of buildings, and local and national 
stakeholder concerns. VA welcomes any support from Congress to 
streamline these processes so that we can more efficiently and 
effectively manage our assets.
    While challenges do exist, and there are many, we have made 
some progress in reducing unneeded buildings. Since 2004 we 
have disposed or reused over 1,000 buildings, totaling 
approximately eight million square feet and about 1,000 acres. 
One of the most successful tools we have experienced using is 
our enhanced use lease authority. EUL allows VA to out-lease 
assets to private and public sector entities for repurposing. 
Currently we can out-lease vacant buildings and excess land in 
return for supportive housing for homeless veterans and their 
families. This program has provided significant benefits to VA 
in terms of cost savings, improved facilities, and increased 
services to our veterans.
    To date over four million square feet has been out-leased 
through EUL and we have in place 2,700 operational housing 
units across the country. VA previously had a broader EUL 
authority but that expired in 2011, and our 2018 budget 
includes legislation requesting the reintroduction of a broader 
scoped EUL.
    VA needs your help and welcomes any new or expanded tools 
to address our most challenging issues that we have. Our 2018 
budget includes proposed legislation to increase VA's 
flexibility to meet some of these needs. The budget includes 
proposals, one, to increase the threshold for the minor 
construction program to $20 million; eliminate statutory 
impediments acquiring joint VA facilities, much as Secretary 
Principi mentioned in his testimony; expanded EUL authority; 
and providing for the authorization of 28 major medical leases 
to serve the outpatient needs of our veterans. In terms of 
addressing recommendations of the independent assessment, the 
Commission on Care, and GAO, VA agrees with the majority of 
these recommendations and recognizes we need to do better. We 
are working towards that goal of a high performing healthcare 
network that takes into account current and future veteran 
demand. VA partnered with private sector experts to conduct 
objective assessments and develop local healthcare 
modernization optimization plans. The primary outcomes of this 
assessment will be plans for each market across the country to 
develop a high performing healthcare network which will then 
feed into VA's capital planning process, SCIP. Once the market 
assessments are complete, recommendations may include needed 
capital investments, divestitures, partnerships, and other 
approaches to modernize VA's infrastructure. These investments 
then will be prioritized and included in future budget 
requests. VA expects the market area optimization plans will 
address many of the issues raised by GAO, the commission, and 
the independent assessment.
    Mr. Chairman, Ranking Member, and Members of this 
Committee, this concludes my statement. We welcome any 
suggestion and as we confront this major challenge facing the 
VA. I am happy to respond to any of your questions.

    [The prepared statement of James M. Sullivan appears in the 
Appendix]

    The Chairman. Thank you, Mr. Sullivan. And I thank all of 
the members of the group that is here today. And I want to 
start by just saying a couple of things.
    One, this is very hard. And this is not glitzy stuff but 
this has got to be done. And I appreciate what each one of you 
bring to the table. And as I said in my opening remarks, that 
the private sector is undergoing exactly the same thing. The 
hospital that my two children were born in in Memphis was at 
the time the largest private hospital in the world, 2,000 beds, 
Baptist Memorial Hospital. That hospital is gone. It has been 
dropped. And they have now downsized to a more efficient, you 
know, 21st Century model where care can be given. And there 
were just hundreds and hundreds of empty beds in that hospital. 
And they realized years ago they had to change their model. And 
I think the VA is undergoing exactly the same thing as the 
private sector is doing now.
    And Mr. Butler, you brought up some great points about the 
historic buildings. And I think we need to look at public-
private partnerships, what we can do with these. We have one in 
my local VA at home that is a medical, basically a museum that 
could be used. But if you engage the private sector and let 
them maintain the building, there are a lot of options out 
there that we could do to maintain these historic buildings and 
have them used for other purposes. And certainly not just 
bulldoze them. I think there are many communities that would 
love to do that and share that rich culture in their community.
    I think Walter Reed is an example. We realized that fixing 
Walter Reed just was not, I mean, as much as I loved going over 
there, it was just too much of an investment for modern 
healthcare. So we moved it out to Bethesda and to a more modern 
facility. So I think the DoD has done some of that and I think 
VA is going to do that.
    And let me just ask, any of you can answer that, how can 
you elaborate on how patient care is impacted by aging 
infrastructure? And would it be fair to say that access to care 
is in some cases negatively impacted by the limitations of an 
aging VA medical facility? And any one of you can take that 
question.
    Mr. Principi. I will start, Mr. Chairman. I certainly think 
that is the case. If you are devoting scarce resources to 
bricks and mortar, you are taking care away from veterans. And 
I think first and foremost we have to provide high quality care 
to veterans, whether it be in a high tech inpatient facility, 
outpatient clinic, or the community. Public-private 
partnership, as this Committee has advocated. So I think there 
is an impact on quality of care. And unless changes are made I 
think it will continue to do so.
    The Chairman. Mr. Butler? Yes, sir?
    Mr. Butler. Hot Springs, South Dakota is a prime example, 
where that facility is a national historic designated facility. 
And it was a facility that was designated to be closed. The 
community was in uproar because of that decision. It would 
place veteran having to drive much further to other facilities 
to obtain their care because care in the local community was 
not available for them. And so I think you have to look at 
everything in totality to make sure that when you make those 
decisions, you are taking everything that needs to be 
considered in play to make sure that the veterans' care, they 
can receive the best care. Regardless of it is in a VA facility 
or it is outside the VA facility. But you have to ensure that 
if you are closing, if the recommendation is to close a 
facility, that the veteran can obtain that quality care 
elsewhere that is convenient for the veteran and does not cause 
hardship to the veteran.
    The Chairman. I could not agree more. I think if you are 
doing that, you should be able to show that actually that 
quality of the care will go up, not lose quality. I could not 
agree more with that.
    Mr. Sullivan, how much total resources are spent 
maintaining space that is either vacant or largely vacant 
across the entire, you may not know this, across the entire VA 
system?
    Mr. Sullivan. The cost we are spending is about $7 million 
annually. If we include what is underutilized as well, it comes 
to about $29 million.
    The Chairman. And so that is a building that is there, that 
is very underutilized or--
    Mr. Sullivan. It is a building, if you look at the example, 
if you had a clinic that had 100,000 square feet and your real 
requirement based upon veteran need is 10,000 square feet, but 
you are using 100,000 to serve them, then that is what an 
underutilized facility would be.
    The Chairman. They did not start the clock on me until some 
time, so I think I have run out of time. I am not sure. So I am 
going to yield to Mr. Walz.
    Mr. Walz. He is kind, I agree. So well thank you all. And 
great testimony, and I think teeing up where we are at. So I am 
going to cut right to the chase, Mr. Secretary, with you is in 
your opinion, I think we all probably know the answer but it is 
important I think to hear it in this setting, what was the 
biggest barrier towards the implementation of the full CARES 
Commission? And how would you suggest we do not make that same 
mistake?
    Mr. Principi. Well I think the clearest limitation, and I 
might add I was very proud of the CARES process. I think the 
team did an extraordinary job. It was data driven. It was based 
on sound information. And very importantly, I insisted that 
there be listening sessions. That they travel around the 
country and talk to the communities, talk to labor, talk to 
management, and really get their insight because it is a 
difficult process. But the clearest, and the veterans 
organizations were fully behind the CARES process and they 
stood with me when the decisions were made. But obviously 
unlike the DoD process, when you do not have some teeth behind 
it, it will fail. The pluses were good but those that wanted to 
realign or close a facility became difficult because of the 
political process, which I enormously respect. It becomes very, 
very difficult. And I tried to point that out in my testimony.
    So I think that this Committee, I urge this Committee to 
create a commission. Allow the Secretary, who I think is doing 
a great job, allow him to come up with the recommendations, 
submit them to a bipartisan commission, and give the commission 
some teeth based on their decisions. Submit the plan to 
Congress and let the Congress vote on the plan up or down, 
rather than singling out individual facilities.
    Mr. Walz. No, I appreciate that. Mr. Butler, I am, up here 
I was just showing the photo around. I am very familiar with 
Hot Springs. I lived in Chadron, Nebraska and then in Pine 
Ridge for a while. I think people need to know that facility is 
drawing from South Dakota, Nebraska, and Wyoming and it is 
pretty open out there. And that is probably one of the most 
beautiful VA buildings. The administration building is 
gorgeous. So I think trying to balance these things about how 
do we save some of these assets in terms of their historic 
value but that one always comes up with me because of the 
massive number of beds. And I think that one might be utilized 
three beds a night because of this change. So I am very 
cognizant of that.
    I want to come back to the process, and maybe this is for 
Ms. Draper, and to you, Mr. Sullivan, about what we are trying 
to get to. And Ms. Draper, first of all, based on what you 
know, are either the VAIP or the SCIP processes truly 
reflective of veteran need, VA resources, and stakeholder 
concerns when managing capital assets? Is this the best 
practice way to do this?
    Ms. Draper. Well we have found limitations with both, as I 
talked about. But one of the issues with the SCIP process, it 
is supposed to be a ten-year planning process but the emphasis 
is really on the first year. So what local facilities told us 
is they often to address gaps identified through the SCIP 
process, they often put projects in out years that they never 
intend to actually undertake. So really the focus is on the 
first year. It is not a long term planning process, as we found 
and we talked about in our report.
    There are also many limitations with the integrated 
planning process. One is that it does not account for the care 
in the community, which is a major assumption that should be 
considered because you do not want to simultaneously develop 
new capacity while you are also getting it delivered in the 
community. But it also has other limitations. For example, the 
costs do not include all the life cycle costs of a project. So 
there are operating costs that are not included that, you know, 
which OMB recommends they be included. There is a lack of 
standardization in the facility master plans. So they have 
different contractors doing the master plans. And so there is a 
lot of variation. So it is really difficult to determine how 
comparable they are. And then the other thing, and I think we 
have talked about this, is accountability. So there are 
recommendations that come out of the integrated planning 
process but there are no requirements for those to be 
implemented.
    Mr. Walz. That is the question, and I think, ma'am, I am 
going to leave it to my colleagues. They will have questions to 
ask because obviously in this, and I am sure Mr. Coffman will 
bring up, in this planning process was certainly the Denver VA 
facility. And this year I am wondering how does all this fit 
together? When we see the VA's budget request a cut to 
construction by 4.3 percent, was that budget crafted by looking 
at these things, putting it together, deciding how we are going 
to dispose of these buildings? How we are going to repurpose? 
And what we need to do to build? I just wonder, and I know it 
is out there and I do not want to be that person who drives by 
a construction project and thinks, I know better than how it is 
done, or why it was decided to do that, but I as a Member of 
this Committee am having a hard time understanding how we are 
making those decisions. So I want to just leave that lay out 
there. That I think we need to know how did we come up with our 
budgeting number? How do we know what we really need? Because I 
am still not convinced we know how to utilize that. And I yield 
back.
    The Chairman. I thank the gentleman for yielding. Dr. 
Wenstrup, you are up.
    Mr. Wenstrup. Thank you, Mr. Chairman. Thank you all for 
being here today. And I think it is important to note that this 
Committee is dedicated to the care of our veterans as well as 
respecting the history of the VA and this Nation. So as we move 
forward, we are going to be facing challenges.
    One of the things I have harped on since I have been here 
is really knowing how productive we are when it comes to 
patient care. And I have always talked about relative value 
units, RVUs, and using that as one standard of measure. So Mr. 
Sullivan or Dr. Crump, maybe you can answer for everyone, how 
exactly doctors that are providing for our veterans in the 
Choice program, how are they paid?
    Mr. Crump. Today in the Choice program doctors are paid 
based on a fee basis. And so we are using the Medicare rates 
for--
    Mr. Wenstrup. Which is RVUs, correct? Relative value units?
    Mr. Crump. Well some of the basis of the fees is RVUs.
    Mr. Wenstrup. Right.
    Mr. Crump. But it is a fee basis.
    Mr. Wenstrup. Okay. So we are tracking that. We know how we 
are paying them and what they are producing. So do we track 
RVUs for all of our producers across the entire VA? Do we know 
what they are producing? And I am going back to something I 
think GAO did a couple of years that ended up evaluating what 
it cost in certain facilities for a primary care visit. And it 
came down to when you add up all the expenses of the facility, 
etcetera, that it was really around $400 to $600 per office 
visit in certain locations. So I think it is important that we 
are tracking productivity as we do this review. So are we able 
at this time to track RVUs of every provider in the VA?
    Mr. Crump. What we are doing right now is changing some of 
our methodologies for tracking productivity and we are 
incorporating the use of RVUs on a national basis.
    Mr. Wenstrup. But so far that has not been done as like a 
requirement?
    Mr. Crump. It has been done to some extent.
    Mr. Wenstrup. Because I think, to some extent, I think that 
is really something we have to look at when we are looking at 
our assets, is how much is actually being produced in a certain 
facility. Maybe it is a physical limitation, or maybe we are 
just spending way too much. It is I think an important tool as 
we are taking on this challenge to understand what is going on. 
Because for example, if I was paid $100 per RVU to pay all of 
my bills in a private practice, I could not sustain that very 
long. And so I think that we have to look at that and say, you 
know, look at our productivity per cost. And the other question 
I have is are there incentives right now in the VA management 
to reduce costs or increase productivity? In other words, 
reduce costs without reducing productivity? Or to increase 
productivity in some way that we are getting more bang for out 
buck? Are there incentives for that in our management?
    Mr. Crump. Dr. Wenstrup, there are provider incentives for 
productivity. And we are also in the process of one of the 
largest modernizations of VA healthcare in history. And so 
improving employee performance and productivity is a part of 
that process.
    Mr. Wenstrup. But can you take a second to describe what 
that incentive is for a provider?
    Mr. Crump. I do not think I would be able to describe the 
exact specification of that methodology today. But we can get 
back to you on it.
    Mr. Wenstrup. And does it vary? Or is it across the board, 
do you know?
    Mr. Crump. It is across the board.
    Mr. Wenstrup. Okay. Well thank you. Because I think this is 
going to be an important thing going forward. And if it takes 
us mandating that this be one of the tools that we have as we 
evaluate our assets, then I think that we should do that right 
here and put that into legislation where we understand what we 
are actually producing. And then hopefully at a local level you 
will have people be able to make some decisions that make 
sense, where you are actually looking at what you are getting. 
What is your bang for the dollar, bang for the buck that we are 
getting?
    So with that, I want to yield back. But I thank you for 
that input. And I do not know if you have anything to add to 
that, Ms. Draper?
    Ms. Draper. I do not. I know that they are working on, you 
talked about productivity, but they do not measure RVUs for 
every specialty that way. So I think they are in the process of 
looking at that, as Dr. Crump talked about.
    Mr. Wenstrup. Thank you. And I yield back.
    The Chairman. I thank the gentleman for yielding. Mr. 
Takano, you are recognized for five minutes.
    Mr. Takano. Thank you, Mr. Chairman. Mr. Sullivan, of the 
430 buildings that the VA has designated as vacant, how many 
provide some type of direct care to veterans?
    Mr. Sullivan. None.
    Mr. Takano. None? Okay. How many, how does the VA plan to 
ensure the veterans' ability, so really, since none of them 
provide direct care, we do not really have a concern about how 
the VHA is going to provide, the veterans, who have, so we do 
not have veterans that are receiving direct care--
    Mr. Sullivan. No. A few of them have some support, some 
administrative support in them. That will be relocated.
    Mr. Takano. Okay.
    Mr. Sullivan. But there is no direct care in any of those 
buildings.
    Mr. Takano. Okay. How was the VA able to determine the 
percentage of utilization for the 430 vacant buildings?
    Mr. Sullivan. It was based upon the folks on the ground, in 
the field, identifying those buildings as vacant or having 
minimal use.
    Mr. Takano. Okay. And of these buildings, so that we 
mentioned that we intend to either dispose or reuse, how many 
have been determined to be unsuitable for the provision of 
services to homeless veterans?
    Mr. Sullivan. In conducting the due diligence, that is one 
of the items that will be looked at.
    Mr. Takano. Okay. So it has not really been determined yet?
    Mr. Sullivan. There has been an initial review annually to 
see if any of those buildings are candidates for homeless 
housing. And some of them, for example in Perry Point, as I 
mentioned earlier, 54 of those buildings are in the 430, came 
off because we could reach a private sector developer to handle 
the housing of those buildings. So there are some, but a lot of 
them are such condition that it really becomes cost effective--
    Mr. Takano. So the evaluation is not really complete for 
all of the 430?
    Mr. Sullivan. Correct.
    Mr. Takano. Okay. Are there current barriers regarding the 
usage of an EUL to ensure the property is determined to be 
suitable for the purpose of providing services to homeless 
veterans? This question is kind of wordy. So are there barriers 
regarding the usage of an EUL to ensure that the property is 
determined to be suitable for the purpose of providing services 
to homeless veterans are utilized quickly and efficiently?
    Mr. Sullivan. The only barriers are actually the financing. 
So from a legislative standpoint, the fix that was made to this 
program a couple of years eliminated most of the barriers in 
terms of housing. What the barrier would be is if you wanted to 
go to a medical EUL model, which is I think what people have 
talked about earlier, which really probably is the future at 
VA. If we can bring in private sector expertise and private 
financing to provide state of the art facilities, that would 
require a change to that program or additional authority to 
that program or a complementary program so that we could use 
that to go out and get needed medical facilities right now 
where we are restricted to just homeless housing or support 
housing.
    Mr. Takano. So , the current statutory framework kind of 
constrains us to serving the homeless. But if we were to expand 
into a--
    Mr. Sullivan. That is correct.
    Mr. Takano [continued]. --partnership in the health area, 
this would greatly expand our ability to--
    Mr. Sullivan. That would be one of the tools to fill the 
gap, especially as I believe GAO and others have testified 
here, we know there is not a limitless pot of money to deal 
with VA facilities. So we have to look at another source. And I 
think tapping private sector financing is the long term 
solution to our capital needs. And not only the capital piece 
of it in terms of their finance ability that they would bring 
to it, but also using some of their expertise using local codes 
and standards, using local practices in the community, so when 
we came in and put a clinic in or a support facility we use 
those standards and those practices there. So that they would 
be financeable and they would also, should VA not have a use 
for them in the future or as time went on, they would easily be 
reusable by the private sector because we were using their 
script for doing this. And I think that is absolutely key as we 
go forward. And I know we are working within the administration 
hopefully in the President's infrastructure bill to submit that 
kind of a proposal to Congress.
    Mr. Takano. Well Mr. Sullivan, with this in mind, what is 
the status of the public-private partnership pilot program?
    Mr. Sullivan. Right now we do not have a true public-
private partnership program. What we have is the CHIP IN Act, 
which is a donation program that Congress gave us which we 
really appreciate for five pilot sites. What we would see is a 
better model, or not a better model, but an additional model 
would be an expanded EUL or a true P3 program that would allow 
us to tap private sector financing and private sector 
expertise. And I think in this instance there is not one single 
tool that is going to give us this. I think we need to look at 
it with multiple tools, whether it is EUL, P3, other models 
which other folks on the Committee may have ideas on as well. I 
mean, we need to look at a whole suite of tools to be able to 
deal with this huge challenge we have.
    Mr. Takano. Speaking to Members who have districts with 
some of these aging facilities, I mean, I think you are right. 
I think there is a lot of folks that are looking at all sorts 
of ways they can reuse these properties which I believe would 
not have to be to the detriment of providing the current 
healthcare needs of the veterans that are being served. I yield 
back, Mr. Chairman.
    The Chairman. I thank the gentleman for yielding. Mr. 
Coffman, you are recognized for five minutes.
    Mr. Coffman. Thank you, Mr. Chairman. And I thank you, Mr. 
Principi, for being here today and for your service to our 
country as the former Secretary of the VA. There are 430 
buildings, VA buildings, vacant for the most part. Now it is my 
understanding that the Secretary, when you were Secretary, and 
the Secretary now, does not have the unilateral authority to 
close any of these facilities or dispose of any of these 
facilities, am I correct in that?
    Mr. Principi. I believe he does have the authority.
    Mr. Coffman. He does have the authority?
    Mr. Principi. Yes, absolutely. And again, it could be 
stopped or rescinded by Congress if they elect to do so. But I 
believe I had the authority to close or realign VA facilities 
or buildings subject to certain limitations.
    Mr. Coffman. Okay. Mr. Sullivan?
    Mr. Sullivan. Yes. That is absolutely correct. What we are 
talking about here are individual buildings, and there is no 
prohibition on the closing of individual buildings, except 
complying with historic, environmental--
    Mr. Coffman. Right.
    Mr. Sullivan [continued]. --and other regulatory issues 
that do take some time. But there is no prohibition on those.
    Mr. Coffman. But I understand closing, but disposing of?
    Mr. Sullivan. There is no prohibition.
    Mr. Coffman. Okay.
    Mr. Sullivan. We will either reuse it through one of our 
tools or we will do a report of excess and give it to GSA as we 
have, for example, just on the Pittsburgh hospital.
    Mr. Coffman. So why have you not moved on the 430 buildings 
that now stand vacant?
    Mr. Sullivan. We have. In this case, we have moved on, in 
the last 30 days we have moved on about, I can give you the 
exact number, it was about 71 of them. We expect to move on an 
additional 71 of them within six months, and within another 
year about 288 additional ones. So by the end of two years we 
will do the entire 430 will be commenced in that process, 
whatever it is.
    Mr. Coffman. And how long does that process take to go 
through? Or is it fairly variable--
    Mr. Sullivan. It is really market driven--
    Mr. Coffman. Yeah.
    Mr. Sullivan [continued]. --based upon, if we are going to 
GSA to sell it, it is going to be based upon the market, what 
GSA can get for those buildings and how hard they find to do 
it. If we find a partner to reuse it, it could move pretty 
quickly. If it is a simple demolition, depending upon historic 
and environmental issues at the site, it can, you know, be 
anywhere from six months to 18 months depending upon that 
process. It is very locally driven and in each state, for 
example, the historic preservation entity in some states are 
very cooperative with VA and look to move forward. In other 
states it is more of a challenge and that takes more time.
    Mr. Coffman. Does GSA, once you turn it over to GSA, do 
they take it from there? Or is it, do you have to, is it a 
cooperative--
    Mr. Sullivan. It is cooperative but they really have the 
ball.
    Mr. Coffman. Okay. Good.
    Mr. Sullivan. They are the ones who do this all the time. 
They have an office set up that just does this as their single 
focus. And that is why we took Pittsburgh, for example, and 
gave it to them. We plan to have two or three other hospitals 
that have been vacant for a long time moving to GSA pretty 
quickly.
    Mr. Coffman. Why has it taken so long to get this process 
started? It just seems like you have identified the 430 but 
then we are just, it seems like we are just starting on this 
process.
    Mr. Sullivan. Well now since 2004, I think I can give you 
the figures--
    Mr. Coffman. Right.
    Mr. Sullivan [continued]. --I think we have gotten rid of 
eight million square feet through this process. We did not use 
GSA, quite honestly, until the last year or two because prior 
experiences with GSA were not very receptive to moving 
properties. But I think they have retooled and refocused so I 
think it is a good opportunity.
    Mr. Coffman. Okay. What is the point of having a hotel in 
Paris?
    Mr. Sullivan. VA--I think you are referring to the Pershing 
Hall facility?
    Mr. Coffman. Yes.
    Mr. Sullivan. Yes. Congress gave it to VA because at the 
time it had fallen dormant. There were squatters in the 
building. They gave it to VA after several other agencies 
attempted to maintain it. And we used a EUL like authority to 
put a hotel in place and VA receives $300,000 to $400,000 a 
year in rent from that hotel. And I know there is a proposal 
for folks who want to sell it. VA supports selling that. We do 
not have the authority to do it. And if it is, if we are given 
the authority, we would hope that the basis for the sale would 
be the market value of that asset, which we believe is 
somewhere between $30 million and $35 million, which we would 
hopefully in that legislation be given the authority to 
reinvest that money in care for veterans or in infrastructure 
improvements. So we were tasked by Congress to take it over and 
we did it. And there is no pride in ownership of that asset, I 
mean.
    Mr. Coffman. Thank you. Mr. Principi--
    Mr. Principi. Yes.
    Mr. Coffman [continued]. --was that under your watch? Or 
was that under--
    Mr. Principi. Actually, Mr. Sullivan knows it was on my 
watch when I was Deputy Secretary during Bush 41 and Chairman 
Montgomery of this Committee urged me to take possession. It 
was actually an American Legion, it is called Pershing Hall, it 
was an American Legion building. An absolutely extraordinary 
structure in the heart of Paris. And it was in really, as Mr. 
Sullivan indicated, really in a state of disrepair and 
magnificent artifacts were being stolen. And so I became the 
landlord, so to speak, and it became a hotel. And that is where 
it stands today.
    Mr. Coffman. Okay. Thank you, Mr. Chairman. I yield back.
    The Chairman. I thank the gentleman for yielding. Ms. 
Brownley, you are recognized for five minutes.
    Ms. Brownley. Thank you, Mr. Chairman. And I too thank the 
panelists for being here this morning. I wanted to direct my 
line of questioning around leasing and what I believe to be 
advantages of leasing versus building brick and mortar 
facilities across the country. And particularly, when you look 
at our community clinics across the country. I know right now 
today we have 30 lease authorizations for facilities for 
clinics across the country, but yet we do not seem to get 
there. And I think there is a rationale behind that. But I was 
just wondering, Mr. Sullivan, you know, with 30 lease 
authorizations out there for new facilities but not meeting 
that need, I mean, what do you think that delay is with 
regarding patient care?
    Mr. Sullivan. Right now we have 28 leases that are, 28 that 
are pending authorization. And that represents about 2.2 
million annual visits of care. Many of these have been 
submitted in the budget for the last two years. We believe 
that, we have not had a case where a lease has closed. But we 
are very fearful that about 50 percent of these are replacement 
leases for existing leases that are out there. And through a 
lot of good work and diligence by our real property people we 
have kept them all open. But at some point an owner of one of 
these leases can say, I do not want to, I do not want to stay 
anymore. So I mean, there is some risk there. We also, probably 
a bigger risk is that once we reach the end of some of these 
terms, we are at the mercy of the person who owns it. In a lot 
of cases they have increased the rents and we have no choice 
but to pay it. So, I mean, it is a big issue for us in terms of 
creating that additional access. And we believe leasing is 
better, not in every case but in a lot of cases, than building 
and owning so that we can walk away at the end of a lease term 
if we have it.
    Ms. Brownley. Well thank you. And I agree. I think leasing 
based on the map that the GAO showed in terms of changing 
demographics across the country, I think leasing gives us the 
appropriate flexibility that we need to be able to change and 
move given the movement and where the greatest needs are. And I 
know that currently the GSA scores leasing for veteran 
facilities differently than they do for any other Federal 
government buildings. And can you comment on, I know I have a 
piece of legislation to try to fix that, but that seems to be 
one of the big barriers in terms of authorizing these leases, 
is that they, if it is a 20-year lease or a 30-year lease it is 
scored for the full cost of 20 years or 30 years in the first 
year, and that is the barrier. So can you comment on that? And 
do you recognize that there needs to be a fix?
    Mr. Sullivan. Absolutely recognize there needs to be a fix. 
Secretary Shulkin challenged us a couple of months ago to meet 
with CBO, who is the scorer, as many people know, of these 
transactions. And we met with CBO and they told us in no 
uncertain terms that the way our leases are structured, and 
even if we change the way they are structured, there is nothing 
we can really do to the transaction that would have them change 
their score. So that is the legislative holdup. And I think the 
score on the legislation is probably around $1 billion, I 
think, is what they came up with.
    Ms. Brownley. I apologize. I said GSA.
    Mr. Sullivan. That--
    Ms. Brownley. I mean CBO.
    Mr. Sullivan [continued]. --CBO, sorry.
    Ms. Brownley. But to Ms. Draper, do you have any comments 
on how these leases are scored and where you think improvements 
might be, or not?
    Ms. Draper. We have, I have not really looked at that. So I 
would be unable to comment on that. But I could see if we have 
done work on that and provide you some additional information.
    Ms. Brownley. Okay. I think, you know, I just, I again just 
personally believe that this is something that we have got to 
fix. That this, the way it is scored, I do not know if anybody 
on the panel, Mr. Principi, maybe you know the history behind 
this? And why it was changed? I am not even sure exactly when 
it changed. But I have been told that it was changed a while 
ago, specifically just for VA facilities and no changes for any 
other Federal buildings.
    Mr. Principi. Yes. I do not recall exactly when it was 
changed. I thought it was done by OMB in the 2000 timeframe, I 
believe. Maybe Mr. Sullivan knows. I do not.
    Ms. Brownley. Nobody knows the rationale for it, though?
    Mr. Sullivan. CBO about four years ago, five years ago, 
just changed the way in which they treated these as operating 
leases and started scoring them over the entire term of the 
lease. I cannot come to explain how they changed their 
interpretation. I leave that to them to explain.
    Ms. Brownley. Well I think it is an important piece of this 
kind of overall discussion, is trying to really focus on this. 
And as we move forward in evaluating facilities and evaluating 
I think the advantages of leasing over building permanent 
structures so that we do have this nimbleness and flexibility. 
With that, I will yield back.
    The Chairman. I thank the gentle lady for yielding. I will 
just make a quick comment that the way this is scored we have 
to give the CBO the Forrest Gump Award, stupid is as stupid 
does. Nobody in the world would score--anyway, I will yield now 
to Mr. Higgins.
    Mr. Higgins. Thank you, Mr. Chairman. Mr. Sullivan, you 
have addressed the enhanced use lease program greatly to my 
colleagues. I would like to add that my office requested data 
from the last couple of months regarding identifying actual 
structures that were perhaps targeted for sale or destruction 
and ultimately last night we found that there was one in my 
state and none in my district. So my comment may apply more to 
my colleagues than to myself. But during the course of 
researching what we would do with those facilities if they 
existed in my district, we are concerned about veteran 
homelessness and transitional housing for our veteran brothers 
and sisters that struggle to, with reentry into civil endeavors 
when they leave the military. And many of these facilities 
have, you know, many rooms that could be considered a small 
apartment. They have kitchen facilities and laundry facilities 
and meeting facilities. And they could be remodeled into 
transitional housing for homeless veterans. So in the process 
of researching this, I spoke with veteran owned construction 
companies in my district, and every one of them was adamant 
that they would be willing to donate their services and their 
own private capital to remodel and restore these facilities. We 
also spoke with charitable services that work with homeless and 
indigent Americans. And they would be willing to lease the 
properties and maintain them once they were remodeled over a 
20- or 30-year lease. So I would suggest that common sense 
solutions like this be considered regarding the structures that 
exist that are targeted for sale or destruction. Perhaps the 
relationship between the VA and the VHA and the public and 
private sector can include solutions that would cost the 
people's treasure virtually nothing and yet would provide an 
invaluable service for transitional housing for homeless 
veterans across the country. It does not affect my district 
because I do not have any structures. But perhaps some of my 
colleagues may consider this approach.
    Ms. Draper, my question is for you regarding the means by 
which money is assessed, and personally I believe the money 
should follow the veteran, and I believe that we should move 
away from the mother ship structure that historically the VA 
and VHA has maintained. My district represents the highest 
density of veterans in the state but we do not receive the 
highest percentage of money. And this money is assessed 
according to the veteran population that is registered within 
the VA. But the veterans because of the need to travel to the 
mothership hospital, in in my case Alexandria, the veterans 
have lost faith in the system so they are not counted. They are 
not counted. The veteran himself is not counted. They are only 
counted and the money is aligned according to those that are 
registered within the system. But we seem to be blind to the 
fact that so many thousands and thousands of our veteran 
brothers and sisters have become disenfranchised with the 
system. That is the problem that we are trying to fix here. So 
can you please speak to whether when assessing where assets are 
most needed, the VA considered the entire eligible veteran 
population or solely the enrolled veteran population? As we 
work to expand more care to veterans I think it is important 
that this money be assessed based on reality.
    Ms. Draper. Well they use a couple of models. One is the 
veteran population model, vet pop, and then you know, looked at 
another model of demand for care and the resources that would 
be needed to supply that demand.
    One of the things that we talked about in terms of the SCIP 
process, the long term planning process, is that try and match 
or align the need of facilities for services for the veteran 
population, one of the key weaknesses that we found is that 
sometimes writing the SCIP narratives, which is a third of the 
scoring process or the score, it really is often dependent on 
the ability of the writer to meet some of the goals of what VA 
has laid out rather than the merits of the project itself. So 
we found cases in the field where some facilities never had a 
SCIP project funded. So you know, there needs to be, that is 
the limitation of that planning process as well. It needs to 
be, you know, looking at the merits of the project itself 
versus somebody's ability to write the narrative.
    Mr. Higgins. Thank you for your answer, ma'am. In the 
interests of time, I would like to ask that could my office 
provide questions, more detailed questions to you, ma'am, that 
we could expect answers to? And perhaps get to the bottom of 
this? Mr. Chairman, thank you for the time. I yield back.
    The Chairman. I thank the gentleman for yielding. Ms. 
Kuster, you are recognized for five minutes.
    Ms. Kuster. Thank you very much. And I just want to pick up 
on my colleague's suggestion. We have an opioid crisis in New 
Hampshire. And one of the issues is transitional housing after 
treatment to continue the intensive outpatient treatment but to 
have a place to live. So I like your idea quite a bit.
    My question about these 430 buildings that we are trying to 
address is that a significant hurdle for disposal of vacant and 
underutilized buildings is finding lessees and buyers, as you 
talked about, because of the condition of the buildings. And my 
question is have you considered whether the VA would actually 
spend money to bring some of the buildings up to code? Or make 
them more usable perhaps for this type of transitional housing? 
Or other uses? And if so, or do you intend to simply demolish 
the buildings and use them, just sell the land? And the 
question relates to whether you have made any cost projects and 
whether you need any additional authorities or appropriations 
to take that approach?
    Mr. Sullivan. At this point we do look at all the 
alternatives. As I think I mentioned earlier, we are going 
through a due diligence process on all of these 430-some odd 
buildings. And we will, you know, there has been an initial cut 
that has looked at the potential for both transitional and 
permanent housing and have not found a particular need as 
identified at the local level. But that will be double checked 
as they go through due diligence. And if there is, then we 
would welcome in any of these places if there is a need and we 
can put together an operator and a developer to run these and 
to finance these that would be the perfect solution to us. We 
have encouraged it. We have done about 100 of these projects 
across the country. The more we can do and especially since 
they are all third party financed, you know, it does not take 
away from our core mission of having those resources to 
directly to veterans' care. So we would continue to do that. In 
terms of a cost estimate we, as we are doing the due diligence 
process we are developing a cost estimate based upon what the 
chosen course of action is in each of those buildings.
    Ms. Kuster. So I would just sing the praises of a program 
in my district in Nashua, New Hampshire, Harbor Homes, that has 
been a game changer for our veterans. We have recently achieved 
a functional zero for homelessness for our veteran population 
due in large part because of the transitional housing that is 
available. And I certainly know from the incredible stories of 
meeting with veterans how this has changed their life. I got to 
know one particular veteran, there was sort of a camp, they 
were living under a bridge. He was an older gentleman. But come 
to find out he was diabetic and he had no access to medication 
and no access to treatment. When he got into the transitional 
housing, got the treatment he needed, got some counseling, some 
job skills training, total turned his life around. And we 
learned that he had been middle management in a high company in 
our area. So he was reunited with his family. It is an 
incredible story.
    The question that I have around this that concerns me, 
however, is that VA's request to cut the construction budget 
for fiscal year 2018 by 4.3 percent, or $45 million, and what 
will this do in terms of your capital assessment for these 
properties going forward? And how can we help to make sure that 
you have both the authorities and the resources that you need?
    Mr. Sullivan. Sure. The fiscal year 2018 budget for minor 
and major construction is what you are referring to. That would 
not have an impact on the disposal of these buildings.
    Ms. Kuster. So which budget would you be taking those funds 
from?
    Mr. Sullivan. Depending upon the amount of money, it would 
probably come out of the non-recurring maintenance budget. And 
in 2018 I believe it is a $809 million increase in 2018 to, I 
can get the exact, I think it is 1.8.
    Ms. Kuster. Okay.
    Mr. Sullivan. But I do want to, you know, because it was 
raised earlier, the budget. I think the major and minor 
construction budget figures were based upon a total 
discretionary dollar figure that was given to VA. And VA in 
these limited budget resource times had to prioritize between 
direct medical care, research, and other things. And it was a 
functioning of balancing the appropriation request to Congress 
to live within a total cap and those, you know, these accounts 
were on the lower end of the scale, if you would.
    Ms. Kuster. Well I would agree with the Secretary that 
every tax dollar is sacred and we need to spend it wisely. But 
we want to make sure that you have the resources to serve the 
veterans. So thank you. My time is up. I am yielding back.
    The Chairman. I thank the gentle lady for yielding. General 
Bergman, you are recognized for five minutes.
    Mr. Bergman. Thank you, Mr. Chairman, and thanks to all of 
you on the panel for being here today. This is so important 
because all the questions you have heard everybody is trying to 
make a positive difference. Mr. Sullivan, CBOCs, I see as a 
drive around the First District of Michigan, we have some nice 
new CBOCs that are built. Are they owned or leased?
    Mr. Sullivan. They are all, they are all leased I think 
except for two or three.
    Mr. Bergman. Okay. In the leasing process, could anyone 
tell me if they considered, regardless of where in the country, 
if they considered possible already existing space? Many of us 
have Native American tribes who have the health clinics that 
have excess space. Were those facilities in conjunction with 
our tribes considered before building or leasing a CBOC?
    Mr. Sullivan. When we go out, and I am not the contracting 
expert and I can get you more details, but my understanding is 
that when we go out for a lease solicitation the first option 
that we ask people to consider is existing building, existing 
space somewhere rather than having to do a build to suit 
project. And some of the smaller leases, we do see that. Most 
of what I think people here were talking about earlier were all 
leases over a $1 million. The smaller CBOCs that are managed 
and contracted for at the local medical center or VISN level, 
they do look at existing space first.
    Mr. Bergman. But were the tribes given any priority?
    Mr. Sullivan. I would have to check with contracting.
    Mr. Bergman. Okay. I would like--
    Mr. Sullivan. I do not--
    Mr. Bergman. I would like you to take that for the record--
    Mr. Sullivan. But we can get back to you.
    Mr. Bergman [continued]. --and get back to me. Because as 
you know, our tribal members have a high, high, high 
participation rate, especially in wartime. And I believe we 
have a, not only an obligation but an opportunity to partner 
with those already existing medical facilities that are 
provided for. So that is, I would like you to look at that very 
closely going forward.
    Mr. Sullivan. And there might also be the opportunity for a 
sharing agreement with the tribes or other entities instead of 
a real property instrument to be able--
    Mr. Bergman. Absolutely. And thank you for using the word, 
because the more we get into the idea of shared services, 
shared services are something that are, number one, going to 
provide a higher quality of care or the housing. And number 
two, it is going to save those valuable dollars. We know that. 
And thank you for going down the shared pathway.
    Different, kind of a different tack here, GAO claims, Mr. 
Sullivan, you are still the winner here.
    Mr. Sullivan. Sure.
    Mr. Bergman. That in, GAO claims that in 2016 VA reported 
370 buildings that were either vacant or less than 50 percent 
occupied. However, last month the VA announced an initiative to 
begin either repurposing or disposing of 430 vacant buildings 
over the next two years. Why did so many more buildings become 
vacant in the last year? And how many more buildings do you 
expect to become vacant or largely so in the next year? And 
why?
    Mr. Sullivan. I think the reason why is can be fairly 
easily explained. Each year we go out to the local users of all 
of our facilities and we do an assessment and ask them to give 
us the status of their assets. All the spaces we own, all the 
owned space, and all the leased space. And in that data call we 
go out and ask them to say identify facilities that are vacant. 
So each year, and it closes at the end of the fiscal year, we 
get a report. And it takes about two months to process. So each 
December we put out a number of what the number of vacant 
buildings are and it is based upon the submissions that came in 
that year. So each year you will see some are added, some are 
taken off, because we have been disposing of about 100 of these 
a year over the last ten years. So the numbers will flex.
    Mr. Bergman. Is there a checklist or anything that you, the 
VA works through when you start this process that, you know, 
some of us could view if we say, okay, here is what triggers it 
and we ask the following questions or the criteria?
    Mr. Sullivan. Yes, I believe there is a validation process 
when they go out to validate the data in the field. I would be 
happy to provide whatever we have to you.
    Mr. Bergman. Okay. Ms. Draper, was GAO able to determine 
costs for maintaining equipment, beds, and utility usage in 
unused portions of the VA medical centers?
    Ms. Draper. We did not look at that for this current work.
    Mr. Bergman. Okay. Thank you. And that is my last question. 
Mr. Chairman, I yield back.
    The Chairman. Thank you, General Bergman. Mr. Correa, you 
are recognized for five minutes.
    Mr. Correa. Thank you, Mr. Chairman. First of all, I want 
to thank all of you, the panelists for being here today and to 
all the veterans here. Thank you for your service to our 
country.
    I wanted to follow up on some of the questions of my 
colleagues, which are shared services and also in my district 
and my state thinking about how many vacant buildings do we 
have in California, Southern California? Number two, have we 
reached out to local, state, county, city services, governments 
to address again the issue of homeless vets? And are we looking 
at operating in silos or have we actually worked with a lot of 
those folks? Local municipalities, local counties, and the 
state, they are all raising taxes right now to address this 
homeless issue that continues to explode in our backyards. We 
are talking about 430 buildings here underutilized.
    Mr. Sullivan. Yes, we do. One of the hallmarks I think of 
working with an enhanced use lease, especially on permanent or 
temporary housing, is that we actually work with the local 
public housing authority and work with the local cities and 
towns. Because in many of the cases some of the funding sources 
could come from tax credits locally or from other funding 
sources, as well as the operator of the facility has to be 
familiar with the local area and with the local providers. And 
in almost every case it is a local on the ground community 
provider who will come in and do that. I know in California we 
have done that in West L.A. We opened up a facility in West 
L.A. a couple of weeks ago. We have four more that are slated, 
that are in process there, where we have developers--
    Mr. Correa. That is the West L.A. UCLA property?
    Mr. Sullivan. Yes, working there with developers, 
nonprofits, to put in homeless housing for another 300 or 400 
units in the next two years.
    Mr. Correa. Any other facilities in Southern California 
that you are working on?
    Mr. Sullivan. I would have to get the list. I--
    Mr. Correa. I would love to see that data, if you have it.
    Mr. Sullivan. Sure.
    Mr. Correa. And also in terms of the 430 facilities, we are 
all looking at taxpayer dollars here. We are all looking at 
cash flows, annual budgets. Yet I cannot help but think at the 
local level where in Southern California, my district, school 
districts 30 years ago where enrollment went down, sold a bunch 
of the schools. Enrollment went up. We had to go buy properties 
back at three or four times the price to make sure we had the 
capacity for new and emerging enrollment. I just want to make 
sure, and I am sure you are looking at that from a financial 
perspective, as you move ahead, you have got to make sure you 
budget yourself, save those taxpayer dollars, but also looking 
to the future in terms of our capacity to take care of our 
vets.
    Mr. Sullivan. We are.
    Mr. Correa. Thank you, Mr. Chair. I yield back my time.
    The Chairman. I thank the gentleman for yielding. Let us 
see, Miss Gonzalez-Colon, you are recognized for five minutes.
    Miss Gonzalez-Colon. Thank you, Mr. Chairman. And thank 
you, all Members of the panel, for being here. Mr. Butler, your 
testimony rightly notes that many of the VA medical centers are 
landlocked, which prevents them from expanding. Do you have any 
recommendations on how to assist those facilities to grow?
    Mr. Butler. Well I think the VA should, those facilities 
should use existing processes in terms of SCIP and so forth to 
evaluate their current needs and then follow that process all 
the way through. The concern that we have is that process takes 
too long. And so VA needs to refine the process to ensure that 
whatever model facilities are using, that model can rapidly 
respond to the urgent and emergent needs available at the time.
    Miss Gonzalez-Colon. Thank you. Ms. Draper, in terms of 
your report, you make some reference to the short term growth 
in demand for the VA healthcare services followed by an 
eventual decline in the veteran enrollment. How would you 
suggest that the VA plan for that in the years ahead? And are 
you aware of any other Federal agency that are making plans for 
those kinds of declines in those kinds of enrollment, or 
similar challenges?
    Ms. Draper. I think it gets to a lot of the discussion 
about ensuring that there is flexibility in what type of health 
services are being provided, either through bricks and mortar 
or through care in the community. And you know, as we reported 
in our report, there are some limitations with the process as 
it currently stands. You know, you are setting up a situation 
by not having an assumption in the planning process that a lot 
of the care is being shifted to care in the community. So you 
are simultaneously developing capacity both in terms of what VA 
is doing and then what care in the community is being done. So, 
you know, when the population is starting to decrease then you 
are going to be left with some situations where you have over 
capacity and that is a concern that we explained in our report.
    Miss Gonzalez-Colon. Thank you. Mr. Sullivan, and this is 
kind of the same matter, with the problems we are facing with 
the recruitment of physicians and personnel to attend that 
demographic decline we are having in the veteran patients, what 
kind of strategic planning is the VA doing for new recruitment 
for healthcare services?
    Mr. Sullivan. I am sorry. That is a little out of my lane. 
I do not know if Dr. Crump here--
    Mr. Crump. Is your question about recruitment for 
providers?
    Miss Gonzalez-Colon. Yes.
    Mr. Crump. There is a very aggressive approach. Even Dr. 
Shulkin, the Secretary, has been out speaking with medical 
schools, speaking with large organizations, requesting that 
people apply. We are also looking at flexibilities to be able 
to directly appoint medical center directors and VISN 
directors. So it is a very aggressive effort to recruit new 
providers into VA because we have a constant turnover.
    Ms. Draper. And I can also address that. We actually have a 
report that will be coming out later this summer that looks at 
provider, physician recruitment and retention.
    Miss Gonzalez-Colon. We face that problem on the island. We 
lack a lot of specialists on the island and we are even 
bringing them from so many states. They do not want to move to 
the island. And we are attending not only the people from the 
island, but from the Virgin Islands, too. And in that manner, 
it is a little bit difficult to attend the patients that we 
have with the shortage of physicians.
    In another area, I was a little bit surprised, Mr. 
Sullivan, to hear that VA is behind only from the DoD in terms 
of the, and the Department of the Interior, in terms of the 
numbers of historic properties. In that matter, are there any 
statutory or regulatory changes that could be made to lessen 
the burden of historic properties on the VA capital asset 
planning that we can make?
    Mr. Sullivan. I think there are. I think we want to be 
fully compliant with historic preservation goals in the 
statutes that are required. I think what we would ask for is 
for a more expeditious process to speed that process up. Right 
now it can be extensive in some cases, which adds a lot of time 
to doing any transaction.
    Miss Gonzalez-Colon. If you want to make any direct 
recommendation of changes, please provide it.
    Mr. Sullivan. Sure, we will. Thank you.
    Miss Gonzalez-Colon. Thank you. Thank you, Mr. Chairman. I 
yield back.
    The Chairman. I thank the gentle lady for yielding. Ms. 
Rice, you are recognized for five minutes.
    Miss Rice. Thank you, Mr. Chairman. Mr. Principi? Is that 
how you say your name? I just want to go back to a comment that 
you made when you were asked about what happened with the CARES 
program and its elimination. You said that there were some 
political concerns. Can you just expound on that?
    Mr. Principi. I think the problem is that politics got 
involves in some of the tougher decisions to close or realign 
medical centers. Canandaigua, New York, a 1,700-bed long term 
psychiatric facility built in 1932 at a time when we took 
veterans with serious psychiatric needs away from their homes, 
away from the cities, and placed them in a long term facility, 
much like we did with all Americans, not just veterans. And 
during the CARES process I noted that there were only, it had 
an average daily census of about 166 patients, less than ten 
percent of this magnificent, this huge, 100-acre campus with a 
1,700-bed facility. Well when the decision was made to close 
that facility, it was stopped. And I think that is part of the 
process when there is not some teeth in this process.
    But I think it is important to bear in mind, 
Representative, that the VA healthcare system, although it 
predates World War II, like 1932 and the 1920s when following 
treating tuberculosis in sanitariums those facilities became VA 
facilities in the twenties. Much of the infrastructure today 
was built after World War II to take care of 16 million 
veterans coming back from the War and then shortly thereafter 
the Korean War. So you have these facilities built in the 
forties and fifties when you needed 800-bed hospitals, maybe 
2,400-bed hospitals in cities that you no longer need today 
because there has been such a significant shift in the way we 
care for people today.
    So although Mr. Sullivan talked about the cost of empty 
buildings and underutilized buildings, I do not think that 
takes in to consideration could we do with new, modern, one 
new, modern healthcare medical facility in a city, as to three 
that were built in 1944? And I do not think the cost, I think 
the cost is much greater than the $9 million or $25 million the 
VA is spending today. And I think that is going to take a very 
comprehensive assessment, careful, open, transparent, data 
driven, visits to around the country to do it right. To look at 
the assessment, the needs, the medical needs of our veterans 
over the next ten to 20 years. I know that is difficult because 
healthcare changes daily. But I think you need an assessment 
like that and I urge the Committee to consider doing that.
    Miss Rice. Well I think it is a very good recommendation. 
And I am going to say what you were I think too cautious and 
respectful to actually say. You know, we, a lot of us up here 
spend a lot of time with panelists like you and say, what can 
we do to help you? Well in this instance, in the subject matter 
that we are talking about right now, I think it is really clear 
what has to be done through all of your hard work, 
recommendations, you implementing it, you making the 
recommendations, you having, all of you, your recommendations. 
What we have to do up here in my humble opinion, and I think 
that, I feel very confident that if there is any Committee in 
Washington, D.C. that has the political courage to do what is 
necessary it is this one. What you are saying, and you were 
talking about a facility in New York, is that you need 
politicians like us to be courageous enough to make the case 
for why certain facilities have to be closed for whatever 
reason and not make it about abandoning veterans in their time 
of need. And that has always been the hot potato that no one 
ever wants to touch. And I think we have to, it is not enough 
for us to just sit here and ask you, what can we do to help 
you? We know what we can do to help this realignment that has 
to happen if we are fully going to enable the VA to go into a 
21st Century medical treatment mode. So I just want to throw 
that out, Mr. Chairman. And I want to say that I am very 
grateful that we have your leadership and the leadership of 
Ranking Member Walz to help us do the right thing here. Thank 
you, and I yield back.
    Mr. Principi. If I can just add very briefly, I think if we 
do not do that, and it would be collective, I think the VA will 
fail and will fail the needs of veterans. I do not think this 
can be sustained ten or 15 years. Looking at the demographics 
of the veteran population, World War II, all but gone; Korea, 
almost all but gone; my generation that fought in Vietnam, 
getting up there. There is going to be a dramatic decline in 
demographics of veteran population, the shifts in where they 
are moving to, this vast infrastructure, the cost to the 
taxpayer. I think we need to look at it very carefully.
    The Chairman. Well the Secretary is doing real well. He 
started talking about Vietnam here, guys. He is meddling now, 
when he was talking about our age guys. Mr. Poliquin, you are 
recognized for five minutes.
    Mr. Poliquin. Thank you, Mr. Chairman, very much. I would 
like to salute Miss Rice for what she said. We have got to have 
the guts to do what is right here. And it is all about taking 
care of our veterans. You know what really drives me crazy? Is 
that we were just dealing, Mr. Chairman, recently with a 
similar issue at the entire Federal government level. There are 
about 3,120 vacant and unused office buildings owned by the 
Federal government, not just the VA. You have about 340 of 
them, but it is about 3,100. It is costing the American 
taxpayers $1.7 billion per year to maintain 3,120 vacant and 
unused office buildings. Office buildings, old barracks and 
what have you. You have got to keep, you have got to make sure 
they are heated, in some cases, right, if they are in the 
northern climates like Maine or Minnesota. Or you have got to 
make sure the roofs are not leaking. Then you have the 
liability with them. So what the heck could we do with that 
$1.7 billion per year? Instead we are hanging on to these darn 
things.
    Now let us drive down, Mr. Sullivan, a little bit and make 
sure I understand this. You folks have about 430 buildings that 
are vacant or unused. By the way, six of them are in Togus, 
Maine in Augusta, which is our only VA hospital. And we love 
Togus. We are watching them closely. But we love Togus.
    Mr. Sullivan. We do too.
    Mr. Poliquin. Good. And someone said that. I do not know 
who said that. But anyway. But we have six right there on 
campus. So my question is if you are spending about $7 million 
a year, or whatever you said, Mr. Secretary, $7 million a year 
to maintain these buildings, and you are going to get rid of 
them over the next couple of years. I understand that. Correct? 
And you have the authority to do that, right? David does.
    Mr. Sullivan. Correct.
    Mr. Poliquin. Secretary Shulkin has the authority to do 
that. Okay. Then what about this Paris Hotel? I want to close 
the loop on this. I think Mike Coffman has a bill, Mr. 
Chairman, that gives Mr. Shulkin the authority to sell a hotel 
that you said, Mr. Sullivan, is worth $35 million--
    Mr. Sullivan. Correct.
    Mr. Poliquin [continued]. --and we are getting $350,000 a 
year in rent. That is a one percent return. What are we in that 
business before? That is the most ridiculous thing I have ever 
seen in my life. Right? But you have, Mike is going to drop 
that bill, right? So we can get rid of that hotel--okay. Good. 
So we are getting there.
    Now I think Jack Bergman asked this question, Mr. Sullivan. 
I want to make sure I get this. As you proceed along this 
process, or Mr. Shulkin does with your help, I want to make 
sure this Committee, if I may, Mr. Chairman, is informed on how 
you are doing. Because the next time you are going to be here, 
I am going to ask you that question. So is there a process in 
place so we know you are on schedule to dispose of these 
buildings? Because every dollar we save, every asset that we 
are not maintaining, can go back into helping our kids that 
come back from combat with wounds, and so forth, and so on.
    Mr. Sullivan. We plan to have a periodic update. Probably--
    Mr. Poliquin. What is periodic?
    Mr. Sullivan. Probably quarterly.
    Mr. Poliquin. Okay.
    Mr. Sullivan. That we are providing directly to the 
Secretary. And then we would be happy to provide that to the 
Committee if you desire.
    Mr. Poliquin. I desire.
    Mr. Sullivan. Okay. We will do it.
    Mr. Poliquin. Okay. With the Chairman's blessing, I desire.
    Mr. Sullivan. And I would like to say, at Togus, you know, 
an example of, an enhanced use lease that we just, awarded 
about a month ago for these housing facilities that are up 
there--
    Mr. Poliquin. Great.
    Mr. Sullivan [continued]. --is a good example of--
    Mr. Poliquin. Yeah.
    Mr. Sullivan [continued]. --getting the community to come 
in and take in that case it was not unneeded buildings, it was 
unneeded land.
    Mr. Poliquin. Okay.
    Mr. Sullivan. And now they are now having permanent housing 
at that site.
    Mr. Poliquin. Great. And you know, what happens also, if I 
may, is when we are disposing of these buildings that we do not 
need and preventing us from taking better care of our men and 
women in uniform, is that these assets go back on the tax rolls 
in local towns and cities and they generate tax revenues if 
they are repurposed. That is good. We do not have a government 
unless we have tax revenues. Let us juice the tax revenues, 
right? It helps everybody.
    Next question. I represent one of the most rural parts of 
America. Tell me how you folks are retooling the VA to provide 
care for those in rural areas. Let us not forget rural America. 
About a third of our country lives in rural America and we 
provide a proportionately large number of our veterans, of 
those that serve in the military from rural areas because we 
know how to use firearms and we know how to shoot straight.
    Mr. Sullivan. I would ask Dr. Crump to comment on that.
    Mr. Crump. I will give you two examples of what we are 
doing to address--
    Mr. Poliquin. Speak up, please. My ears are so bad.
    Mr. Crump. Sorry. I will give you two examples of what we 
are trying to do to address the needs of veterans in rural 
areas. First we have an Office of Rural Health. And one of the 
things they do is focus primarily on the needs of those 
veterans, looking at different methodologies, sometimes 
innovative ways. We are putting resources out there to all of 
the VA medical centers, giving them the opportunity to request 
additional funding for things like telehealth hubs for mental 
health, for primary care.
    Mr. Poliquin. I am almost out of time and Mr. Roe is very 
strict on time. So I am going to get right to the chase.
    Mr. Crump. Okay.
    Mr. Poliquin. When it comes to these assets that are 
underperforming assets and costing us money, how can this issue 
help rural veterans?
    Mr. Crump. We are conducting a plan for a methodology 
that--
    Mr. Poliquin. When is that plan going to be ready?
    Mr. Crump. September--to look at a market by market 
analysis--
    Mr. Poliquin [continued]. Okay. So that is three months.
    Mr. Crump. --market by market analysis of the services and 
the needs. The needs of the veterans and the services available 
in every market, and then optimize that plan so that we can 
deliver that care. A combination of direct care delivery by 
VA--
    Mr. Poliquin. Got it.
    Mr. Crump [continued]. --telehealth, partnerships, leases--
    Mr. Poliquin. Thank you, sir. And early September or late 
September?
    Mr. Crump. It will begin in September.
    Mr. Poliquin. When is it going to be done?
    Mr. Crump. Next September. That is to do 90--
    Mr. Poliquin. Why do you not start it now and finish it 
this September?
    Mr. Crump. We are completing the pilot and developing the 
methodology now. We need to socialize that with the veteran--
    Mr. Poliquin. Good. Our staff will be in touch with you 
folks to make sure we can see if there is any way we can speed 
this up. Thank you very much, doctor.
    The Chairman. Thank you, Mr. Poliquin. Mr. Banks, you are 
recognized for five minutes.
    Mr. Banks. Thank you, Mr. Chairman. I will be brief. I 
know, Mr. Sullivan, you have already addressed questions about 
public-private partnerships. But I wonder if you could be more 
specific? Get into the weeds with us a little bit as policy 
makers on what greater flexibility can we provide you to 
enhance public-private partnerships to provide more 
opportunities for you to partner with the private sector on 
facilities across the country?
    Mr. Sullivan. Sure. A little bit in the weeds. But we 
believe that there is a great market for us out-leasing 
existing facilities or land to a private entity and having them 
either upgrade them or replace them or bring in another 
complementary private sector entity on the same campus, which 
would allow them to in essence cross-subsidize the development 
costs of renovating a building or providing a new building.
    Right now we do not have the authority to out-lease any of 
our property to undertake that. And if you are looking at 
developing or setting up financing, there has to be an interest 
in the property that the private entity can take to the bank, 
if you will, and get financing. So having that out-lease 
authority would allow us to do that and we would enter into an 
agreement where we could occupy all of the building or a 
portion of the building, or all of the campus or a portion of 
the campus, in the long term.
    That will work where there is a market for this. It will 
not work at every site. So that is when I said earlier we need 
a whole, if you will, suite of tools. Because if there is a 
market in the private sector for the property and it is 
valuable, you can trade off that to have a public-private 
venture done at that site. If you have property that is in some 
place that has very low real estate value, very low private 
interest in anything going on at the site, it is going to be 
pretty impossible to do a public-private venture unless someone 
is willing to come in and donate all of the money.
    Mr. Banks. How can we help you and give you that out-
leasing authority? Is that legislative? Is that--
    Mr. Sullivan. Yes, it is. It would require legislation.
    Mr. Banks. Okay. Are you aware, have there been--I am the 
new kid on the block on the Committee. Have there been efforts 
to give you that authority?
    Mr. Sullivan. We had that authority at one point. It 
expired. It was renewed with this Committee's help to focus on 
housing at the time. And again, CBO is a challenge to get this 
legislation through, as it is with many capital related items. 
So expanding the EUL authority in some form would help do that. 
And there are various gradations of that legislation. You know, 
the more you give us the higher the score may be for the 
legislation.
    Mr. Banks. Right. I look forward to working with you on 
that.
    Mr. Sullivan. I am happy to work with anyone on that.
    Mr. Banks. Thank you very much. Mr. Chairman, I yield back.
    The Chairman. I thank the gentleman for yielding. First of 
all, I want to thank the panel, for you all being here today. 
It has been very, very instructive and constructive. And I 
think this is the beginning of a dialogue that is going to, 
that needs to continue and will continue. I now will yield to 
Ms. Brownley for any closing remarks.
    Ms. Brownley. Well I thank you, Mr. Chairman, for having 
the hearing. I think it has been a productive one and the 
beginning of a longer conversation that we are going to have to 
have over all of this. But I do think we need to expand the 
conversation from not just obsolete facilities but, what are 
the opportunities around public-private partnerships? The 
leasing issues? All of this I think is, under the same umbrella 
of, how we move forward and be in a mode of continuous 
improvement as it relates to our facilities. Where we, you 
know, as time goes on, how are we going to remove facilities 
and enhance facilities where they are needed in a more timely 
way? So with that, I would yield back, and thank you again for 
the hearing.
    The Chairman. Thank you all. And again, I appreciate the 
panel being here. You all have been very helpful. And this is a 
very complex, emotional issue. And it is going to have to be 
done, as Secretary Principi said, in a very thoughtful way, an 
open, transparent way, where all, everyone who is involved has 
input. And I can just tell you that when you live in rural 
America, and Mr. Poliquin mentioned this, you know, in rural 
America where I live we are seeing businesses shuttered. We do 
not see the growth that you see in other areas. And when you 
see a public facility, whether it is a post office or whether 
it is a school, an indication that your community is dying, and 
not growing. And you see a VA close or taking buildings down, 
it affects the whole community. I totally understand that. And 
we have to be sensitive to that.
    But we also have to be sensitive to the fact that the 
mission of the VA is to provide healthcare, the very top 
quality healthcare we can to our veterans, our servicemen and 
women who have served this great country. And I think Ms. 
Brownley brought up a great point, several great points, about 
using leasing where you can be more nimble and put the CBOCs 
and outpatient clinics where much care is given where the 
veterans are, actually are. And the demographics, as I think 
was pointed out, Ms. Draper pointed out, are changing. Not just 
for veterans, but for the American population. I mean, Texas in 
2010 picked up four congressional seats. That is three million 
people that moved into Texas. That is more demand. Probably 
many of them are veterans.
    You know, I think the capital needs and we are looking at a 
$4 billion a year, $50 billion deficit, it looks like. And we 
are spending around $2 billion a year. I think we need the 
information of where do we need those capital assets before we 
go out and just build a bunch of stuff and then realize, oops, 
we have put this in the wrong place. So I think that needs to 
be done. And the VA's track record on capital has been spotty 
when you look at Denver, and New Orleans, and Orlando, and so 
forth. And we know we can do better. Just the leasing of a 
major lease, I read in the documents that I was given that it 
takes nine years from the time the VA plans it to the actual 
activation of the lease, whereas the private sector is three 
years. We have to get better, and we will. I think we certainly 
will with the leadership that we have.
    And I think one of the things you have to do is involve the 
veteran community when we are making these decisions. What do 
the veterans want the VA to look like and what services do they 
want? And I think they are actually telling us by where they 
are going to get their care.
    So I cannot thank you enough. This is not something that is 
going to get a lot of publicity and nobody is going to go home 
to the Kiwanis Club and say I am talking about VA assets. I 
mean, that is like talking about the fiduciary rule, what I got 
to talk about on the other Committee that I am on. But it is 
incredibly important for the future of the VA and how we care 
for our veterans.
    And with that, I ask unanimous consent that all Members 
have five legislative days to revise and extend their remarks 
and include extraneous material. Without objection, so ordered. 
The hearing is adjourned.

    [Whereupon, at 11:46 a.m., the Committee was adjourned.]


                           A P P E N D I X

                              ----------                              

           Prepared Statement of The Hon. Anthony J. Principi
    Mr. Chairman, Ranking Member Waltz and members of the Committee, 
good morning. Thank you for this opportunity to testify on an issue of 
great importance to the VA and our Nation's veterans.
    Medical care is a key component of the benefits and services 
enacted by Congress in recognition of the sacrifices of the men and 
women whose service in uniform preserved and protected our Nation's 
freedoms.
    Neither medical science nor the veteran population is static and 
unchanging, and VA must always provide veterans with modern, high-tech 
facilities to offer them high quality health care.
    The department will fail to honor our Nation's commitment to its 
veterans if VA's medical system does not evolve with the times.
    VA is a proud organization with a great history. I was honored to 
be associated with the department, both as Secretary and as Deputy 
Secretary.
    VA's partnership with medical schools, begun in 1945, 
revolutionized the way medicine is taught in America.
    VA researchers led the way in developing effective treatments for 
tuberculosis, schizophrenia, and hypertension.
    Three VA researchers have won Nobel Prizes; seven have won Lasker 
awards.
    The department has made an enormous contribution to American health 
care-and has been a lifeline for tens of millions of veterans.
    But while VA has a storied past and a turbulent present, many VA 
medical centers were designed and built in an era in which medical care 
was synonymous with hospital care. It made sense, in the 20th Century, 
to define our nation's health care commitment to most veterans as 
access to a hospital bed to the extent beds were available.
    But American medicine-and VA health care-has transformed itself 
from hospital-centered to patient-centered treatment. Most veterans, 
like most Americans, see their physicians on an outpatient basis, and 
most treatment is provided by prescription drugs.
    VA medicine has kept up with, and sometimes led, these innovations.
    As a result, the number of VA outpatient visits increased from 46.5 
million in Fiscal Year 2002 to 92.4 million in Fiscal Year 2014, while 
in that same period the number of inpatient admissions increased only 
from 564,700 to 707,400.
    While the practice of VA medicine has evolved, VA's medical 
infrastructure has not kept pace. VA facilities are out of step with 
changes in the practice of medicine, with demographic changes in the 
veteran population, and with statutory changes in VA's health care 
benefits packages.
    Mentally ill patients, for example, are no longer consigned to 
remotely located, thousand-bed asylums for the remainder of their 
lives. Treatment for tuberculosis no longer involves lengthy 
institutionalization.
    In addition, millions of veterans, following the population 
migration patterns of the nation, moved to the South, the West, and the 
Southwest.
    And as GAO noted in its recent report on VA Real Property, the new 
Choice program has also reduced the need for some facilities and 
services VA offers.
    If VA does not realign itself, and close its unneeded facilities, 
the current decline in the veteran population will make many VA medical 
centers museums of the past-not the guideposts for the future they 
should be.
    When I became VA Secretary in 2001, President George W. Bush 
reminded me that every dollar my agency spent is a dollar taken out of 
someone else's hard-earned pay. It's not how much money you are given 
in your budget that's important, he said-it's whether you spend that 
money wisely.
    We are stewards of the public trust, he concluded, and we must 
never forget that.
    I had the opportunity to recall his words a short time later, when 
I was stuck in traffic in New York City. As my car idled in front of 
VA's Manhattan hospital, I looked up at the hospital's patient bed 
tower. Among the hundreds of windows looking out on First Avenue, only 
a handful were lit. I didn't know what to make of it.
    I learned the Manhattan VA hospital was one of many VA built in the 
1950's to handle the influx of ill and injured World War II and Korean 
War veterans. It once held 800 veterans, as did nearby hospitals in 
Brooklyn and the Bronx. I was told the three hospitals that night were 
caring for only 283 veteran patients-all together. All the other beds 
were empty-and there were tens of thousands of empty beds throughout 
VA's system.
    Accordingly, I commissioned a comprehensive assessment of VA's 
capital infrastructure and the demand for VA health care. The process 
was called Capital Asset Realignment for Enhanced Services (CARES), and 
it was modeled on DoD's infrastructure review process.
    The CARES commission, which completed its work in 2004, offered 
sound recommendations for realignment and allocation of the 
Department's capital assets to meet demand for VA's services over the 
next twenty years. Unfortunately, the CARES and DoD processes differed 
in one specific way. Under CARES there was no requirement for Congress 
to adopt or reject the commission's final recommendations as a package.
    As a result recommendations for some needed new hospitals and 
outpatient clinics were accepted; most of those to close or realign the 
mission of facilities were rejected.
    I know that the difficulties of agreeing to such a procedure for 
members of Congress cannot be overstated. Having served as Chairman of 
the 2005 Defense Base Closure and Realignment Commission I know 
firsthand from visiting many of the military installations slated for 
closure or realignment how trying this process is for them.
    The words ``closure'' and ``realignment'' are easy to write on 
paper, but they have profound effects on communities, and the people 
who bring those communities to life.
    But VA is spending too much money on bricks and mortar, rather than 
doctors and nurses. VA's current budget request is for $186.5 billion; 
in my last year as Secretary, in Fiscal Year 2005, that figure was 
$69.4 billion-a 268 percent increase.
    We are doing a disservice to the veterans VA is charged to serve, 
and to the American people, if those resources are not used wisely and 
well.
    Our nation simply cannot afford to maintain a vast infrastructure 
built for a different time in health care delivery that was to care for 
tens of millions of veterans as they returned from World War II, Korea 
and Vietnam-and even from the Civil War, the Spanish American War, and 
World War I.
    A full review of VA infrastructure is the right thing to do. One 
that is open, transparent and apolitical. Those impacted deserve no 
less.
    Thank you.

                                 
                 Prepared Statement of Roscoe G. Butler
    Chairman Roe, Ranking Member Walz, and distinguished members of the 
committee, On behalf of our National Commander, Charles E. Schmidt, and 
the over 2 million members of The American Legion, we thank you for 
this opportunity to testify regarding The American Legion's views on 
``Care Where It Counts: Assessing VA's Capital Asset Needs''.
    Each year since 2003, The American Legion System Worth Saving (SWS) 
program has conducted site visits to VA Health Care facilities across 
the country and one thing we find in common is that VA has an enormous 
amount of aging buildings that are either underutilized or vacant. VA 
has a large inventory of buildings that are over a half-century old 
resulting in significant costs for upgrades and needed replacement of 
many parts of the facilities aging infrastructure.
    In 1866, the United States Congress established the National Home 
for Disabled Volunteer Soldiers (NHDVS), the precursor of the VA, to 
provide medical and other facilities for veterans of the American Civil 
War. Three centers were established in the following years: the Eastern 
branch in Togus, Maine, the Central Branch in Dayton, and the 
Northwestern Branch in Milwaukee, Wisconsin. The Dayton facility was 
the administrative center of the home and its principal commissary. 
Today these facilities still deliver health care to our nation's 
veterans, and all have been designated by the National Historical 
Society as a historical site.
    Medical Centers like the Phoenix VA, which first opened its doors 
in 1951 was built on 27 acres of the Indian School Reservation. After 
the medical center had been built, the community was built around the 
medical center leaving the medical center landlocked resulting in VA's 
inability to expand their footprint which is the case with a lot of VA 
properties.
    Today, the Veterans Health Administration (VHA) is the largest 
integrated health care system in the United States, providing care at 
1,233 health care facilities, including 168 VA Medical Centers and 
1,065 outpatient sites of care of varying complexity (VHA outpatient 
clinics), serving more than 8.9 million veterans. In spite of the 
exceptional health care VA provides, its aging infrastructure with a 
number of buildings being underutilized or vacant, creates problems for 
VA to maximize the use of its capital assets.
    In a 2015 House Veterans Affairs Committee (HVAC) budget hearing, 
Secretary McDonald said that the VA had 336 buildings across the 
country that are less than half-occupied, and many are not being 
utilized to their full potential. Additionally, it apparently costs 
more than 24 million dollars a year to maintain these buildings. 
Secretary McDonald stated ``VA cannot be a sound steward of the 
taxpayers' resources with the asset portfolio that we're currently 
carrying,'' McDonald told lawmakers. ``No business would carry such a 
portfolio. Veterans deserve much better. It's time to close the VA's 
old substandard and underutilized infrastructure.'' \1\
---------------------------------------------------------------------------
    \1\ Military Times (February 2017): VA looking at its own version 
of BRAC
---------------------------------------------------------------------------
    According to information provided by VA in FY2016, VA had 403 
vacant buildings at an annual operating cost of $6,674,227 and 784 
underutilized buildings at an annual operation cost of $20,266,271. VA 
defines an underutilized building as an individual building that is 
occupied and in use, but the function(s) housed there do not require 
the full amount of space in the building to operate.
    If there was unlimited funding, the easy answer would be to dispose 
of all of VA's vacant buildings and build new modern facilities but the 
reality is funding is not unlimited. Based on a June 22, 2017 VA news 
release, Dr. Shulkin announced plans to dispose of all of its vacant 
buildings over the next 24 months. \2\ According to Dr. Shulkin, if it 
cannot sell, re-use or otherwise dispose of the property, the plan is 
to knock them down and clear the site for something else. The American 
Legion has reviewed the Government Accountability Office (GAO) April 
2017 report entitled, VA Should Improve Its Efforts to Align Facilities 
with Veterans' Needs. \3\
---------------------------------------------------------------------------
    \2\ VA news Release: VA announces plan to dispose of or reuse all 
its vacant buildings in 24 months
    \3\ GAO Report No. 17-349 (April 2017): VA Should Improve Its 
Efforts to Align Facilities With Veterans Needs
---------------------------------------------------------------------------
    The American Legion agrees that over time there has been many 
changes which have impacted VA's ability to align its medical 
facilities and services in order to meet the needs of our nation 
veterans. According to GAO geographic shifts in the veteran population, 
changes in health care delivery, and an aging infrastructure affects 
the Department of Veterans Affairs' (VA) efforts to align its services 
and real property portfolio to meet the needs of veterans.
    Since VA began treating veterans, eligibility has expanded from 
treating service-connected veterans to providing care to all veterans 
who are eligible to enroll in the VA Health Care System. As a result, 
the need for increased space in the VA healthcare systems across the 
country has not been able to keep up with the shifting veteran 
population.
    When The American Legion System Worth Saving team is out conducting 
System Worth Saving Site visits, VA employees often express concerns 
about the lack of space, the amount of time it takes to acquire lease 
space, and the time it takes to build a new facility or community-based 
outpatient clinic. VA employees express concerns about VA's Strategic 
Capital Investment Planning (SCIP) process. According to GAO, VA is 
aware of many of the limitations of the SCIP process-as the Independent 
Assessment found many of the same limitations and made recommendations 
to address them, but VA has taken little action. Specifically, in 2015, 
the Independent Assessment found that SCIP's scoring and approval 
processes and time frames undermined VA's capital planning and 
prioritization process.
    In 2016, The American Legion renewed Resolution No. 136, Strategic 
Capital Investment Planning Program, which urges Congress to provide 
increased appropriations annually to address Department of Veterans 
Affairs construction deficiencies and gaps identified by VA's Strategic 
Capital Investment Planning program; VA includes activation costs in 
their future SCIP cost projections and allocations, so VA's budget will 
not have to offset this lack of national funding, and VA continues to 
be transparent about SCIP's progress by publicly posting information 
about projects and costs on an annual basis. \4\
---------------------------------------------------------------------------
    \4\ The American Legion Resolution No. 136 (Aug. 2016): Strategic 
Capital Investment Planning Program
---------------------------------------------------------------------------
    Based on The American Legion's review, addressing VA's capital 
asset needs is not a new phenomenon. There have been numerous 
government reports over the last 26 years addressing this topic to 
include the following GAO reports:

      1991- GAO/T-HEHS-00-91, VA Is Struggling to Respond to 
Asset Realignment Challenges \5\
---------------------------------------------------------------------------
    \5\ GAO Report No.T-HEHS-00-91 (April 2000): VA Is Struggling to 
Respond to Asset Realignment Challenges
---------------------------------------------------------------------------
      2000 - GAO/T-HEHS-00-88 - VA Health Care: VA is 
Struggling to Address Asset Realignment Challenges \6\
---------------------------------------------------------------------------
    \6\ GAO Report No. T-HEHS-00-88 (April 2000): VA Is Struggling to 
Address Asset Realignment Challenges
---------------------------------------------------------------------------
      2003 - GAO-03-1103R - VA Health Care: Framework for 
Analyzing Capital Asset Realignment for Enhanced Services Decisions \7\
---------------------------------------------------------------------------
    \7\ GAO Report (August 2003): VA Health Care: Framework for 
Analyzing Capital Asset Realignment for Enhanced Services Decisions
---------------------------------------------------------------------------
      2005- GAO-05-429, Key Challenges to Aligning Capital 
Assets and Enhancing Veterans' Care \8\
---------------------------------------------------------------------------
    \8\ GAO Report No. 05-429: (August 2005): Key Challenges to 
Aligning Capital Assets and Enhancing Veterans' Care
---------------------------------------------------------------------------
      2007 - GAO-07-048, Overview of VA's Capital Asset 
Management
      2009 - GAO-09-686T, Overview of VA's Capital Asset 
Management \9\
---------------------------------------------------------------------------
    \9\ GAO Report No -09-686T (June 2009) Overview of VA's Capital 
Asset Management
---------------------------------------------------------------------------
      2017 - GAO-17-349, VA Should Improve Its Efforts to Align 
Facilities with Veterans' Needs \10\
---------------------------------------------------------------------------
    \10\ GAO report No. 17-349 (April 2017): VA Should Improve Its 
Efforts to Align Facilities with Veterans' Needs

    In 2004, the Veterans Affairs Capital Asset Realignment for 
Enhanced Services Commission (CARES) delivered their report to 
Congress. \11\ All of these reports included recommendations for 
improvements. Since the 1999 report was issued, GAO continues to report 
on deficiencies in the Department of Veterans Affairs Capital Alignment 
and Asset Needs.
---------------------------------------------------------------------------
    \11\ http://www.goldenwest.net/veteranstown/doc/CARES--Final--
Report.pdf
---------------------------------------------------------------------------
    The American Legion is concerned that VA has not routinely engaged 
Veteran Service Organizations (VSOs) in discussions about their plans 
to address VA's capital asset needs. VA must do a better job in 
engaging VSOs in these discussions. Twenty-six years later, and we are 
still trying to find solutions to VA's Capital Asset Needs. For God and 
Country, The American Legion hopes it doesn't take another twenty-six 
years to find solutions to VA's Capital Asset Needs.
                               Conclusion
    As always, The American Legion thanks this Committee for the 
opportunity to explain the position of the over 2 million veteran 
members of this organization. For additional information regarding this 
testimony, please contact Mr. Matthew Shuman, Director at The American 
Legion's Legislative Division at (202) 861-2700 or [email protected].

                                 
                   Prepared Statement of Debra Draper
                            VA REAL PROPERTY
    Planning and Communication Improvements Could Help Better Align 
                    Facilities with Veterans' Needs
    Chairman Roe, Ranking Member Walz, and Members of the Committee:
    I am pleased to be here today to discuss our April 2017 report on 
the Department of Veterans Affairs' (VA) efforts to align its medical 
facilities and services. \1\ As you know, VA operates one of the 
largest health care systems in the United States, providing care to 
more than 8.9 million veterans each year. VA is also one of the largest 
federal property-holding agencies. In September 2014, VA's reported 
inventory included 6,091 federally-owned and 1,586 leased buildings. 
However, in recent decades, the veteran population and preferences have 
shifted. VA has recognized this and the need to modernize its aging 
infrastructure and align its real property assets to provide 
accessible, high-quality and cost-effective services to veterans.
---------------------------------------------------------------------------
    \1\ GAO, VA Real Property: VA Should Improve Its Efforts to Align 
Facilities with Veterans' Needs, GAO 17 349 (Washington, D.C.: Apr. 5, 
2017).
---------------------------------------------------------------------------
    Aligning VA facilities to improve veteran access to services 
integrates two of GAO's high risk areas: veterans' health care and 
federal real property. In 2015, GAO placed veterans' health care on its 
High Risk List due to persistent weaknesses and systemic problems with 
timeliness, cost-effectiveness, quality, and safety of the care 
provided to veterans. \2\ In 2003, GAO placed federal real property 
management-including management of VA real property-on its High Risk 
List due to long-standing challenges including effectively disposing of 
excess and underutilized federal property. \3\
---------------------------------------------------------------------------
    \2\ GAO, High-Risk Series: An Update, GAO 15 290 (Washington, D.C.: 
February 2015). GAO maintains a high-risk program to focus attention on 
government operations that it identifies as high risk due to their 
greater vulnerabilities to fraud, waste, abuse, and mismanagement or 
the need for transformation to address economy, efficiency, or 
effectiveness challenges. See, for example, GAO, VA Health Care: 
Actions Needed to Improve Newly Enrolled Veterans' Access to Primary 
Care, GAO 16 328 (Washington, D.C.: Mar. 18, 2016) and GAO, VA Mental 
Health: Clearer Guidance on Access Policies and Wait-Time Data Needed, 
GAO 16 24 (Washington, D.C.: Oct. 28, 2015). See also, for example, 
Department of Veterans Affairs, Office of Inspector General, Veterans 
Health Administration, Review of Alleged Patient Deaths, Patient Wait 
Times, and Scheduling Practices at the Phoenix VA Health Care System, 
Report No. 14-02603-267 (Washington, D.C.: Aug. 26, 2014) and VA, 
Department of Veterans Affairs Access Audit, System-Wide Review of 
Access, Results of Access Audit Conducted May 12, 2014, through June 3, 
2014.
    \3\ See GAO, High-Risk Series: Federal Real Property, GAO 03 122 
(Washington, D.C.: January 2003).
---------------------------------------------------------------------------
    Today I will summarize the findings from our April 2017 report 
including (1) the factors that affect VA facility alignment, (2) the 
extent to which VA's capital-planning process facilitates the alignment 
of facilities with the veteran population, and (3) the challenges VA 
faces in its alignment activities. In addition, I will highlight key 
actions that we recommended in our report that VA can take to improve 
its ability to plan for and facilitate the alignment of its facilities 
with veterans' needs.
    For our report, we reviewed VA's facility-planning documents and 
data and interviewed VA officials in headquarters and at seven medical 
facilities selected for their geographic location, veteran population, 
and past alignment efforts. We also evaluated VA's actions against 
federal standards for internal control, federal capital-acquisition 
guidance, and GAO-identified best practices for capital planning. \4\ 
Additional information on our scope and methodology is available in our 
report. The work on which this testimony is based was conducted in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives.
---------------------------------------------------------------------------
    \4\ See GAO, Standards for Internal Control in the Federal 
Government, GAO/AIMD-00-21.3.1 (Washington, DC: November 1999), and 
GAO, Standards for Internal Control in the Federal Government, GAO 14 
704G (Washington, D.C.: September 2014), Office of Management and 
Budget, Circular No. A-11: Preparation, Submission, and Execution of 
the Budget, July 2016, and GAO, Streamlining Government: Questions to 
Consider When Evaluating Proposals to Consolidate Physical 
Infrastructure and Management Functions, GAO 12 542 (Washington, D.C.: 
May 23, 2012).

Facility Alignment Is Affected by Shifting Veteran Populations, 
---------------------------------------------------------------------------
    Evolving Health Care Delivery, and an Aging Infrastructure

    Geographic shifts in the veteran population, changes in health care 
delivery, and an aging infrastructure affect VA's efforts to align its 
services and real property portfolio to meet the needs of veterans. For 
example, a shift over time from inpatient to outpatient care will 
likely result in underutilized space once used for inpatient care. In 
such instances, it is often difficult and costly for VA to modernize, 
renovate, and retrofit these older facilities. In June 2017, VA 
reported that its facility inventory includes 430 vacant or mostly-
vacant buildings that are, on average, more than 60 years old, and an 
additional 784 buildings are underutilized.
    The historic status of some VA facilities adds to the complexity of 
converting or disposing of them. In 2014, VA reported holding 2,957 
historic buildings, structures, or land parcels-the third most in the 
federal government after the Department of Defense and the Department 
of the Interior. In some instances, it may be more expensive to 
renovate than demolish and rebuild outdated facilities. In other cases, 
however, there may not be an option to demolish if these buildings are 
designated as historic. For example, planning officials at four medical 
facilities in our review told us that state historic preservation 
efforts prevented them from demolishing vacant buildings, even though 
these buildings require upkeep costs and pose potential safety hazards. 
(See fig. 1.)

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

Note: Kerrville VA Medical Center, Kerrville, Texas: These pictures 
show a dwelling formerly used for medical staff housing that has been 
designated as a historic building. The outside of the building shows 
broken windows, missing bricks, and gutters that have nearly detached 
from the building. On the inside, portions of the ceiling have 

collapsed, spraying debris onto the floors and walls.Limitations in 
    VA's Capital-planning Processes Impede Its Alignment of Facilities

    Two of the planning processes VA uses to align its facilities-VA's 
Strategic Capital Investment Planning (SCIP) and the VA Integrated 
Planning (VAIP)-have limitations. \5\
---------------------------------------------------------------------------
    \5\ Established in 2010, the goal of SCIP is to identify the full 
capital needed to address VA's service and infrastructure gaps and to 
demonstrate that all project requests are centrally reviewed in an 
equitable and consistent way throughout VA, including across market 
areas within VA's health care system. Annually, planners at the medical 
facilities develop 10-year action plans for their respective 
facilities, which include projects to address gaps in service 
identified by the SCIP process. Medical facility officials then develop 
more detailed business plans for the capital improvement projects that 
are expected to take place in the first year of the 10-year action 
plan. These projects are validated, scored, and ranked centrally based 
on the extent to which they address the annual VA-approved SCIP 
criteria using the assigned weights.
---------------------------------------------------------------------------
    Implemented in fiscal year 2011 as a pilot project, the VAIP 
process's goal was to identify the best distribution of health care 
services for veterans; where the services should be located based on 
the veterans' locations and referral patterns; and where VA should 
adapt services, facilities, and health care delivery options to better 
meet these needs as determined by locations and referral patterns.

SCIP Process

    VA relies on the SCIP process to plan and prioritize capital 
projects system-wide, but SCIP's limitations-including subjective 
narratives, long timeframes, and restricted access to information-
undermine VA's ability to achieve its goals. For example, the time 
between when planning officials at VA medical facilities begin 
developing the SCIP narratives and when they are notified that a 
project is funded has taken between 17 and 23 months over the past 6 
fiscal-year SCIP submissions. \6\ (See fig. 2.) As such, VA routinely 
asks its facility planners to submit their next year's planned project 
narratives before knowing if their project submissions from the 
previous year have been funded.
---------------------------------------------------------------------------
    \6\ The scoring of submitted projects includes both narrative 
responses that are evaluated (about one-third of the overall score) and 
data-driven scoring based on gap closure (the remaining two-thirds of 
the overall score).

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


(a) Although planning officials at VA medical facilities obtain initial 
    information from SCIP about what gaps they need to address, they do 
    not officially start developing the narratives until they receive a 
    request from VA to submit a project for SCIP scoring and approval. 
    Officials from the office that oversees SCIP told us that 
    facilities usually have access to the tools for submission about a 
---------------------------------------------------------------------------
    week prior to the request date.

(b) Medical facilities officially find out which major (over $10 
    million) and minor construction (under $10 million) SCIP projects 
    are approved and will be funded when Congress passes the 
    department's budget for that fiscal year. Non-recurring maintenance 
    SCIP projects-repairs and renovations within the existing square 
    footage of a facility that total more than $25,000-are available 
    for funding on the first day of the fiscal year for that project's 
    submission because they have advance appropriations.

    An official from the office that oversees SCIP told us that the 
timing of the budgeting process, which is outside VA's control, 
contributes to these delays. While these aspects are outside of its 
control, VA has chosen to wait about 6 to 10 months to report the 
results of the SCIP scoring process to the medical facilities. This 
situation makes it difficult for local officials to understand the 
likelihood that their projects will receive funding. A VA official said 
that for future SCIP cycles, VA plans to release the scoring results 
for minor construction and non-recurring maintenance projects to local 
officials earlier in the process. At the time of our review, however, 
the official did not have a timeframe for when VA would do this. 
Although VA acknowledges many of these limitations, it has taken little 
action in response. Federal standards for internal control state that 
agencies should evaluate and determine appropriate corrective action 
for identified limitations on a timely basis. \7\ If VA does not 
address known limitations with the SCIP process, it will not have 
reasonable assurance that SCIP can be used to accurately identify the 
capital necessary to address its service and infrastructure gaps. In 
our April 2017 report, we recommended that VA address identified 
limitations to the SCIP process, including limitations to scoring and 
approval, and access to information. VA partially concurred, noting 
that it generally concurred with the recommendation to address 
limitations in the SCIP process, but limited its concurrence to 
addressing the limitations that are within its control.
---------------------------------------------------------------------------
    \7\ See GAO 14 704G.

---------------------------------------------------------------------------
VAIP Process

    The VAIP process produces a market-level health services delivery 
plan for each Veterans Integrated Service Network (VISN) and a facility 
master plan for each medical facility-which VA has estimated to cost 
$108 million when fully complete. \8\ However, the VAIP process's 
facility master plans assume all future growth in services will be 
provided directly through VA facilities. This assumption is not 
accurate given that VA obligated about $10.1 billion to purchase care 
from non-VA providers in fiscal year 2015. VA can provide care directly 
through its medical facilities or purchase health care services from 
non-VA providers through both the Non-VA Medical Care Program (referred 
to as ``care in the community'' by VA) and clinical contracts. \9\
---------------------------------------------------------------------------
    \8\ VA organizes its system of care into regional networks (VISNs), 
which are responsible for coordination and oversight of all 
administrative and clinical activities within its specified geographic 
region. As of January 2017, VA officials told us they had mostly 
completed the VAIP process in 6 of the 18 VISNs and had plans to start 
or complete the remaining VISNs by October 2018.
    \9\ VA uses the services of non-VA providers in non-VA facilities 
under the following statutory authorities: 38 U.S.C. Sec. Sec.  1703, 
1725, 1728, 8111, and 8153. The Non-VA Medical Care Program includes 
the Choice Program and Patient-Centered Community Care. The Choice 
Program was authorized under the Veterans Access, Choice, and 
Accountability Act of 2014 (Choice Act), which appropriated $10 billion 
for the furnishing of non-VA care when veterans' access to VA health 
care does not meet applicable timeliness or travel requirements. Pub. 
L. No.113-146, 128 Stat. 1754 (2014). VA may authorize Choice Program 
care until such funds are exhausted. Pub. L. No. 115-26, Sec.  1, 131 
Stat. 129 (2017). Patient-Centered Community Care is a nationwide 
program where VA may authorize non-VA care when a VA facility is unable 
to provide certain specialty care services, such as cardiology or 
orthopedics, or under other conditions. To implement the program, VA 
utilizes two contractors, Health Net and TriWest, to establish networks 
of providers in a number of specialties-including primary care, 
inpatient specialty care, and mental health care.
---------------------------------------------------------------------------
    The Office of Management and Budget's acquisition guidance notes 
that investments in major capital assets should be made only if no 
alternative private sector source can support the function at a lower 
cost. \10\ This consideration is particularly relevant as VA's data 
projects that the number of enrolled veterans will begin to fall after 
2024. Officials who oversee the VAIP process said that they were still 
awaiting other VA offices to complete analyses required by recently 
released VA guidance, but as a result of this and other limitations, 
some local VA officials said that they already bypass the VAIP process 
and contract for their own facility master plans. In our April 2017 
report, we recommended that VA assess the value of the VAIP's facility 
master plans as a facility-planning tool, and based on conclusions from 
the review, either (1) discontinue the development of VAIP's facility 
master plans or (2) address the limitations of VAIP's facility master 
plans. VA concurred with the recommendation and noted that all future 
VAIP facility master plans will embrace all recent and evolving 
guidance, especially regarding care in the community opportunities.
---------------------------------------------------------------------------
    \10\ See Office of Management and Budget, Circular No. A-11.

VA Has Faced Challenges When Not Fully Engaging Stakeholders in Its 
---------------------------------------------------------------------------
    Facility Alignment Efforts

    VA has encountered challenges to its facility alignment efforts, in 
part, because it has not consistently followed best practices for 
effectively engaging stakeholders. VA may align its facilities to meet 
veterans' needs by expanding or consolidating facilities or services. 
Stakeholders-including veterans; local, state, and federal officials; 
Veterans Service Organizations; historic preservation groups; VA staff; 
and Congress-often view changes as working against their interests or 
those of their constituents, especially when services are eliminated or 
shifted from one location to another.
    We have previously identified best practices for stakeholder 
engagement in facility consolidation actions, recommending that 
stakeholder outreach begin well in advance of any facility changes and 
developing a two-way communication strategy to address concerns and 
explain the data, the rationale, and the overarching benefits behind 
decisions. \11\ Failure to effectively engage with stakeholders about 
alignment changes can undermine or derail facility alignment. We found 
that VA has not consistently engaged stakeholders, and, in some cases, 
this resulted in adversarial relationships that reduced VA's ability to 
better align facilities with the needs of the veteran population. In 
other cases, we observed two-way communication with stakeholders that 
resulted in more productive relationships and effective alignment 
efforts, such as with a medical facility that successfully closed an 
underutilized inpatient wing, closed a leased community based 
outpatient clinic, and relocated a domiciliary.
---------------------------------------------------------------------------
    \11\ See GAO 12 542.
---------------------------------------------------------------------------
    This inconsistency in communication practices may result, in part, 
from a lack of VA guidance for incorporating best practices into 
stakeholder communication. Further, VA officials stated that they do 
not monitor and evaluate their communication methods for effectiveness 
in reaching their intended audiences. This runs counter to federal 
standards for internal control, which note that agencies should monitor 
and evaluate their activities. \12\ Without guidance that adheres to 
best practices for fully integrating stakeholders and without 
monitoring and evaluation of this process, VA does not have reasonable 
assurance that its staff are meaningfully or effectively engaging 
stakeholders in the capital alignment decisions that affect them. In 
our April 2017 report, we recommended that VA (1) develop and 
distribute guidance for VISNs and facilities using best practices on 
how to effectively communicate with stakeholders about alignment 
change, and (2) develop and implement a mechanism to evaluate VISN and 
facility communication efforts with stakeholders to ensure that these 
communication efforts are working as intended and align with guidance 
and best practices. VA concurred with our recommendations and outlined 
a plan to implement these recommendations.
---------------------------------------------------------------------------
    \12\ See GAO 14 704G.
---------------------------------------------------------------------------
    Chairman Roe, Ranking Member Walz, and Members of the Committee, 
this concludes my prepared statement. I am happy to answer any 
questions related to our work on VA's efforts to align its medical 
facilities and services.

GAO Contact and Staff Acknowledgments

    If you or your staff members have any questions concerning this 
testimony, please contact me at (202) 512-7114 or [email protected]. 
Contact points for our Offices of Congressional Relations and Public 
Affairs may be found on the last page of this statement. Other 
individuals who made key contributions to this testimony include Dave 
Wise, Director; Keith Cunningham, Assistant Director; Jacquelyn 
Hamilton; Jeff Mayhew; Malika Rice, Michelle Weathers; and Crystal 
Wesco.

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                Prepared Statement of James M. Sullivan
    Thank you, Chairman Roe, Ranking Member Walz, and Members of the 
Committee, for the opportunity to appear today to discuss the 
Department of Veterans Affairs (VA) capital asset program and address 
VA's responses the findings in the Commission on Care report, the 
Independent Assessment, and Government Accountability Office (GAO) 
Report 17-349 ``VA REAL PROPERTY - VA Should Improve its Efforts to 
Align Facilities with Veterans' Needs.'' Additionally, I would like to 
discuss VA's ongoing efforts to dispose or reuse vacant buildings and 
the need for additional tools that will provide extended opportunities 
to reduce VA's portfolio of vacant assets.

VA Real Property Portfolio

    VA's mission is distinct from other Federal agencies, in that we 
operate the nation's largest integrated healthcare system, with more 
than 1,700 health service delivery sites, including hospitals, clinics, 
community living centers, domiciliaries, residential rehabilitation 
sites, and other types of facilities. Additionally, VA administers a 
variety of benefits and services, and operates 135 national cemeteries 
nationwide.
    The Department owns and leases real property in hundreds of 
communities across the U.S., and overseas. Overall, VA maintains 
approximately 155 million square feet (SF) in 6,274 owned buildings, 
and more than 35,000 acres of land. Approximately 24.6 million SF of 
space has been acquired through over 1,926 leases for the Department. 
VA's portfolio of nearly 180 million SF is one of the largest in the 
Federal Government and is unlike many Federal agencies; VA owns the 
majority of its portfolio - 86 percent of its square footage - which 
means real estate plays an important role in our overall asset 
management. Another aspect that separates VA from other Federal 
agencies is the fact that the average age of a VA owned building is 
approaching 60 years old. Managing a portfolio of that size and age is 
complex, takes a significant amount of resources, and requires a great 
deal of flexibility to both modernize and adjust to changing 
demographics of the Veteran population.

VA's Capital Asset Needs

    Most of the VA's infrastructure portfolio is dated, in need of 
repair/replacement, and requires considerable investment. The need is 
exacerbated because the majority of VA facilities have out-lived their 
useful life-cycle. VA has more than $50 billion in capital needs, 
identified through VA's Strategic Capital Investment Planning (SCIP) 
process, over the next 10 years to modernize and maintain its 
infrastructure. Specifically, VA's fiscal year (FY) 2018 budget 
requests $512 million for major construction, $342 million for minor 
construction, $1.9 billion for non-recurring maintenance and $954 
million in medical facilities funds for VA real property leases. VA's 
FY 2018 request reflects VA's commitment to modernize and fix its 
existing infrastructure by directing significant resources to projects 
that correct critical building and infrastructure deficiencies that are 
in need of repair. VA will also need flexibility to repurpose some 
facilities and develop partnerships or joint ventures with academic 
affiliates, the Department of Defense, and the private sector where 
appropriate. This flexibility will allow VA to assure both access and 
quality of care, and even expand access to care for Veterans in some 
markets.

VA Real Property Disposal

    One of Secretary Shulkin's top five priorities is ``Modernizing 
(VA) Systems'' which includes focusing on infrastructure improvements 
and streamlining. In support of this priority, VA has identified 430 
individual vacant buildings totaling 5.9 million gross SF that are 
geographically dispersed through VA campuses nationwide. On June 20, 
2017, the Secretary announced VA's plans to initiate disposal through 
demolition, sale or transfer; or reuse actions for these vacant 
buildings totaling 5.9 million square feet, over the next 24 months. 
These buildings are not being used to serve Veterans, and the $7 
million in annual capital and operating expenses currently used to 
maintain these vacant buildings can be better utilized to serve 
Veterans.
    VA evaluated the 430 vacant buildings and categorized them for 
disposal based on data regarding several factors. These factors 
included whether the buildings were classified as historic or historic 
eligible, had environmental concerns, or if there were more complex 
issues preventing disposal or reuse of the buildings. VA welcomes 
support from Congress to streamline approval timelines and processes in 
order for VA to better align owned assets and make business decisions 
without undue statutory or regulatory constraints from environmental 
and historic preservation stakeholders who might unintentionally 
negatively impact cost effective disposal or reuse actions, while still 
maintaining good environmental outcomes. On June 20, 2017, Secretary 
Shulkin also announced that VA will review another 784 non-vacant, but 
underutilized buildings to determine if additional efficiencies can be 
identified to be reinvested in veterans' services. This effort will be 
incorporated as the Department works towards the goal of high 
performing healthcare networks

Available Outleasing Tools

    VA has made progress in its efforts to reduce its vacant building 
footprint, and is continuing to aggressively pursue reuse and disposal 
strategies. Since 2004, VA has disposed or reused 1,059 assets totaling 
approximately 8.3 million gross SF and 932 acres. One of VA's most 
successful real property asset management tools is its Enhanced-Use 
Lease (EUL) authority. The EUL authority currently allows VA to 
outlease assets to private and public sector entities, and to transform 
vacant buildings into housing for homeless Veterans, at little or no 
long-term carrying cost to VA. The program has provided significant 
benefits to VA in terms of annual cost savings; improved facilities 
consistent with VA's mission and operations; increased healthcare 
services; substantial private investment in VA's capital facilities and 
infrastructure; creation of jobs; and increased tax revenues for local 
communities.
    VA is one of the few Federal agencies with an EUL authority, and VA 
manages one of the most successful versions of these programs within 
the Federal Government. Approximately 4.5 million SF of VA building 
space has been outleased in public-private partnerships through VA's 
EUL authority. This has resulted in over 2,700 operational housing 
units for homeless Veterans, Veterans that are at-risk for 
homelessness, and in some situations, their families.
    VA previously had broader EUL authority that allowed for mixed-use 
and other wide-ranging partnerships beyond supportive housing. Such 
uses were consistent with VA's mission and operations. While that 
authority lapsed in December 2011, VA has submitted draft legislation 
to Congress that proposes to expand the EUL authority beyond the scope 
of supportive housing. This would allow greater reuse flexibility of 
unneeded assets, and to improve services for Veterans.
    Additionally, VA is embarking on a program authorized through the 
National Historic Preservation Act (NHPA) for Historic Outleasing and 
Exchange Actions that allows expanded ability for reuse of historic 
properties beyond housing.

Public-Private Partnerships

    In addition to utilizing the EUL program, VA welcomes opportunities 
to explore other forms of public-private partnerships that can provide 
additional tools to supplement VA's capital requirements and offer new 
methods to enhance the facilities used to serve Veterans and their 
families. VA could utilize additional public-private partnerships 
opportunities to support the right-sizing and adaptation of VA's owned 
infrastructure. Further flexibility to engage potential partnerships to 
renovate or reuse existing facilities could provide VA with cost 
savings upfront and help support improved services for Veterans.

Choice Act - Independent Assessment

    The Independent Assessment Recommendations related to facilities 
(Section K) focused on VA capital project selection/project portfolio; 
capital project delivery; utilization of existing infrastructure; and 
the use of transformative options to address unfunded capital 
requirements. In response to language in the Fiscal Year 2017 
Appropriations Bill requiring a National Realignment Strategy, VA began 
efforts to conduct objective assessments of the markets within the VA 
healthcare system.

Commission on Care

    VA agreed that the Commission on Care's recommendation on 
facilities was critical to enabling a successful transformation of VA's 
healthcare system to a modern high-performing integrated network to 
better serve the needs of Veterans now and in the future. VA stated 
that a strong suite of capital planning programs, tools, resources, 
modernized facilities where appropriate, and proper dispositioning of 
outdated facilities, consistent with the Commission's recommendations, 
would be needed to fully realize the benefits and Veteran outcomes 
expected from implementing an integrated healthcare network. 
Specifically, VA agreed with the Commission that it is critical for VA 
to determine the optimal mix of healthcare services to meet Veterans 
needs at the market level before realigning its infrastructure in 
concert with partner resources in the market. VA also agreed that 
greater statutory authority and tools are needed to address the 
Department's real property needs and realign VA's capital assets, 
including divestiture of outdated properties where appropriate.

GAO Report 17-349 - VA REAL PROPERTY

    The report highlighted GAO's findings related to VA's SCIP process, 
the VA Integrated Planning (VAIP) process, and VA's stakeholder 
communication efforts related to facility alignment decisions. In 
response to GAO's report, VA partially concurred with the 
recommendation regarding the SCIP process, and agreed to address the 
limitations that are within VA's control. Many of the items noted by 
GAO are found outside of the SCIP program's purview, in areas where VA 
has limited ability to influence changes. The SCIP process is a data-
driven, long-range planning tool that integrates all capital investment 
needs across VA. SCIP informs investment and annual budget decisions by 
annually setting capital investment policy direction and project 
priorities, but it is not a budget tool. It does not guarantee whether 
or when necessary levels of funding will be received or otherwise made 
available.
    To the extent possible, VA is implementing changes to the SCIP 
process to support better access to project data, improve the 
visibility and prioritization of sequenced projects, minimize 
administrative burdens, rationalize proposals based on the realities of 
Veteran Choice and shifting demographics, and to improve communication 
of SCIP results to VA planners as early as possible in the process. 
This also includes reducing the administrative burden of providing SCIP 
documents.
    Through the VAIP process, an estimated 60 Facility Master Plans 
(FMP) were completed on a Veterans Integrated Service Network (VISN) 
basis following development of Service Delivery Plans. These FMPs 
provided a guide for planning and development over a 10-year period. 
The FMPs were considered highly valuable at the time of inception. VA 
has considered the feedback from GAO's report and in support of 
emphasis on Care in the Community, there will be a strategic pause in 
the VAIP process. VA is in the process of reassessing facility needs as 
a consequence of the assessment of local health systems during the 
market based health system optimization process. VA will evaluate 
service delivery opportunities in each market to build local high-
performing integrated healthcare networks.
    GAO also stated that VA needs to enhance communication with 
stakeholders. To ensure consistency in stakeholder engagement efforts 
and address GAO's recommendations, the Veterans Health Administration's 
(VHA) Office of Communications is developing a standard operating 
procedure (SOP) for all VISN and facility public affairs officers to 
follow when there is a change in mission and/or realignment. The SOP 
directs that VHA use the template communications plan, including 
timeline for notifications, target audiences, and example key 
messaging. In addition, the SOP provides guidance for facilities to 
implement evaluation tools to measure the return on their 
communications investment in sharing information with stakeholders, 
including after action reports, media monitoring tools, and direct 
feedback from target audiences. The VHA Deputy Under Secretary for 
Health for Operations and Management disseminated the SOP through a 
memorandum to facility and VISN leadership on June 30, 2017, and the 
topic will be discussed on Network Director monthly conference calls 
and facility leadership calls, providing an opportunity for discussion 
and questions. VHA has also established a mechanism for sharing best 
practices.

Way Forward - High Performing Healthcare Networks

    VA is working collaboratively to address the Independent Assessment 
Recommendations, the Commission on Care's recommendation on facilities, 
and GAO Report 17-349. VA is working towards the goal of high 
performing healthcare networks that take into account current and 
future Veteran demand for medical care, and responsive services by 
integrating community care, telehealth services and VA-provided 
healthcare. VA is partnering with private sector healthcare experts to 
conduct objective assessments and develop local health system 
optimization plans.
    The assessment methodology was developed between the VHA Office of 
Policy and Planning, VHA Clinical Operations and the VHA Office of 
Community Care. The assessment methodology was subsequently tested in 
three pilot markets between April and July 2017. An acquisition process 
is underway to select a contractor to assist VA with using the pilot 
results to create a final methodology for use beginning in September 
2017 to assess and recommend health system optimization in all 96 
markets of the VA healthcare system by the first quarter of FY 2019.
    The primary outcomes of the assessments will be a plan for each 
market to develop a high performing healthcare network. Creating a high 
performing network will include an evaluation and potential use 
assessment of all market capabilities including VA, Department of 
Defense (DoD), Academic Affiliates, Federally Qualified Health Centers, 
and other community providers. Once the market assessment is complete, 
recommendations may include capital investments, divestments, leasing, 
public-private partnerships, and other approaches for modernizing VA 
services and infrastructure. In addition to the capital component, the 
plan will include programmatic/service-line recommendations, as well as 
opportunities to increase capacity from process improvement and 
integration of telehealth services.
    VA expects that these market area optimization plans will address 
the Independent Assessment, the Commission on Care recommendations, and 
GAO concerns by balancing demand for and supply of services in each 
local market by using government partners, academic affiliates, and 
private sector resources to provide Veterans improved access, excellent 
quality care, and greater satisfaction. In addition, the plans will 
encourage cost effective strategies for coordinating all aspects of a 
high performing healthcare network while eliminating duplicative and 
inefficient processes.

Support from Congress

    In order to build upon VA's success, continued support from 
Congress is needed. As the Secretary stated at his recent FY 2018 
budget hearings, VA's budget submission includes proposed legislative 
requests that, if enacted, would increase the Department's flexibility 
to meet its capital needs. VA included proposals to: (1) increase from 
$10 million to $20 million the dollar threshold for minor construction 
projects; (2) modify title 38 to eliminate statutory impediments to 
acquiring joint facility projects with DoD and other Federal agencies; 
and (3) expand VA's EUL authority beyond supportive housing. VA is also 
seeking Congressional authorization of 27 major medical leases in order 
to establish new points of care, expand sites of care, replace expiring 
leases, and expand VA's research capabilities. The majority of these 
leases have been included in previous budget requests, some dating back 
to the FY 2015 budget submission.

Conclusion

    VA has a complex real estate portfolio, and seeks to maintain the 
optimal mix of assets needed to provide high quality care, readily 
accessible services, and outstanding benefits to our Nation's Veterans. 
VA welcomes new or expanded tools and the necessary flexibilities to 
address its infrastructure needs and reduce vacant real property 
assets, including establishing viable reuses where possible and saving 
taxpayer dollars. The Department will keep the Committee informed as 
progress is made on healthcare market assessments.
    Mr. Chairman, Ranking Member, and Members of the Committee, this 
concludes my statement. Thank you for the opportunity to testify before 
the Committee today. I would be happy to respond to any questions you 
may have.

                                 [all]