[Senate Hearing 115-276]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 115-276

                    THE FISCAL YEAR 2018 BUDGET FOR 
                           VETERANS' PROGRAMS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 14, 2017

                               __________

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

                   Johnny Isakson, Georgia, Chairman

Jerry Moran, Kansas                  Jon Tester, Montana, Ranking 
John Boozman, Arkansas                   Member
Dean Heller, Nevada                  Patty Murray, Washington
Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota            Sherrod Brown, Ohio
Thom Tillis, North Carolina          Richard Blumenthal, Connecticut
Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                     Joe Manchin III, West Virginia

                  Thomas G. Bowman, Staff Director \1\
                  Robert J. Henke, Staff Director \2\
                Tony McClain, Democratic Staff Director

                      Majority Professional Staff
                            Amanda Meredith
                             Gretchan Blum
                            Leslie Campbell
                            Maureen O'Neill
                               Adam Reece
                             David Shearman
                            Jillian Workman

                      Minority Professional Staff
                            Dahlia Melendrez
                            Cassandra Byerly
                                Jon Coen
                              Steve Colley
                               Simon Coon
                           Michelle Dominguez
                             Eric Gardener
                               Carla Lott
                              Jorge Rueda


\1\ Thomas G. Bowman served as Committee majority Staff Director 
through September 5, 2017, after being confirmed as Deputy Secretary of 
Veterans Affairs on August 3, 2017.
\2\ Robert J. Henke became the Committee majority Staff Director on 
September 6, 2017.
                            C O N T E N T S

                              ----------                              

                        Wednesday, June 14, 2017
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     2
Moran, Hon. Jerry, U.S. Senator from Kansas......................    66
Sanders, Hon. Bernard, U.S. Senator from Vermont.................    69
Rounds, Hon. Mike, U.S. Senator from South Dakota................    72
Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    73
Heller, Hon. Dean, U.S. Senator from Nevada......................    75
Murray, Hon. Patty, U.S. Senator from Washington.................    78
Boozman, Hon. John, U.S. Senator from Arkansas...................    80
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    82
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    83

                               WITNESSES

Shulkin, Hon. David J., MD, Secretary of Veterans Affairs, U.S. 
  Department of Veterans Affairs, accompanied by: Edward Murray, 
  Acting Assistant Secretary for Management and Chief Financial 
  Officer; Richard Chandler, Deputy Assistant Secretary, IT 
  Resource Management; Mark Yow, Chief Financial Officer, 
  Veterans Health Administration; James Manker, Acting Principal 
  Deputy Under Secretary for Benefits, Veterans Benefits 
  Administration; and Matthew Sullivan, Deputy Under Secretary 
  for Finance and Planning and Chief Financial Officer, National 
  Cemetery Administration........................................     4
    Prepared statement...........................................     7
    Response to prehearing questions submitted by Hon. Johnny 
      Isakson....................................................    15
    Response to posthearing questions submitted by:
      Hon. Johnny Isakson........................................   110
      Hon. Jon Tester............................................   121
      Hon. Bill Cassidy..........................................   134
      Hon. Patty Murray..........................................   135
      Hon. Joe Manchin III.......................................   136
      Hon. Mazie K. Hirono.......................................   138

                   Independent Budget Representatives

Blake, Carl, Associate Executive Director, Government Relations, 
  Paralyzed Veterans of America..................................    88
    Prepared statement of IBVSOs.................................    90
Acosta, LeRoy, Assistant National Service Director, Disabled 
  American Veterans..............................................    94
    Prepared statement...........................................    96
Fuentes, Carlos, Director of the National Legislative Service, 
  Veterans of Foreign Wars of the United States..................    99
    Prepared statement...........................................   100

                  Other Veterans Service Organizations

Rowan, John, National President, Vietnam Veterans of America.....   103
    Prepared statement...........................................   105

                                APPENDIX

Chenelly, Joseph R., National Executive Director, AMVETS 
  (American Veterans); prepared statement........................   141

 
           THE FISCAL YEAR 2018 BUDGET FOR VETERANS' PROGRAMS

                              ----------                              


                        WEDNESDAY, JUNE 14, 2017

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:41 p.m., in 
room 418, Russell Senate Office Building, Hon. Johnny Isakson, 
Chairman of the Committee, presiding.
    Present: Senators Isakson, Moran, Boozman, Heller, Rounds, 
Tillis, Tester, Murray, Sanders, Brown, Blumenthal, and 
Manchin.

      OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN, 
                   U.S. SENATOR FROM GEORGIA

    Chairman Isakson. I call this meeting of the Senate 
Veterans' Affairs Committee to order. I apologize again for 
being a little bit late, but I wanted to make sure we were on 
the right track and I did not mess anything up.
    I want to welcome Secretary Shulkin, who has had a great 
start. I do not think anybody in this administration started 
out with a unanimous vote he received. You cannot do any better 
than unanimous when you get confirmed. I think the vote last 
week on accountability was extraordinary, and the way we got to 
the decision, working together hand in hand, was extraordinary. 
I commend the Ranking Member on his help in doing the same.
    We have got some other things to do today to talk about, 
budget-wise, and we will have some other decisions to make. We 
can keep the same tempo, same discipline, and the same 
commitment to making sure we all know what each other knows 
before they happen rather than finding out after the fact, 
which we will all be an awful lot better off.
    I welcome Dr. Shulkin and the other members of the VA staff 
that are here today. I appreciate all that they had done in our 
meeting the other day to explain where we are going with the 
Veterans Administration, which is upward and outward and 
further ahead all along.
    I am not going to make a long statement at all, except to 
say a couple of things. I do not want to make this David 
Shulkin Day, but one other thing I have to brag about, the 
Cerner decision and getting our electronic medical records 
issue solved after years of unwillingness to address it is 
extraordinary. I think, from what I have heard, there are 
already signs that people are coming together who in the past 
had not been together to make sure this happens and works 
efficiently for our veterans and for the Department of Defense 
and the Department of Veterans Affairs at the same time.
    It was silly to have two different agencies in the same 
government serving the same soldiers, fighting for the same 
country and the same Constitution that had two medical systems 
that were not interoperable, one to the other, and where our 
veterans who fought for us would literally fall in a hole going 
from active duty from the Department of Defense to Veterans 
Affairs. I think this move to Cerner is going to prove to be a 
tremendous move economically for the VA and benefit-wise for 
our veterans. There is no possible way to do any better than 
that. So, I commend you on that decision as well.
    With that, instead of getting into details, I am going to 
ask for an opening statement from the Ranking Member, Jon 
Tester.

  OPENING STATEMENT OF HON. JON TESTER, RANKING MEMBER, U.S. 
                      SENATOR FROM MONTANA

    Senator Tester. Thank you, Mr. Chairman, and thanks for 
having this hearing. I think it is important to say that our 
thoughts are with the colleagues who were with the victims this 
morning. We wish a speedy recovery for Congressman Scalise and 
everybody else who was injured, and a big, big thank-you to the 
Capitol Police officers who work every day to make sure this 
place is a safe place. Our thoughts are with them.
    Now, Secretary Shulkin, I want to thank you for being here, 
and I want to thank you for being here with your VA team. We 
spoke last week at some length about the future of the Choice 
Program, and I hope I made my perspective clear: the Choice 
Program was intended to supplement care, provided, directed by 
the VA, not replace it, not now and not into the future.
    I worry that the budget proposed by this administration 
starts us down a path of unfettered choice that will hollow out 
the VA. In doing so, it proposes to increase funding for 
community care by a third, while proposing that the VA's own 
hospitals receive an increase that is less than half of the 
medical inflation rate--not much.
    Further, the budget does absolutely nothing to address VA's 
aging infrastructure. If we are starving VA's hospitals for 
funding used to hire staff and actually provide care for 
veterans while also denying them money to address the 
environmental care concerns, we know what that outcome is going 
to be. Soon enough, there will not be any quality VA hospitals 
staffed by quality providers, and the VA care will become 
nothing more than a voucher plan to send veterans into the 
private sector to hunt for a doctor who has the time and the 
capacity and the knowledge to treat them. That is not what our 
veterans need, and it is not what the veterans want to happen. 
For a rural State like Montana, it would truly be a disaster.
    We need to be honest. Each year, more and more rural 
hospitals are at the risk of closing, and if there are 
rollbacks to recent Medicaid expansions, it is likely that 
these closures would accelerate. We cannot assume that private 
care will work in rural communities where there are no 
providers in the first place or where the third-party 
administrators (TPAs) do not have sufficient networks.
    We know that the vast majority of veterans using Choice 
over the last 2 years are eligible due to long wait lines, not 
because they live too far from a VA facility. Data shows that 
rural veterans are not just choosing Choice as much, but they 
actually do depend on VA care.
    Now, based on your request yesterday, we may have to shift 
additional funds around and out of VA care accounts to get the 
Choice Program through the fiscal year. For months, we have 
been asking about the Choice Program spend rate and the amount 
of funds, the amount of remaining funds. We were never provided 
with those answers we needed to make informed decisions, and 
now we are in a difficult spot.
    Mr. Secretary, no one wants to delay care for veterans--no 
one--and we will act appropriately and in a timely manner to 
solve this problem. But, for that to happen this late in the 
game is a bit frustrating to me, and my frustration is 
compounded by a budget that cuts services that veterans rely 
on, makes cuts to education oversight, makes cuts to 
information technology (IT), which impact every business line 
and how the department operates. I am most concerned that it 
appears that these cuts are being made in order to pay for 
certain veterans to get private care.
    The new policies proposed in this budget to pay for private 
care are simply untenable. To put forward a proposal that 
would, without warning, stop earned benefits payments to 
severely disabled vets is unacceptable. In this case, we are 
not talking about folks milking the system for government-
funded compensation that they do not need or do not deserve. To 
get the individual unemployment benefit payment, it must be 
determined that a veteran is unable to engage in substantive 
work as a direct result of service to their country.
    President Trump's budget proposes that we just stop paying 
these veterans at a time when more Americans are having to work 
longer in their lives to make ends meet and all in the name of 
finding more money for Choice. That is a nonstarter, and I hope 
we can get your commitment today to keep this important benefit 
in place.
    I look forward to working with my colleagues on both sides 
of the aisle to address these concerns and look forward to 
hearing from you and how you intend to prioritize funding for 
veterans who get care and benefits direction from the VA.
    Finally, I would like to wish the U.S. Army a happy 
birthday.
    I look forward to your testimony, Secretary Shulkin.
    With that, thank you, Mr. Chairman.
    Chairman Isakson. Secretary, welcome. Let me introduce 
those you brought with you to back you up and accompany you 
along the way, which we appreciate them being here too. Edward 
Murray, thank you for being here today as Acting Assistant 
Secretary for Management and Chief Financial Officer; Richard 
Chandler, Deputy Assistant Secretary, Resource Management; Mark 
Yow, Chief Financial Officer, Veterans Health Administration; 
James Manker, Acting Principal Deputy Under Secretary for 
Benefits; and Mr. Matthew Sullivan, Deputy Under Secretary for 
Finance and Planning and Chief Financial Officer, National 
Cemetery Administration.
    Secretary Shulkin, the floor is yours.

   STATEMENT OF HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY EDWARD MURRAY, 
 ACTING ASSISTANT SECRETARY FOR MANAGEMENT AND CHIEF FINANCIAL 
   OFFICER; RICHARD CHANDLER, DEPUTY ASSISTANT SECRETARY, IT 
    RESOURCE MANAGEMENT; MARK YOW, CHIEF FINANCIAL OFFICER, 
VETERANS HEALTH ADMINISTRATION; JAMES MANKER, ACTING PRINCIPAL 
    DEPUTY UNDER SECRETARY FOR BENEFITS, VETERANS BENEFITS 
 ADMINISTRATION; AND MATTHEW SULLIVAN, DEPUTY UNDER SECRETARY 
FOR FINANCE AND PLANNING AND CHIEF FINANCIAL OFFICER, NATIONAL 
                    CEMETERY ADMINISTRATION

    Secretary Shulkin. Well, thank you, Chairman Isakson, 
Ranking Member Tester, and other Members of the Committee.
    As you can see, I brought a big team with me because I know 
you are going to have lots of questions, in particular, with 
the opening statements, I really do look forward to having a 
meaningful discussion and getting to some solutions and some 
closure on some of these issues.
    I also did want to echo the Ranking Member's concern that 
this is a sad day for the Nation where public servants who work 
as hard as I know all of you do have to worry about their 
personal safety, and our thoughts and prayers are with the 
Congressman and the staff and the Capitol Police as well.
    Thank you again for allowing us to be here today. What we 
want to talk about today is the 2018 President's budget and the 
2019 advanced appropriations, and all of this is in way of 
showing support for veterans. We appreciate the legislation 
that recently had been passed. As you know, you passed just 
within the past week, the accountability bill, and that went 
through the House yesterday. We are looking forward to actually 
next Tuesday bringing it for a signature for the President, 
which is good news.
    We also appreciate your support for the Veterans Choice 
Improvement Act that you supported and for providing us, really 
for the first time in a long time, the full 2017 budget. This 
has really allowed us to make real progress for veterans, and 
we are, again, grateful for that support.
    I have submitted the full written statement for the record, 
so let me just start by thanking you again for allowing us to 
participate in the hearing last week. It seems like we were 
just here with you, but I thought it was an excellent hearing, 
a good discussion on Choice. That type of discussion and dialog 
is going to allow us to help get it right for veterans.
    When I testified before the House Veterans' Affairs 
Committee on March 7, we had $2.0 billion in the Choice 
account. Less than a month and a half later, when the President 
signed the Choice Extension Act into law, our Choice account 
was at $1.5 billion. Today, that account is at $821 million.
    As we know, more veterans than ever are using Choice. We 
have authorized 8.2 million Community Care appointments since 
January of this year. That is 2.6 million more than last year 
or a 46 percent increase. In fact, March, April, and May were 
the largest months ever for Choice, and frankly, that happened 
because we fixed so many of the problems that we have all been 
working to fix with Choice. We have been increasing our use of 
Choice. One of the reasons why is the 2017 budget, as you may 
remember, actually had $2 billion less in Community Care, so we 
have been putting more through Choice.
    Two years ago--I am sure you are going to remember in July 
2015, we had too little money in our Community Care accounts 
within the VA, which we solved with your help by accessing 
unused funds in the Choice account, so we transferred money 
from Choice into Community Care. We now have too little money 
in the Choice account, which we are working to solve, again, 
working with you, with legislative authority to replenish funds 
into the Choice account.
    This is the situation that we have described before, where 
for a single purpose of providing care in the community, we 
have two checking accounts, and I will tell you, I wish it were 
easier than it is. We have to figure out how to balance these 
two checking accounts at all times. Obviously, it is not a 
science; it is an art. We are having difficulty with that once 
again. That is why we need to work with you to solve it.
    The Veterans CARE Program that we outlined for you last 
week will solve this recurring problem permanently by 
modernizing and consolidating all of the Community Care 
accounts, including Choice. The President's budget in 2018 and 
2019 provides additional funds for Choice and the resources 
necessary to continue the ongoing modernization of VA. It 
requests $186.5 billion for VA, $104.3 billion in mandatory 
funding, and $82.1 billion in discretionary funding, for a 
total increase of $6.4 billion or 3.6 percent over 2017.
    It provides $2.9 billion in mandatory funding to continue 
the Choice Program in 2018 plus a 7.1 percent increase in 
discretionary funding for VHA to improve patient access and 
timeliness of care.
    It supports the strengthening of foundational services as 
well as modernization in consolidating VA Community Care 
through the Veteran CARE Program announced last week, so 
veterans can make the right decisions about their care together 
with their physician or provider, giving them yet another 
reason to choose VA.
    This budget reflects the President's strong personal 
commitment to the Nation's veterans. It is also a budget we 
need to achieve my five priorities as Secretary: providing 
greater choice for veterans; modernizing our systems; focusing 
our resources toward what is most important for veterans; 
improving the timeliness of our services; and suicide 
prevention.
    We are already taking steps to meet the challenges that we 
face. At the President's direction, we have established a VA 
Accountability Office. The recent decisions made by the Senate 
and the House will help us with that.
    We have recently removed two medical center directors and 
three other senior executive service leaders. We simply will 
not tolerate employees who act counter to our values or put 
veterans at risk.
    I recently announced a new Fraud, Waste, and Abuse 
Prevention Advisory Committee, which will be set up and running 
later this summer.
    I have also directed the VA Central Office remain under a 
hiring freeze--those are for administrative positions--as we 
consolidate program offices, implement shared services, and 
realign overhead to get more money back to the field.
    We now have same-day services for primary care and mental 
health at all of our medical centers. Veterans can now access 
wait-time data for their local VAs using an online easy-to-use 
tool to understand access and quality. No other health system 
in the country has this type of transparency.
    We have made it easier for veterans to fill online health 
care applications, so much easier, in fact, that since last 
summer, we have received eight times as many online 
applications than the year before.
    Last month, we were able to process a disability claim in 
just 3 days--I said that right: a disability claim processed in 
3 days--using a new process called Decision Ready Claims. We 
will be introducing Decision Ready Claims nationally 
September 1.
    At our regional offices, we will be completely paperless 
for claims by mid-2018.
    A few months ago, the Veterans Crisis Line had a call 
rollover rate of more than 30 percent. Today, that rate is less 
than 1 percent.
    We have launched a new predictive modeling tool called 
REACH VET allowing VA to provide proactive support for veterans 
who are at higher risk for suicide.
    We are also launching a new initiative this summer, Getting 
to Zero, to help us end veteran suicide. This is my top 
clinical priority.
    But, to keep moving forward, we are going to need your 
help. We have identified over a thousand facilities that are 
either vacant or underutilized, and we are working now to move 
forward with 142 of those facilities. With your help, we could 
do more of the same.
    We need Congress to fund our IT modernization to keep our 
legacy systems from failing and to replace VistA with the 
system already in use by the Department of Defense. This will 
ultimately put all patient data in one shared system, enabling 
seamless care between the VA and DOD, without manual and 
electronic exchange and reconciliation of data between separate 
systems.
    We also need Congress to authorize and overhaul our broken 
and failing claims appeals process. We have worked closely with 
VSOs and other stakeholders to draft a proposal to modernize 
the system, and we were pleased to see the House unite behind 
the bill last month. Now we just need the Senate to act.
    Most of all, we need Congress to ensure the continued 
success of Choice for veterans. Veterans are responding to our 
modernization efforts by choosing VA more than before. To keep 
up with those choices, we need to fully fund Choice and help us 
modernize and consolidate VA Community Care through the 
Veterans CARE Program. The Veterans CARE Program will 
coordinate care so that veterans get the right care at the 
right time with the right provider, whether in a VA facility or 
from a high-performing VA Community Care provider. We just need 
your help to make it happen, including funding, to keep up with 
veterans as they choose VA.
    Thank you, and we look forward to your questions today.
    [The prepared statement of Secretary Shulkin follows:]
     Prepared Statement of Hon. David J. Shulkin, M.D., Secretary, 
                  U.S. Department of Veterans Affairs
    Good afternoon, Chairman Isakson, Ranking Member Tester, and 
Distinguished Members of the Senate Committee on Veterans' Affairs. 
Thank you for the opportunity to testify today in support of the 
President's 2018 Budget and 2019 Advance Appropriation (AA) Request and 
to define my priorities to continue the dynamic transformation within 
the Department of Veterans Affairs (VA). I am accompanied today by 
Edward Murray, Acting Assistant Secretary for Management and Acting 
Chief Financial Officer; Richard Chandler, Deputy Assistant Secretary, 
IT Resource Management; Mark Yow, Chief Financial Officer for the 
Veterans Health Administration; James Manker, Acting Principal Deputy 
Under Secretary for Benefits in the Veterans Benefits Administration; 
and Matthew Sullivan, Deputy Under Secretary for Finance and Planning 
for the National Cemetery Administration. I also want to thank Congress 
for providing the Department its full 2017 budget prior to the start of 
the Fiscal Year--this is significant and has been extremely beneficial 
to our ability to provide services and care to Veterans. The 2018 
budget request fulfills the President's strong commitment to all of our 
Nation's Veterans by providing the resources necessary for improving 
the care and support our Veterans have earned through sacrifice and 
service to our country.
                  fiscal year (fy) 2018 budget request
    The President's 2018 budget requests $186.5 billion for VA--$82.1 
billion in discretionary funding (including medical care collections), 
of which $66.4 billion was previously provided as the 2018 AA for 
Medical Care. The discretionary request is an increase of $4.3 billion, 
or 5.5 percent, over 2017. It will improve patient access and 
timeliness of medical care services for over 9 million enrolled 
Veterans, while improving benefits delivery for our Veterans and their 
beneficiaries. The President's 2018 budget also requests $104.3 billion 
in mandatory funding, of which $103.9 billion was previously provided, 
such as disability compensation and pensions, and for continuation of 
the Veterans Choice Program (Choice Program).
    For the 2019 AA, the budget requests $70.7 billion in discretionary 
funding for Medical Care and $107.7 billion in 2019 mandatory advance 
appropriations for Compensation and Pensions, Readjustment Benefits, 
and Veterans Insurance and Indemnities benefits programs in the 
Veterans Benefits Administration. The budget also requests $3.5 billion 
in mandatory budget authority in 2019 for the Choice Program.
    This budget request will ensure the Nation's Veterans receive high-
quality health care and timely access to benefits and services. I urge 
Congress to support and fully fund our 2018 and 2019 AA budget 
requests--these resources are critical to enabling the Department to 
meet the increasing needs of our Veterans.
                             modernizing va
    As you all know, I was part of the VA team for the last year and a 
half prior to being confirmed as the Secretary of Veterans Affairs. I 
came to VA during a time of crisis, when it was clear Veterans were not 
getting the timely access to high-quality health care they deserved. I 
soon discovered that years of ineffective systems and deficiencies in 
workplace culture led to these problems. I know that the organization 
has made significant progress in improving care and services to 
Veterans. But I also know that VA needs more changes to the way we do 
business for Veterans and the country as a whole, in order for all to 
say, ``That is a different organization now.'' VA needs to continue to 
fix numerous areas of the business, including access, claims and 
appeals processing, and many of our core functions, to ensure that the 
basics are done correctly. Beyond that, VA has to deliver to Veterans 
revolutionary leaps in care, benefits, and services. Congress, along 
with our VA employees, Veterans Service Organizations (VSO), and 
private industry, will play a critical role in making those 
revolutionary leaps a reality.
Focus on Execution
    Above all else, VA needs to perform its core functions well. When 
Veterans arrive at a VA facility for care, they must be treated with 
respect, see a clean and modern facility, be seen by their provider on 
time, and understand what the next steps for their care will be. 
Veterans should be able to receive clear and accurate information about 
their claims and understand where they are in the process. We must 
ensure that this is every Veteran's experience every time they interact 
with VA. Where we fall short, we will hold employees accountable, 
ensure we are good stewards of the taxpayer dollar, and ask for 
Congress's support for legislative fixes where needed.
Make Bold Change
    We know it is paramount that we increase our focus and intensify 
the efforts to improve how we execute our mission--Veterans should and 
do expect that from us. We also recognize that incremental change is 
not sufficient to achieve the additional improvements VA and Veterans 
need and demand for restoring the trust of Veterans and the American 
public.
    As I have noted, VA is a unique national resource that is worth 
saving, and I am committed to doing just that. Veterans have unique 
needs, and the services VA provides to Veterans often cannot be found 
in the private sector. The Veterans Health Administration (VHA) 
provides support to Veterans through primary care, specialty care, peer 
support, crisis lines, transportation, the Caregivers program, 
homelessness services, vocational support, behavioral health 
integration, medication support, and a VA-wide electronic medical 
record system. These services and supports are unparalleled. We also 
know that VA hospitals perform well on quality compared to non-VA 
hospitals. In a study published in the Journal of American Medical 
Association (JAMA) Internal Medicine in April, researchers compared 
hospital-level quality data on 129 VA hospitals and 4,010 non-VA 
hospitals obtained through the Centers for Medicare and Medicaid's 
website. They found VA hospitals had better outcomes than non-VA 
hospitals on six of nine patient safety indicators, and there were no 
significant differences on the other three indicators. VA hospitals 
also had better mortality and readmission rates than non-VA hospitals. 
With the continued support of Congress, VA will supplement its services 
through private-sector health care, but we realize it is not a 
replacement for the services VA provides to Veterans.
    We are already implementing bold changes in the agency. We are 
working hard to ensure employees are held accountable to the highest of 
standards and working with Congress to provide us with greater 
authority and flexibility to do that. We are also working with Congress 
on appeals reform and on a long-term solution for providing greater 
community care options. I will discuss these efforts in greater detail 
below.
                            five priorities
    As I prepared for my confirmation hearing earlier this year, I 
identified my top priorities to address as Secretary. These areas have 
shaped the first several months of my tenure and provide focus for our 
attention and resources, and the foundation for rebuilding trust with 
our Veterans. We will also use the budgeting process to support our 
strategy by shifting resources toward our ``foundational services'' 
that make VA unique while maintaining support to our strategic 
priorities.
Priority 1: Greater Choice for Veterans
    The Choice Program is a critical program that has increased access 
to care for millions of Veterans. Coming into this new administration, 
extending the Choice Program was one of my top priorities for quick 
action, as VA anticipated that based on Veteran program participation, 
there would be an estimated $1.1 billion in unobligated funds left on 
the original expiration date of August 7, 2017. On April 19, 2017, the 
President signed into law the Veterans Choice Program Improvement Act 
(Public Law 115-26), allowing the Choice Program to continue until the 
Veterans Choice Fund is exhausted. Without this legislation, VA would 
have been unable to use funding specifically appropriated for the 
Choice Program by Congress, so we commend Congress for passing this 
legislation swiftly and in a bipartisan manner. This legislation also 
provides VA and Congress more time to develop a long-term solution for 
community care.
    Since the start of the Choice Program, over 1.6 million Veterans 
have received care through the program. In FY 2015, VA issued more than 
380,000 authorizations to Veterans through the Choice Program. In FY 
2016, VA issued more than 2,000,000 authorizations to Veterans to 
receive care through the Choice Program, more than a fivefold increase 
in the number of authorizations from 2015 to 2016.
    Looking at early data for 2017, it is expected that Veterans will 
benefit even more this year than last year from the Choice Program. In 
the first quarter of FY 2017, we have seen a more than 30 percent 
increase from the same period in FY 2016 in terms of the number of 
Choice authorizations. In addition to increasing the number of Veterans 
accessing care through the Choice Program, VA is working to increase 
the number of community providers available through the program. In 
April 2015, the Choice Program network included approximately 200,000 
providers and facilities. As of March 2017, the Choice Program network 
has grown to over 430,000 providers and facilities, a more than 150 
percent increase during this time period.
    As these numbers demonstrate, demand for community care is high. In 
2018, VA plans to spend a total of $13.2 billion to support community 
care for Veterans. Community care will be funded by a discretionary 
appropriation of $9.4 billion for the Medical Community Care account 
($254 million above the enacted advance appropriation), plus $2.9 
billion in new mandatory budget authority for the Choice Program. This, 
combined with an estimated $626 million in carryover balances in the 
Veterans Choice Fund, provides a total of $13.2 billion in 2018 for 
community care.
    VA will continue to partner with Congress to develop a community 
care program that addresses the challenges we face in achieving our 
common goal of providing the best health care and benefits we can for 
our Veterans. We have also worked with and received crucial input from 
Veterans, community providers, VSOs, and other stakeholders in the 
past, and we will continue doing so going forward. However, we do need 
your help.
    One such area is in modernizing and consolidating community care. 
Veterans deserve better, and now is the time to get this right. We are 
committed to moving care into the community where it makes sense for 
the Veteran. The ultimate judge of our success will be our Veterans, 
and our only measure of success will be our Veterans' satisfaction. 
With your help, we can continue to improve Veterans' care in both VA 
and the community.
            Empower Veterans through Transparency of Information
    We are also increasing transparency and empowering Veterans to make 
more informed decisions about their health care through our new Access 
and Quality Tool (available at www.accesstocare.va.gov). This Tool 
allows Veterans to access the most transparent and easy to understand 
wait-time and quality-care measures across the health care industry. 
That means Veterans can quickly and easily compare access and quality 
measures across VA facilities and make informed choices about where, 
when, and how they receive their health care. Further, they will now be 
able to compare the quality of VA medical centers to local private 
sector hospitals. This Tool will take complex data and make it 
transparent to Veterans. This new Tool will continue to improve as we 
receive feedback from Veterans, employees, VSOs, Congress, and the 
media.
Priority 2: Modernizing our System
            Infrastructure Improvements and Streamlining
    In 2018, VA will focus on fixing VA's infrastructure while we 
transform our health care system to an integrated network to serve 
Veterans. This budget requests $512.4 million in Major Construction 
funding as well as $342.6 million in Minor Construction for priority 
infrastructure projects. This funding supports projects including a new 
outpatient clinic in Livermore, CA, as well as gravesite expansions in 
Sacramento, CA; Bushnell, FL; Elwood, IL; Calverton, NY; Phoenix, AZ; 
and Bridgeville, PA. VA is also requesting $953.8 million to fund more 
than 2,000 medical leases in FY 2018, an increase of $141.9 million 
over the FY 2018 AA, and $862 million for activation of new medical 
facilities. In 2018, VA is seeking Congressional authorization of 27 
major medical leases. The majority of these leases have been included 
in previous budget requests, some dating back to the FY 2015 budget 
submission. These major medical leases are vital to establish new 
points of care, expand sites of care, replace expiring leases, and 
expand VA's research capabilities.
    The 2018 budget submission includes proposed legislative requests 
that if enacted, would increase the Department's flexibility to meet 
its capital needs. These proposals include: 1) increasing from $10 
million to $20 million the dollar threshold for minor construction 
projects; 2) modifying title 38 to eliminate statutory impediments to 
acquiring joint facility projects with DOD and other Federal agencies; 
and 3) expanding VA's enhanced use lease (EUL) authority to give VA 
more opportunities to engage the private sector and local governments 
to repurpose underutilized VA property.
    The Department is also a key participant in the White House 
Infrastructure Initiative to explore additional ways to modernize and 
obtain needed upgrades to VA's real property portfolio to support our 
continued delivery of quality care and services to our Nation's 
Veterans. We are excited about the opportunity to transform the way we 
approach our infrastructure.
            Electronic Health Record Interoperability and IT 
                    Modernization
    The 2018 Budget continues VA's investment in technology to improve 
the lives of Veterans. The planned IT investments prioritize the 
development of replacements for specific mission critical legacy 
systems, as well as operations and maintenance of all VA IT 
infrastructures essential to deliver medical care and benefits to 
Veterans. The request includes $358.5 million for new development to 
replace four specific mission critical legacy systems, including the 
Financial Management System, and establish an Integrated Project Team 
to develop the requirements and acquisition strategy for a new 
enterprise health information platform. It also invests $340 million 
for information security to protect Veterans' information and improve 
VA's information networks' resilience.
    The 2018 budget submission includes a proposed legislative request 
that if enacted, would increase the Departments ability to apply agile 
program management to the dynamics of modern Information Technology 
development requirements. To do this, the Department recommends 
advancing the transfer threshold from $1 million to $3 million between 
development project lines, which equates to less than 1 percent of the 
Development account. Through the Certification process, Congress will 
maintain visibility of proposed changes.
    VA recognizes that a Veteran's complete health history is critical 
to providing seamless, high-quality, integrated care, and benefits. 
Interoperability is the foundation of this capability, by making 
relevant clinical data available at the point of care and enabling 
clinicians to provide Veterans with prompt, effective care. Today, VHA, 
the Veterans Benefits Administration (VBA), and the Department of 
Defense (DOD) share more medical information than any public or private 
health care organization in the country. We have developed and 
deployed, in close collaboration with DOD, the Joint Legacy Viewer 
(JLV). JLV is available to all clinicians in every VA facility. It is a 
web-based user interface that provides clinicians with an intuitive 
display of DOD and VA health care data on a single screen. VA and DOD 
clinicians can use JLV to access the health records of Veterans, Active 
Duty, and Reserve Servicemembers from all VA, DOD, and any third party 
community providers who participate in Health Information Exchanges 
where a patient has received care. Multiple releases of Community Care 
applications, including JLV-Community Viewer, Community Provider 
Portal, and Virtru Pro Secure Email have enhanced care coordination 
with Community Providers through multiple methods of exchanging health 
records and multiple modes of communication improving the care the 
Veteran receives and allowing Community Providers not in Health 
Information Exchanges the ability to share medical documentation.
    VA will complete the next iteration of the VistA Evolution Program, 
VistA 4, in 2018. VistA 4 will bring improvements in efficiency and 
interoperability, and will continue VistA's award-winning legacy of 
providing a safe, efficient health care platform for providers and 
Veterans. VistA Evolution funds have enabled investments in systems and 
infrastructure that support interoperability, networking and 
infrastructure sustainment, continuation of legacy systems, and efforts 
such as clinical terminology standardization. These investments are 
critical to the maintenance and deployment of the existing and future 
modernized VistA and essential to operational capability. That said our 
current VistA system is in need of major modernization to keep pace 
with the improvement in health information technology and 
cybersecurity, and software development.
    I promised a decision on our EHR system by July 1st, and I have 
honored that commitment by announcing that, after much deliberation, VA 
will adopt the same EHR system as DOD, now known as MHS Genesis, which 
at its core consists of Cerner Millennium. VA's adoption of the same 
EHR system as DOD will ultimately result in all patient data residing 
in one common system and enable seamless care between the departments 
without the manual and electronic exchange and reconciliation of data 
between two separate systems. Still, VA has unique needs and many of 
those are different from the DOD. For this reason, VA will not simply 
be adopting the identical EHR that DOD uses, but we intend to be on a 
similar Cerner platform. VA clinicians will be very involved in how 
this process moves forward and in the implementation of the system.
    Another critical system that will touch the delivery of all health 
and benefits is our new financial management system, which is under 
development. The 2018 budget continues modernizing our financial 
management system by transforming the Department from numerous 
stovepipe legacy systems to a proven, flexible, shared service business 
transaction environment. The budget requests $83 million in Information 
Technology funds and $61.6 million for business process re-engineering 
to support Financial Management Business Transformation (FMBT) across 
the Department.
Priority 3: Focus Resources More Efficiently
            Strengthening of Foundational Services in VA
    VA is committed to providing the best access to care for Veterans. 
To deliver the full care spectrum as defined in VA's medical benefits 
package, VA will focus on its foundational services--those areas in 
which it can excel--and build community partnerships for complementary 
services. VA developed the following guiding principles, centered on 
improving the health, well-being, and experience of Veterans receiving 
care from VA and in the community. These principles include:

     Enabling VA to provide access to high-quality care for 
Veterans, by balancing services provided by VA and the community given 
changing demands for care and resource limitations;
     Promoting operational efficiency and simplicity, while 
supporting VA's clinical care, education, and research missions; and
     Allowing facilities to meet the changing needs of Veterans 
in a flexible way.

    High-performing organizations cannot excel at every capability and 
thus must make decisions about how best to invest its resources. VA 
will therefore further define and grow its foundational services to 
excel in the provision of clinical care to Veterans.
    Investing in foundational services within the Department is not 
limited to only health care. For over a decade, VA's National Cemetery 
Administration (NCA) has achieved the highest customer satisfaction 
rating of any organization--public or private--in the country. They 
achieved this designation through the American Customer Satisfaction 
Index six consecutive times. The President's 2018 Budget recognizes the 
need to nurture and advance this unprecedented success with a request 
for $306.2 million for NCA in 2018, an increase of $20 million (7 
percent) over 2017. This request will support the 1,881 FTE needed to 
meet NCA's increasing workload and expansion of services. In 2018, NCA 
will inter approximately 133,600 Veterans and eligible family members, 
care for over 3.7 million gravesites, and maintain 9,400 acres. NCA 
will continue to memorialize Veterans by providing 366,000 headstones 
and markers, distributing 702,000 Presidential Memorial Certificates 
and expanding the Veterans Legacy program to communities across the 
country. VA is committed to investing in NCA infrastructure, 
particularly to keep existing national cemeteries open and to construct 
new cemeteries consistent with burial policies approved by Congress. In 
addition to NCA's funding, the 2018 request includes $255.9 million in 
major construction funds for six gravesite expansion projects. When all 
new cemeteries are opened, nearly 95 percent of the total Veteran 
population--about 20 million Veterans--will have access to a burial 
option in a Veterans' cemetery within 75 miles of their home.
            VA/DOD/Federal Coordination
    VA has proposed legislation to eliminate certain statutory 
impediments to VA more effectively pursuing joint projects with other 
Federal agencies, including DOD. Today, medical facilities that are not 
specifically under the jurisdiction of the Secretary require specific 
statutory authorization for optimal collaboration. I look forward to 
working with Congress to: (1) enhance our ability to coordinate with 
DOD and other Federal agencies; (2) improve the access, quality, and 
cost effectiveness of direct health care provided to Veterans, 
Servicemembers, and their beneficiaries; (3) permit joint capital asset 
planning and capital investments to design, construct, and utilize 
shared medical facilities; and (4) provide authority for VA to procure 
the use of joint medical facilities for itself and other Federal 
agencies like DOD, and to transfer funds between VA and other Federal 
agencies for such initiatives.
            Deliver on Accountability and Effective Management 
                    Practices
    Another critical area in which VA is serious about making 
significant changes relates to employee accountability. The vast 
majority of employees are dedicated to providing Veterans the care they 
have earned and deserve. It is unfortunate that certain employees have 
tarnished the reputation of VA and so many who have dedicated their 
lives to serving our Nation's Veterans. We will not tolerate employees 
who deviate from VA's I-CARE values and underlying responsibility to 
provide the best level of care and services to them. We support 
Congress' ongoing efforts to provide VA with the tools it needs to take 
timely action against employees who perform poorly or engage in 
misconduct. Where employees engage in inappropriate behavior, do not 
perform the duties of their job, are engaged in illegal activities, or 
otherwise do not meet the standards we expect of VA employees, we want 
the ability to ensure they can be promptly removed. Certain laws hamper 
our ability to optimally hold our employees accountable and remove 
those individuals that run afoul of my intent for the Department to 
function as a high-performing organization. We support legislation that 
is consistent with the following principles:

     Increase flexibility to remove, demote, or suspend VA 
employees for poor performance or misconduct;
     Provide authority to recoup bonuses of employees for poor 
performance or misconduct;
     Enable recovery of relocation expenses that occur through 
fraud or malfeasance; and
     Ensure that VA has the ability to retain high performers 
by paying them a salary that is competitive with the private sector and 
performance awards that are commensurate with other Federal agencies.

    We thank the Senate for passing critical accountability 
legislation, S. 1094,--all signs point to new accountability rules for 
VA being the law of the land soon, but while that process continues, we 
are also focused on updating internal hiring practices. VHA is the 
largest health care system in the United States, and in an industry 
where there is a national shortage of health care providers, VHA faces 
competition with the commercial sector for scarce resources. 
Historically, VA has followed hiring practices that have proven unduly 
burdensome. Over the past year, VHA's business process improvement 
efforts have resulted in a more efficient hiring process. We were able 
to reduce the time it took to hire Medical Center Directors by 40 
percent and obtained approval from the Office of Personnel Management 
(OPM) for critical position pay authority for many of our senior health 
care leaders. We recognize there is much work left to do. As we strive 
to find internal solutions, we look forward to working together on 
legislation to reform recruitment and compensation practices to stay 
competitive with the private sector and other employers.
    To ensure that VA's management practices are effective, I have 
announced a major initiative to improve our ability to detect and 
prevent fraud, waste, and abuse within VA. The initiative includes:

     forming a fraud, waste, and abuse advisory committee 
comprised of experts from the private sector and other government 
organizations;
     identifying cutting edge tools and technologies available 
in the private sector; and
     coordinating all fraud, waste, and abuse detection and 
reporting activities through a single office.

    With these improvements, VA has the potential to save millions of 
taxpayer dollars and more effectively serve America's Veterans. I look 
forward to updating you in the future regarding this initiative.
Priority 4: Improve Timeliness of Services
            Access to Care and Wait Times
    VA is committed to delivering timely and high quality health care 
to our Nation's Veterans. Veterans now have same-day services for 
primary care and mental health care at all VA medical centers across 
our system. I am also committed to ensuring that any Veteran who 
requires urgent care will receive timely care.
    In March 2017, 96.82 percent of appointments, 5.15 million 
appointments, were completed within 30 days of the clinically-indicated 
or veteran's-preferred date, and as of April 15, 2017, VHA has reduced 
and the Electronic Wait List from 56,271 entries to 22,383 entries, a 
60.2 percent reduction between June 2014 and April 2017. The Electronic 
Wait List reflects the total number of all patients for whom 
appointments cannot be scheduled in 90 days or less.
    In 2018, VA will expand Veteran access to medical care by 
increasing medical and clinical staff, improving its facilities, and 
expanding care provided in the community. The 2018 Budget requests a 
total of $75.2 billion in funding for Veterans' medical care, which 
includes the following:

     $69.0 billion in discretionary budget authority ($2.65 
billion above the 2018 AA enacted level of $66.4 billion and a $4.6 
billion (7.1 percent) increase over the 2017 enacted level);
     $2.9 billion in mandatory budget authority to continue the 
Veterans Choice Program; and
     $3.3 billion in medical care collections.

    The 2018 request will support nearly 315,000 medical care staff, an 
increase of over 7,000 above the 2017 level.
    Through the Choice Program, VHA and its contractors created more 
than 3.6 million authorizations for Veterans to receive care in the 
private sector from February 1, 2016 through January 31, 2017. This 
represents a 23 percent increase in authorizations when compared to the 
period February 1, 2015 through January 31, 2016. When looking at 
overall appointment data not specific to the Choice Program, the 
March 15, 2017, pending appointment data set shows VA has increased the 
number of overall pending appointments ``in house'' by nearly 1.8 
million over the same data the prior year. According to the same data, 
the number of appointments scheduled greater than 30 days from the 
Veterans clinically indicated data or preferred date has decreased by 
3.9 percent (19,645) since the beginning of FY 2017.
            Accelerating Performance on Disability Claims
    Since 2013, VA has made remarkable progress toward reducing the 
backlog of disability compensation claims pending over 125 days and is 
working to use more effectively the resources provided by Congress. 
VBA's 2018 budget request of $2.8 billion allows VBA to maintain the 
improvements made in claims processing over the past several years. 
This budget supports the disability compensation benefits program for 
4.6 million Veterans and 420,000 Survivors. VBA implemented new 
professional standards for Veterans Service Representatives (VSR) on 
March 1, 2017. In May 2016, VBA implemented the National Work Queue 
(NWQ) process. This allows VBA to prioritize and quickly distribute 
disability compensation claims according to processing capacity within 
VBA's regional footprint, regardless of the Veteran's place of 
residence. The NWQ process enables VA to more effectively balance the 
workloads nationally, relative to the productive capacity at each 
regional office. This means that Veterans who live in a location where 
claims decisions take longer, VBA can appropriately adjust capacity to 
match the changes in claims volume. In FY 2017, VBA added non-rating 
related claims to the NWQ. VBA has completed nearly 1.7 million non-
rating claims from October 2016 through the end of April 2017. The 
effort to address non-rating claims has resulted in a 269,000 claim 
reduction in the dependency claims inventory since August 2015, from 
359,000 to less than 90,000.
    To continue improving disability compensation claim processing, VBA 
is currently piloting an initiative called Decision Ready Claims (DRC). 
The DRC initiative offers veterans and survivors faster claims 
decisions in which VSOs and other accredited representatives assist 
Veterans with ensuring all supporting medical evidence is included with 
the claim at the time of submission. The DRC initiative empowers 
Veterans by allowing them to receive medical examinations as early as 
possible in the claims process. This initiative also enhances 
partnerships with VSOs by improving access and capabilities to assist 
with gathering all required evidence and information to accelerate 
claims decisions. Submission of claims submitted through the DRC 
process will result in claim decisions within 30 days of submission to 
VA.
            Decisions on Appeals
    The current VA appeals process undoubtedly needs further 
improvements for our Nation's Veterans. As of April 30, 2017, VA had 
470,546 pending appeals. The average processing time for all appeals 
resolved by VA in FY 2016 was approximately 3 years. For those appeals 
that were decided by the Board of Veterans' Appeals (the Board) in FY 
2016, on average, Veterans waited at least 6 years from filing their 
Notice of Disagreement until the Board's decision was issued that year.
    The 2018 request of $155.6 million for the Board continues the 
funding level enacted for 2017, which was a 42 percent increase over 
2016. In combination with carryover resources from 2017, the requested 
funding will support a total of 1,050 FTE, an increase of 164 FTE above 
the 2017 estimate of 886 FTE. This request maintains the increased 
budgetary authority the Board received in 2017. In addition, VBA's 
request of $185 million for appeals processing maintains its current 
level of appeals FTE at 1,495. This funding level in tandem with 
sweeping legislative reform initiates a long-term strategy aimed at 
improving the timeliness of appeals for Veterans and is the best policy 
option for taxpayers.
    Without significant legislative reform to modernize the appeals 
process, Veteran wait times and the cost to taxpayers will only 
increase. Comprehensive legislative reform is necessary to replace the 
current lengthy, complex, confusing VA appeals process with a new 
process that makes sense for Veterans, their advocates, VA, and other 
stakeholders. This reform is crucial to enable VA to provide the best 
service to Veterans and is one of my top priorities.
    VA worked collaboratively with VSOs and other stakeholders to 
design this new process for Veterans who disagree with a VA decision. 
The result of that work was a legislative proposal that was introduced 
in the 114th Congress and has been reintroduced in the 115th Congress. 
The proposed process: (1) establishes multiple options for Veterans 
instead of the single option available today; (2) provides early 
resolution of disagreements and improved notice as to which option 
might be best; (3) eliminates the inefficient churning of appeals that 
is inherent in the current process; (4) features quality feedback loops 
to VBA; and (5) improves transparency by clearly defining VBA as the 
claims agency and the Board as the appeals agency in VA. This clear 
definition between VBA and the Board also provides workload 
transparency for better workload/resource projections, and efficient 
use of resources for long-term savings.
    The new process, described in the legislation currently pending, 
will provide a modernized process going forward. However, VA is also 
committed to concurrently reducing the pending inventory of legacy 
appeals. VA has worked collaboratively with stakeholders to identify 
opt-ins that would make the new process available to Veterans who would 
otherwise have an appeal in the legacy process. After assessing these 
various options, and collaborating with our partners, we have 
identified two opt-ins that we intend to implement to address the issue 
of the legacy appeals inventory.
    The legislation must be enacted now to fix this process. It has 
wide stakeholder support and the longer we wait to enact this 
legislative reform, the more appeals enter the current, broken system. 
The status quo is not acceptable for our Nation's Veterans. The new 
process will provide much needed comprehensive reform to modernize the 
VA appeals process and provide Veterans a decision on their appeal that 
is timely, transparent, and fair.
Priority 5: Suicide Prevention--Eliminating Veteran Suicide
    Every suicide is tragic, and regardless of the numbers or rates, 
one Veteran suicide is too many. Suicide prevention is VA's highest 
clinical priority, and we continue to spread the word throughout VA 
that ``Suicide Prevention is Everyone's Business.'' The 2018 Budget 
requests $8.4 billion for Veterans' mental health services, an increase 
of 6 percent above the 2017 level. It also includes $186.1 million for 
suicide prevention outreach. VA recognizes that Veterans are at an 
increased risk for suicide and implemented a national suicide 
prevention strategy to address this crisis. VA is bringing the best 
minds in the public and private sectors together to determine the next 
steps in implementing the Eliminating Veteran Suicide Initiative. VA's 
suicide prevention program is based on a public health approach that is 
ongoing, utilizing universal, selective, indicated strategies while 
recognizing that suicide prevention requires ready access to high 
quality mental health services, supplemented by programs that address 
the risk for suicide directly. VA's strategy for suicide prevention 
requires ready access to high quality mental health (and other health 
care) services supplemented by programs designed to help individuals 
and families engage in care and to address suicide prevention in high-
risk patients.
    As part of VA's commitment to put forth resources, services, and 
technology to reduce Veteran suicide, VA initiated the Recovery 
Engagement and Coordination for Health Veterans Enhanced Treatment 
(REACH VET). This new program was launched by VA in November 2016 and 
was fully implemented in February 2017. REACH VET uses a new predictive 
model in order to analyze existing data from Veterans' health records 
to identify those who are at a statistically elevated risk for suicide, 
hospitalization, illnesses, and other adverse outcomes. Not all 
Veterans who are identified have experienced suicidal ideation or 
behavior. However, REACH VET allows VA to provide support and pre-
emptive enhanced care in order to lessen the likelihood that the 
challenges these Veterans face will become a crisis.
            Other than Honorable Expansion
    We know that 14 of the 20 Veterans who on average commit suicide 
each day did not, for various reasons, receive care within VA. Our goal 
is to more effectively promote and provide care and assistance to such 
individuals to the maximum extent authorized by law. In that regard, VA 
intends to expand access to emergent mental health care for former 
Servicemembers, who separated from active duty with other than 
honorable (OTH) administrative discharges. This initiative specifically 
focuses on expanding access to former Servicemembers with OTH 
administrative discharges who are in mental health distress and may be 
at risk for suicide or other adverse behaviors. VA estimates there are 
more than 500,000 former Servicemembers with OTH administrative 
discharges. As part of this initiative, former Servicemembers with OTH 
administrative discharges who present to VA seeking mental health care 
in emergency circumstances for a condition the former Servicemember 
asserts is related to military service would be eligible for evaluation 
and treatment for their mental health condition. Such individuals may 
access the system for emergency mental health services by visiting a VA 
emergency room, outpatient clinic, Vet Center, or by calling the 
Veterans Crisis Line. Services may include: medication management/
pharmacotherapy, lab work, case management, psycho-education, and 
psychotherapy. We intend to carry this initiative out within our 
existing resources because it is the right thing to do for Veterans.
                                closing
    Thank you for the opportunity to appear before you today to address 
our 2018 budget and 2019 Advance Appropriations budget requests and to 
provide you with the priorities that I am taking to ensure VA is viewed 
with pride from Veterans and beneficiaries for the services provided to 
them. I ask for your steadfast support in funding our full FY 2018 and 
FY 2019 AA budget requests and continued partnership in making bold 
changes to improve our ability to serve Veterans. I look forward to 
your questions.
                                 ______
                                 
 Response to Prehearing Questions Submitted by Hon. Johnny Isakson to 
   Hon. David Shulkin, Secretary, U.S. Department of Veterans Affairs
                             appeals reform
    Question 1. In June 2016, then Deputy Secretary Sloan Gibson sent a 
letter regarding VA's proposed appeals reform legislation to the Senate 
Committee on Veterans' Affairs, including several attachments. One 
attachment contains this information:

    Is the legislation enough to solve the current appeals problem 
without new money?

        . . . . The legislation is an effective fix for new appeals, 
        but alone is insufficient to resolve the current pending 
        inventory.
        In execution, if VA received no new funding for legacy appeals, 
        VA must either keep the promise of the new legislation (125 
        day/365 day processing) and allow legacy appeals to languish OR 
        prioritize legacy appeals, some of which will have been pending 
        for years when the legislation takes effect, and delay action 
        on the new framework appeals--which will impact the Board [of 
        Veterans' Appeals] and also increase [the Veterans Benefits 
        Administration's] pending rating claim inventory and claims 
        backlog.
        The answer is NO. The legislation alone frees up some existing 
        resources to work appeals, but these resources are insufficient 
        to clear the legacy inventory alone.
        (Emphasis added.)

    a. If the appeals reform legislation is enacted this calendar year, 
what level of funding would VA need to ensure that legacy appeals will 
not ``languish'' and by what date would VA need to have that funding 
made available?
    Response. In fiscal years (FY) 2015 and 2016, Congress provided 
funding for additional staff that included a total of 300 full-time 
equivalent (FTE) employees for appeals processing at the Veterans 
Benefits Administration (VBA). In FY 2017, the Board of Veterans' 
Appeals (Board) received funding for an additional 242 FTE. As the 
result of hiring falling short of goals, the Board projects to have 
carryover of $15,609,600 from FY 2017, which the Board intends to 
utilize for personnel costs in FY 2018. By utilizing carryover, the 
Board's FY 2018 annualized FTE level is estimated to be 1,050, which is 
164 FTE higher than the FY 2017 current estimate. VA continues to 
assess the current and future allocation of FTE to work appeals to 
ensure that the pending legacy appeals inventory is addressed in a 
timely and efficient manner. Whether VA will need additional resources 
for appeals after enactment of appeals reform legislation is contingent 
upon resource allocation decisions made by the Department of Veterans 
Affairs and the Administration during the annual budget process and 
cannot be predicted at this time.

    b. What steps--other than potentially adding resources--is VA 
taking to speed up processing of legacy appeals, such as information 
technology improvements or making sure appeals staff work only on 
appeals, and what impact are those initiatives expected to have on the 
inventory of legacy appeals?
    Response. VA is committed to reducing the pending inventory of 
legacy appeals. In January 2017, VBA realigned its appeals policy and 
oversight of its national appeals operations under a single office, the 
Appeals Management Office (AMO). The realignment promotes increased 
accountability of appeals performance and establishes a clear division 
of labor between claims and appeals work, with dedicated appeals FTE. 
Under this realignment, specific guidance has been disseminated 
instructing field offices that appeals staff must maintain authorized 
staffing levels and complete appeals production work exclusively. VBA's 
appeals productivity through May 31, 2017, has increased by 32% over FY 
2016 production during the same period. This realignment allows VBA to 
focus on internal people, process and technology appeals initiatives, 
and implementation of appeals reform legislation if enacted. Unlike 
VBA, which adjudicates both claims and appeals, the Board only 
adjudicates appeals. The Board monitors its personnel resources to 
ensure they are focused on the Board's mission of holding hearings and 
deciding appeals.
    Additionally, we have worked with our congressional committees and 
stakeholder partners to modify the design of the draft appeals reform 
legislation to provide opportunities for Veterans who would otherwise 
have an appeal in the legacy process to opt-in to the new process. The 
availability of these opt-ins ensure that as many Veterans as possible 
benefit from the streamlined features of the new process, while 
simultaneously assisting with the elimination of the inventory of 
legacy appeals.
    The Board is also committed to modernizing appeals processing 
technology to optimize efficiency to best serve Veterans and their 
families and to ensure the seamless transfer of appeals between 
jurisdictions by leveraging industry best practices and Human Centered 
Design principles. The Board is fortunate to have Digital Service at VA 
leading the technical approach to this effort. While modernized 
technology is part of increasing efficiency in appeals processing, 
comprehensive legislative reform is required to ensure Veterans receive 
a timely decision on their appeal, which is why the opt-ins that allow 
Veterans who would otherwise have a legacy appeal to enter the new 
process offer a good potential opportunity to speed processing of the 
pending legacy appeals inventory.

    Question 2. In May 2017, the Congressional Budget Office provided a 
cost estimate regarding H.R. 2288, the Veterans Appeals Improvement and 
Modernization Act of 2017, which includes this information: ``VA also 
expects that the efficiencies of the new system would allow the agency 
to continue processing legacy appeals under the current system, very 
gradually reducing the existing backlog, without the need for 
additional employees. (Reducing the backlog in a more expedited manner 
would require more employees and would have a substantial cost.)''

    a. Please clarify whether VA intends, if the appeals reform 
legislation is enacted, to ``very gradually'' reduce the inventory of 
existing appeals or to address them in a ``more expedited manner.''
    Response. If the appeals reform legislation is enacted, VA remains 
committed to reducing the pending inventory of legacy appeals as 
quickly and efficiently as possible. VA intends to resource the 
modernized system to maintain timely processing in the new process and 
then allocate all remaining appeals resources to address the inventory 
of legacy appeals. VA also worked collaboratively with stakeholders to 
identify opt-ins that will make the new process available to more 
Veterans. The opt-in features of the legislation will assist VA with 
more quickly and efficiently addressing the legacy appeals inventory.

    b. In response to post-hearing questions in May 2016, VA indicated 
that, if the appeals reform proposal is enacted without added 
resources, ``at least 214,837 appeals will take longer than 9 years to 
be resolved'' and ``some of these legacy appeals will take 28 years to 
be resolved.'' Is this in line with what would be expected if VA ``very 
gradually'' reduces the inventory of legacy appeals? If VA has more 
recent modeling data on this scenario, please provide copies.
    Response. Depending upon legislative reform and available 
resources, VA intends to address the legacy appeals inventory as 
quickly and efficiently as possible. Without significant legislative 
reform to modernize the appeals process, VA projects that Veteran wait 
times and the cost to taxpayers will continue to increase over time. 
The goal is to eliminate the inventory of legacy appeals in a timely 
manner following enactment of the appeals modernization legislation, 
while also maintaining timely processing in the new process. 
Prioritization, assessment of resource requirements in the annual 
budget process, and the opt-in features of the new process will assist 
VA in accomplishing that goal. However, due to the nature of the 
complex, inefficient and outdated legacy process, VA projects that 
there will be an inventory of legacy appeals for a substantial amount 
of time, regardless of the amount of resources made available to legacy 
appeals processing. VA continues to refine its forecast modeling, to 
include based on annual budget levels.
                              medical care
    Question 3. The Budget Justification shows an aggregate number of 
full-time equivalent employees (FTE) in the Medical Support and 
Compliance account for fiscal years 2016 through 2019. For each office 
within the Medical Support and Compliance account, please provide the 
total number of FTE for fiscal year 2016 and the estimate number of FTE 
for fiscal years 2017 through 2019.
    Response. See ``FTE by Program Office'' table.

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
    

    Question 4. In 2017 the Veterans Health Administration (VHA) 
consolidated three Veterans Integrated Service Networks (VISN). Please 
provide the number of FTE within each of those VISN's prior to 
consolidation and the total number of FTE in the new consolidated VISN.
    Response. See attached file

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]    

    Question 5. The Budget Justification indicates that VHA created a 
new office, the Medical Center Solutions (MCS) office. Please describe 
in detail the duties of this office, the number of FTE associated with 
this office, and the estimated budget request for MCS.
    Response. Member Services-Medical Center Solutions (MCS) office 
will provide for and support the development of comprehensive VA 
Medical Call Center capability solutions with applicability across the 
VHA enterprise. MCS, the first of its kind in VHA, will provide 
leadership and management for the purposes of improving access to 
clinical care and services by positively affecting the myriad of 
complexities associated with VA Medical Center and VISN-wide call 
centers. When activated effective 1QFY 2018, MCS will initially provide 
primary care appointment scheduling and call center-based nurse triage 
call center support for all (8) VISN 1 VA medical centers with the 
intent of expanding services to remaining VA Health Networks. This will 
result in system-wide, standardized improvements in access to clinical 
care and services, improved first contact resolution and an improved 
Veteran experience. The FY 2018 transition is being effected by a 
planned transfer of existing resources and FTEE from VISN 1 to MS-MCS 
that when combined with existing MS-MCS resources (1 FTEE and $2.691M) 
will establish the needed capability to provide comprehensive call 
centers services to VISN 1 while providing the basis for expanding 
services to remaining VISNs. The consolidation of VISN1 call center 
operations under MCS represents an organizational realignment and is 
FTEE and cost neutral.

    Question 6. The Veterans Access, Choice, and Accountability Act of 
2014 gave VHA the authority to enter into provider agreements to 
provide Veterans with care in the community. While the vast majority of 
that care is provided through the Patient Centered Community Care (PC3) 
contract, in 2016 VHA started using the provider agreement authority by 
entering into local agreements at the VA medical centers (VAMC).
    a. Please provide the total number of provider agreements VHA has 
entered into broken out by VAMC.
    Response. Please see spreadsheet that follows:

         Count of Active Provider Agreements as of June 6, 2017
------------------------------------------------------------------------
                                                              Count of
                                Station                       Provider
                                                             Agreements
------------------------------------------------------------------------
    (402Togus, ME                                              681
    (405White River Junction, VT                               361
    (518Bedford, MA                                             60
    (523VA Boston HCS, MA                                      183
    (608Manchester, NH                                         158
    (631VA Central Western Massachusetts HCS                   168
    (650Providence, RI                                         112
    (689VA Connecticut HCS, CT                                 180
 (528 A4Batavia, NY                                              1
 (528 A8Albany, NY                                              21
    (528Bath, NY                                                 9
    (528Canandaigua, NY                                         22
    (528Syracuse, NY                                           107
    (528Western New York, NY                                    60
    (526Bronx, NY                                                6
    (561New Jersey HCS, NJ                                     210
    (620VA Hudson Valley HCS, NY                                33
    (630New York Harbor HCS, NY                                 10
    (632Northport, NY                                          136
    (460Wilmington, DE                                         192
    (503Altoona, PA                                            258
    (529Butler, PA                                              71
    (542Coatesville, PA                                        139
    (562Erie, PA                                               142
    (595Lebanon, PA                                            104
    (642Philadelphia, PA                                        67
    (646Pittsburgh, PA                                         371
    (693Wilkes-Barre, PA                                       145
    (512Baltimore HCS, MD                                      139
    (517Beckley, WV                                             79
    (540Clarksburg, WV                                          70
    (581Huntington, WV                                          73
    (613Martinsburg, WV                                         83
    (688Washington, DC                                         140
    (558Durham, NC                                             177
    (565Fayetteville, NC                                        60
    (590Hampton, VA                                             65
    (637Asheville, NC                                          108
    (652Richmond, VA                                           222
    (658Salem, VA                                               38
    (659Salisbury, NC                                           95
    (508Atlanta, GA                                            240
    (509Augusta, GA                                            112
    (521Birmingham, AL                                         129
    (534Charleston, SC                                         235
    (544Columbia, SC                                           188
    (557Dublin, GA                                             174
    (619Central Alabama Veterans HCS, AL                       193
    (679Tuscaloosa, AL                                          41
    (516Bay Pines, FL                                          215
    (546Miami, FL                                               71
    (548West Palm Beach, FL                                    144
    (573Gainesville, FL                                        401
    (672San Juan, PR                                           160
    (673Tampa, FL                                              201
    (675Orlando, FL                                             72
    (596Lexington, KY                                           45
    (603Louisville, KY                                          40
    (614Memphis, TN                                            104
    (621Mountain Home, TN                                      160
    (626Middle Tennessee HCS, TN                               129
    (506Ann Arbor, MI                                          145
    (538Chillicothe, OH                                         74
    (539Cincinnati, OH                                         126
    (541Cleveland, OH                                          179
    (552Dayton, OH                                             142
    (757Columbus, OH                                           105
    (515Battle Creek, MI                                       441
    (553Detroit, MI                                             28
    (583Indianapolis, IN                                       330
 (610 A4Ft. Wayne, IN                                          156
    (610Northern Indiana HCS, IN                                 1
    (655Saginaw, MI                                            279
    (537Jesse Brown VAMC (Chicago), IL                          69
    (550Danville, IL                                            57
    (556Captain James A Lovell FHCC                              1
    (578Hines, IL                                              310
    (585Iron Mountain, MI                                      288
    (607Madison, WI                                             55
    (676Tomah, WI                                               39
    (695Milwaukee, WI                                           76
 (589 A4Columbia, MO                                           250
    (589Eastern KS HCS, KS                                     192
    (589Kansas City, MO                                        101
    (589Wichita, KS                                             43
 (657 A4Poplar Bluff, MO                                       140
 (657 A5Marion, IL                                              58
    (657St. Louis, MO                                          168
    (667Topeka, KS                                               1
    (502Alexandria, LA                                          39
    (520Gulf Coast HCS, MS                                      85
    (564Fayetteville, AR                                       123
    (580Houston, TX                                            203
    (586Jackson, MS                                             93
    (598Little Rock, AR                                         54
    (623Muskogee, OK                                           120
    (629New Orleans, LA                                        113
    (635Oklahoma City, OK                                      162
    (667Shreveport, LA                                         202
    (504Amarillo, TX                                            24
    (549Dallas, TX                                              15
    (671San Antonio, TX                                         45
    (674Temple, TX                                              29
    (740VA Texas Valley Coastal Bend HCS                         4
    (756El Paso, TX                                             21
    (501New Mexico HCS                                          96
    (644Phoenix, AZ                                            195
    (649Northern Arizona HCS                                   144
    (678Southern Arizona HCS                                    73
    (436Montana HCS                                            316
    (442Cheyenne, WY                                            53
    (554Denver, CO                                             184
    (575Grand Junction, CO                                      92
    (660Salt Lake City, UT                                     576
    (666Sheridan, WY                                            90
    (463Anchorage, AK                                           21
    (531Boise, ID                                               51
    (648Portland, OR                                           257
    (653Roseburg, OR                                           102
    (663VA Puget Sound, WA                                     399
    (668Spokane, WA                                            105
    (687Walla Walla, WA                                         64
    (692White City, OR                                          67
    (459Honolulu, HI                                           175
    (570Fresno, CA                                              65
    (612N. California, CA                                      164
    (640Palo Alto, CA                                          376
    (654Reno, NV                                               103
    (662San Francisco, CA                                      110
    (593Las Vegas, NV                                          129
    (600Long Beach, CA                                          24
    (605Loma Linda, CA                                         401
    (664San Diego, CA                                          415
    (691Greater Los Angeles HCS                                144
    (437Fargo, ND                                              334
    (438Sioux Falls, SD                                        175
    (568Black Hills HCS, SD                                     62
    (618Minneapolis, MN                                        176
 (636 A6Des Moines, IA                                         119
    (636Iowa City, IA                                          314
    (636Nebraska-W Iowa, NE                                    316
    (656St. Cloud, MN                                          132
                                                         ---------------
            Total                                           20,215
------------------------------------------------------------------------
        Source: VCP Provider Agreement Sharepoint
        Only displaying agreements in an active status


    b. What processes are in place to ensure the provider agreements do 
not duplicate care available in the PC3 contract?
    Response. Currently Provider Agreements may only be used under the 
Veterans Choice Program (VCP) to provide medical care to our Nations 
Veterans. Provider Agreements are used to provide care and services 
that are not available through the contractor network. There are 
instances, when Provider Agreements are used to provide services that 
may be available through the PC3 Contract for Choice, those 
circumstance occur when the contractor has returned referrals they are 
unable to schedule. In addition, recently the Office of Community Care 
has allowed facilities to utilize Provider Agreements when a facility 
has identified a certain percentage of returns from the contractor for 
specific categories of care and the facility has identified they have 
active provider agreements for those categories of care and adequate 
staffing to schedule the Veterans identified, this new process ensures 
Veterans are receiving the medical care needed in a more timely manner.

    Question 7. The Budget Justification identifies the creation of a 
VHA transitional care program office as one of its 2017-2019 goals. 
Please describe in detail the duties of this office, the number of FTE 
associated with this office, the estimated budget request for this 
office, and a projected timeline for its creation.
    Response. VHA had the goal of realigning the Federal Recovery 
Coordination Program (FRCP) under Care Management and Social Work (CM/
SW), and Transition and Care Management Services, to integrate care 
coordination services under one leadership. At this time, a new VHA 
transitional care program office is not under development. VA continues 
to provide assistance to transitioning Servicemembers and Veterans (SM/
V) and their families through Transition and Care Management Services 
and the FRCP. These programs work in coordination to assist wounded SM/
V to navigate the recovery care continuum.
    Transition and Care Management (TCM) Services leads two national 
programs:

     The VA Liaison Program consists of 43 VA Liaisons for 
Health Care at 21 Military Treatment Facilities (MTF) to facilitate 
ongoing VA health care for ill and injured Servicemembers transitioning 
from Department of Defense (DOD) to VA. Since the inception of the 
program, VA Liaisons for Healthcare have coordinated over 84,000 
transitions. In fiscal year (FY) 2016, VA Liaisons for Healthcare 
coordinated 11,130 transitions; provided 22,906 professional 
consultations and 2,412 briefings; and ensured Servicemembers 
transitioning from DOD to VA received timely access to care by ensuring 
100 percent of Servicemembers who wanted VA healthcare had an initial 
VA appointment scheduled at the VA healthcare facility of their choice; 
89 percent had appointments scheduled prior to leaving the MTF.
     The TCM Program consists of a TCM team at each VA Medical 
Center to provide comprehensive and specialized transition assistance 
and ongoing case management services to Post-9/11 Veterans as they 
reintegrate into their home communities and into VA health care. VA has 
approximately 400 TCM case managers nationwide providing case 
management services to almost 30,000 Veterans. In FY 2016, 90 percent 
of these Veterans were contacted regarding their individualized care 
management plan, resulting in over 347,000 contacts.

    The FRCP was developed as a joint program by VA and DOD, in 
January 2008, to provide care coordination services to SM/V who were 
severely wounded, ill, or injured after September 11, 2001. The program 
utilizes Federal Recovery Coordinators (FRCs), either social workers or 
nurses funded by VA Central Office, to monitor and coordinate clinical 
services, including facilitating and coordinating medical appointments; 
and non-clinical services, such as providing assistance in obtaining 
financial benefits or special accommodations needed by program 
enrollees and their families.

    Question 8. The Comprehensive Addiction and Recovery Act of 2016 
requires naloxone prescriptions and related education to be provided 
free of charge to Veterans.

    a. The Budget Justification does not clearly state whether or not 
this reduction in co-pays is reflected in the estimated medical care 
collections. Please provide a detailed analysis of the expected 
reduction in estimated medical care collections for 2017 and 2018, 
including any impact caused by the reduction in copays for naloxone 
prescriptions.
    Response. The Naloxone prescriptions and related education analysis 
was performed after the FY 2017 and FY 2018 medical care collections 
budgets were formulated. As such, there was no reduction explicitly 
incorporated into the FY 2017 & FY 2018 budgets as a result of the 
elimination of copayments for Naloxone prescriptions or outpatient 
visits pertaining solely to the education. Further, the number of 
Naloxone kits dispensed to Veterans has remained stable over the past 
three years with the percent of billable prescriptions assumed stable 
through FY 2026. The resulting impact of the copayment on the Pharmacy 
portion is only 0.03% of the FY 2017 First Party Rx estimated 
collections. These impacts will be explicitly incorporated into the 
baseline collections forecasting when using FY 2017 data for future 
medical care collections budgets.

    b. The Budget Justification states that over 50,000 naloxone kits 
have been dispensed as of January 2017 and that naloxone distribution 
will continue to expand. However, the 2017 current estimate for 
naloxone distribution is listed as $0. For 2018 and 2019, the Budget 
Justification includes $25 million a year for naloxone distribution. 
Please provide additional details on the expected naloxone kit 
distribution for 2017 and provide details for the $25 million 
requested, to include expected number of Veterans receiving overdose 
education and the estimated number of naloxone kits to be distributed.
    Response. See table below.

 
----------------------------------------------------------------------------------------------------------------
                                                                                  Distribution/
                  Fiscal Year                    Naloxone Kits     Drug Cost       Dispensing       Total Cost
                                                  Distributed                         Cost
----------------------------------------------------------------------------------------------------------------
FY-16..........................................      48,462        $8,622,450       $169,925        $8,792,375
FY-17*.........................................      62,037        $7,310,048       $225,194        $7,535,242
FY-18**........................................      68,241        $9,174,283       $259,316        $9,433,599
FY-19**........................................      75,065       $10,091,710       $296,507       $10,388,217
----------------------------------------------------------------------------------------------------------------
 * FY-17 estimated based on YTD distribution
** FY-18/19 assume 10% increase in usage and current contract price stabilization


    Question 9. Please provide a sample of the preconception care 
counseling template found in the Computerized Patient Record System 
described in Volume II, VHA-191.
    Response. Attached is the sample of the preconception care 
counseling template found in the Computerized Patient Record System 
described in Volume II, VHA-191 requested below.

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


    Question 10. What percentage of women veteran gender-specific care 
is provided at VA facilities and what percentage is provided through 
non-VA care? Please break out each category included under gender-
specific health care for fiscal year 2017 as well as projections for 
fiscal year 2018.
    Response. See table below.
    
    
    Question 11. Please provide an updated list of VA medical 
facilities that have a gynecologist on staff and whether they are full-
time, part-time, or contracted.
    Response. See attached.

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]    

    Question 12. Current law allows VA to cover care for newborns of 
eligible women Veterans for the first seven days after birth. Please 
provide a breakout of the average number of days VA has covered care 
for newborns and the total cost of this care in fiscal year 2017 and 
projections for fiscal year 2018.
    Response. To reiterate this data only relates to the newborn care, 
it does not include any expenditure for services provided to the 
mother. On average, VA authorizations in FY 2017 covered 3 days for 
inpatient newborn care. Please refer to the table below.

 
----------------------------------------------------------------------------------------------------------------
                                                                            Average Length of
                                                               Neonates            Stay           Obligations $m
----------------------------------------------------------------------------------------------------------------
Actual FY 2016.............................................       2,705                   3.44           $19.82
Annualized FY 2017.........................................       2,264                   3.10           $16.67
Estimated FY 2018..........................................       2,176                   3.02           $16.04
----------------------------------------------------------------------------------------------------------------

                              construction
    Question 13. The Budget Justification requests authorization for 27 
leases in 2018. Twenty-one of these leases were submitted in prior 
years but were not authorized. Six are new lease requests. Three leases 
in Pontiac, Michigan; Birmingham, Alabama; and Mission Bay, California 
were requested in previous budgets but are not included in the 2018 
request. Please provide additional details for removing these three 
leases from the Budget Justification.
    Response. In preparing the FY 2018 Budget Request, lease 
requirements previously authorized but not yet in the solicitation 
process were reviewed and validated to assure optimum use of 
alternatives. The following three leases pending authorization were 
removed from the request after this review.
          1. Outpatient Clinic Lease Birmingham, AL--Expanding 
        community care and additional efficiencies realized at the 
        local medical center mitigate the need for this 89,900 Net 
        Useable Square Feet (NUSF) lease.
          2. Research Lease Mission Bay, CA--Use of available space on 
        the medical center campus and private partnering solutions are 
        being pursued to meet this research space need.
          3. Outpatient Clinic Lease Pontiac, MI--This replacement/
        expansion lease is being re-scoped which will reduce the size 
        of the lease under the Major Lease threshold.

    Question 14. Please provide a detailed breakout of the judgment 
fund payments for 2017 and the estimated judgment fund payments for 
2018.
    Response. On January 25, 2017, VA reimbursed the Department of the 
Treasury for Contract Disputes Act Claims in the total amount of $9 
million as follows:

    (1) $4,019,844.67--For a claim against the Menlo Park, CA, Seismic 
Corrections project.
    (2) $4,050,306.54--For two claims against the Denver, CO, New 
Medical Facility project.

    In FY 2018, VA will use the Judgment Fund to reimburse the 
Department of the Treasury for Contract Disputes Act Claims in the 
amount of $10 million for claims related to the Menlo Park, CA, project 
and the Orlando, FL, New Medical Facility project.

    Question 15. For the major construction staff request, please 
provide the total number of FTE for fiscal year 2016 and the estimated 
number of FTE for fiscal years 2017 and 2018.
    Response. For the major construction staff request, the total 
number of FTE in FY 2016 was 115. The estimated number for FY 2017 is 
139 FTE, and for FY 2018 the estimate is 197 FTE. Note the 
appropriation language was changed in FY 2017 to allow major 
construction staff funding to include support for contracting officers 
working directly on major construction projects to ensure alignment 
with the program they are supporting.

    Question 16. Please provide a list of the non-recurring maintenance 
projects included in the $1.9 billion request for 2018. Specifically 
break out the projects included in the ``second bite'' $1.3 billion 
portion of the request for 2018 advance appropriations.
    Response. Attached is the list of ``first bite'' and ``second 
bite'' NRM projects for FY 2018. NRM projects that have had design 
funded in years prior to SCIP 2018, and only needing construction 
funding to complete, are mostly funded in the ``first bite.'' Design of 
newly scored SCIP projects is funded in the ``second bite,'' as well as 
some projects prior to FY 2018.

                                                     Planned 2018 Non-Recurring Maintenance Projects
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                               Total      Planned
                                                                                                             Estimated    FY 2018    "First     "Second
VISN              Location               ST           Project Type        Project Name - Short Description     Cost         Obs       Bite"      Bite"
                                                                                                              ($000)      ($000)     ($000)     ($000)
--------------------------------------------------------------------------------------------------------------------------------------------------------
   1Newington                             CT BT                         Emergency Generator #7..........         678         600                   600
   1Newington                             CT SCIP 2018                  Replace the Boilers and Systems        9,700         970                   970
                                                                         for Newington VAMC, Phase 1.
   1Newington                             CT SCIP 2018                  Demolish Buildings 6,7, & 8.....       2,561         256                   256
   1West Haven                            CT BT                         Yard Drain Tunnel Refurbishment.         685         500       500
   1West Haven                            CT BT                         West Haven SPS Chiller..........         825         750                   750
   1West Haven                            CT CSI                        Fisher House Infrastructure and        3,500       3,200     3,200
                                                                         Prep.
   1West Haven                            CT SCIP 2016                  Renovate Mental Health Inpatient       6,571       5,863                 5,863
                                                                         Unit.
   1West Haven                            CT SCIP 2015                  Replace and Upgrade Electrical         2,300       2,070                 2,070
                                                                         Supervisory Control and Data
                                                                         Acquisition System.
   1West Haven                            CT SCIP 2018                  Refurbish Building Exterior For        6,300         630                   630
                                                                         Building 1.
   1Bedford                             MA   SCIP 2018                  Replace Water Mains.............       3,300         330                   330
   1Boston (JP)                         MA   SCIP 2016                  IT infrastructure upgrades JP...       2,200       2,000                 2,000
   1Boston (JP)                         MA   SCIP 2018                  Install Site Security Systems          7,150         715                   715
                                                                         Campus Wide Jamaica Plain.
   1Boston (WR)                         MA   SCIP 2013                  Building 5 Fire and Safety             2,400       2,200     2,200
                                                                         Improvements.
   1Boston (WR)                         MA   SCIP 2012                  EM Infrastructure Backup Water         1,650       1,500     1,500
                                                                         supply.
   1Boston (WR)                         MA   BT                         FCA Window Replacement..........         766         701                   701
   1Boston (WR)                         MA   SCIP 2013                  Site Security Installation WR...       7,600       7,000     7,000
   1Boston (WR)                         MA   SCIP 2015                  FCA HVAC Upgrade PH3............       5,060       5,400                 5,400
   1Boston (WR)                         MA   SCIP 2015                  FCA Electrical Upgrade WR, PH 3.       4,840       4,356                 4,356
   1Boston (WR)                         MA   SCIP 2018                  IT infrastructure upgrades WR...       3,300         330                   330
   1Boston (WR)                         MA   SCIP 2018                  Construct Central Chiller Plant        9,850         985                   985
                                                                         West Roxbury.
   1Brockton                            MA   SCIP 2013                  Install Sprinkler System........       2,000       1,800     1,800
   1Brockton                            MA   SCIP 2013                  FCA Replace Damaged Doors and          2,200       2,050     2,050
                                                                         Upgrade Card Access System
                                                                         Phase 2.
   1Brockton                            MA   SCIP 2016                  Improve Site Parking Roadway and       3,410       3,100                 3,100
                                                                         Drainage Systems.
   1Brockton                            MA   SCIP 2018                  Central Chiller Plant Phase 1...       9,900         990                   990
   1Northampton                         MA   Pending OOC                Water System Improvement &             4,981       4,000                 4,000
                                                                         Legionella Prevention Phase 1.
   1Northampton                         MA   Pending OOC                Replace HVAC System Building 4         3,800       3,500                 3,500
                                                                         Upper.
   1Northampton                         MA   Pending OOC                Upgrade Building 5 Electrical          1,600       1,500                 1,500
                                                                         and HVAC Systems.
   1Northampton                         MA   Pending OOC                Exterior Site Improvements......       4,396       4,000                 4,000
   1Northampton                         MA   BT                         Exterior Wayfinding.............         720         650       650
   1Northampton                         MA   BT                         Occupational Therapy wing                 40          28        28
                                                                         Asbestos Abatement.
   1Northampton                         MA   BT                         Ward 4 Lower Upgrades...........         778         670       670
   1Northampton                         MA   Pending OOC                Electrical Distribution System         5,050       4,600                 4,600
                                                                         Upgrade Phase I.
   1Togus                               ME   CSI                        Provide Infrastructure to Fisher       1,351       1,351                 1,351
                                                                         House.
   1Togus                               ME   SCIP 2016                  Install Legionella Mitigation          4,235       3,876                 3,876
                                                                         Infrastructure.
   1Togus                               ME   SCIP 2018                  Relocate Primary Care Clinic to        5,500         550                   550
                                                                         B205.
   1Togus                               ME   SCIP 2018                  Correct Stormwater System              3,710         371                   371
                                                                         Deficiencies throughout Campus.
   1Togus                               ME   SCIP 2018                  Replace Damaged Roofs and              4,845         485                   485
                                                                         Masonry.
   1Togus                               ME   SCIP 2018                  Repair Damaged Windows and             4,405         441                   441
                                                                         Entranceway Doors.
   1Manchester                          NH   BT                         Replace OR Suite Doors..........         360         300       300
   1Manchester                          NH   SCIP 2016                  Replace Aboveground Storage            1,164       1,063                 1,063
                                                                         Tanks.
   1Manchester                          NH   BT                         Building #2 demolishing.........         495         425       425
   1Manchester                          NH   SCIP 2018                  Renovate Building 1, 3rd Floor         2,914         291                   291
                                                                         for Dental.
   1Providence                          RI   SCIP 2015                  Renovate Wing 2C & 3C for              9,210       8,560                 8,560
                                                                         Dentistry.
   1Providence                          RI   SCIP 2013                  Renovate Space for Relocation of       2,237       2,013     2,013
                                                                         Inpatient Pharmacy.
   1Providence                          RI   SCIP 2014                  FCA Pavement Repairs............       2,600       2,507                 2,507
   1Providence                          RI   BT                         Repair and Upgrade 5B and 6B             670         600       600
                                                                         Isolation Suite HVAC System.
   1Providence                          RI   SCIP 2016                  Install Legionella Remediation         3,500       3,250                 3,250
                                                                         System.
   1White River Junction                VT   Pending OOC                Renovate Clinical Lab...........       6,200       6,026                 6,026
   1White River Junction                VT   SCIP 2017                  Underground Utility Replacement.       7,700       7,000                 7,000
   1White River Junction                VT   BT                         Acute Mental Health PH2.........         990         900       900
   1White River Junction                VT   SCIP 2015                  Repair and Upgrade Building 1          5,227       4,758                 4,758
                                                                         Heating, Ventilation, and Air
                                                                         Conditioning (Phase II).
   2East Orange                          N   BT                         Upgrade men's bathrooms&                 889         800       800
                                                                         Drinking Fountains.
   2East Orange                         NJ   Pending OOC                Improve outpatient Environment         2,854       2,594                 2,594
                                                                         (4D).
   2East Orange                         NJ   BT                         Storage Building................         440         400       400
   2East Orange                         NJ   BT                         Legionella Plumbing Field Study.         140         140                   140
   2Lyons                               NJ   BT                         Tuckpoint & Waterproofing B 1,           350         315       315
                                                                         2, 53.
   2Lyons                               NJ   BT                         Repair & Repave Roadways........         540         500       500
   2Lyons                               NJ   BT                         Demolish Bldg 18................         440         400       400
   2Lyons                               NJ   BT                         Replace Porch Roofs & Woodwork           577         525       525
                                                                         Bldg 10, 11.
   2Lyons                               NJ   BT                         Repair Brick Facade--B-135......         550         500       500
   2Lyons                               NJ   BT                         Repair Sidewalks Phase II.......         450         450                   450
   2Lyons                               NJ   BT                         Replace Steps & Railings........         550         500       500
   2Lyons                               NJ   CSI                        Digital Radiography Room (K113           500         500                   500
                                                                         LY).
   2Lyons                               NJ   BT                         Upgrade Generator & Transfer             605         550       550
                                                                         Switches.
   2Albany                              NY   BT                         Structural Repairs at Chapel             116         101       101
                                                                         Windows.
   2Albany                              NY   BT                         Roof Improvements & Misc Work...         669         669                   669
   2Albany                              NY   SCIP 2017                  Radiology Master Plan...........       3,740       3,400                 3,400
   2Albany                              NY   SCIP 2015                  Renovate 6B for Dialysis........       7,262       6,631                 6,631
   2Albany                              NY   Pending OOC                Renovate for CLC phase 4........       5,741         473                   473
   2Batavia                             NY   SCIP 2016                  Replace Fire Alarm System.......       3,150       2,700                 2,700
   2Batavia                             NY   SCIP 2016                  Replace Roofs Batavia...........       2,950       2,700                 2,700
   2Batavia                             NY   SCIP 2018                  Improve Potable Water                  2,300       2,070                 2,070
                                                                         Distribution Systems Batavia,
                                                                         Bldgs #1 & 5.
   2Bath                                NY   BT                         Upgrade 104 Sprinklers and Hot           935         850       850
                                                                         Water.
   2Bath                                NY   SCIP 2017                  Replace Roof/Renovate Wood             1,225       1,125                 1,125
                                                                         Molding, B76.
   2Bath                                NY   SCIP 2017                  FCA Renovate Main Kitchen, B24..       1,375       1,250                 1,250
   2Bath                                NY   OOC                        Renovate CLC 3..................       5,200       4,750     4,750
   2Bath                                NY   BT                         Improve Accessibility & Install           20          20                    20
                                                                         2nd Floor Handicap Accessible
                                                                         Bathroom, B-32.
   2Bath                                NY   SCIP 2018                  B76 Renovations.................       3,000         300                   300
   2Bronx                               NY   Pending OOC                Combined Heat & Power Plant           18,000      18,000                18,000
                                                                         Construction.
   2Bronx                               NY   Pending OOC                Renovate CLC for Polytrauma Ph 3       4,380       3,900                 3,900
   2Bronx                               NY   SCIP 2016                  Modernize ER....................       4,194       3,724                 3,724
   2Bronx                               NY   OOC                        Renovate CLC Recreation & Dining       3,850       3,500     3,500
                                                                         Area.
   2Bronx                               NY   SCIP 2017                  Renovate ICU....................       4,900       4,500                 4,500
   2Bronx                               NY   OOC                        Correct Safety Deficiencies at         2,750       2,500     2,500
                                                                         Loading Dock.
   2Bronx                               NY   OOC                        Replace Air Handling Units,            5,400       5,100     5,100
                                                                         Phase 4.
   2Bronx                               NY   SCIP 2013                  Replace Air Handler Units, Phase       3,150       2,500     2,500
                                                                         3 (for GG, 2B, 2C, 2G).
   2Bronx                               NY   SCIP 2014                  Renovate for New Learning Center       5,335       4,850                 4,850
   2Bronx                               NY   OOC                        Replace Existing Boilers #1 & 2.       4,300       4,000     4,000
   2Bronx                               NY   SCIP 2016                  Replace/Install Parking Lot/           2,950       2,600                 2,600
                                                                         Street Lights Ph 2.
   2Bronx                               NY   BT                         Install 20 KW Roof-Mounted Wind          594         500       500
                                                                         Turbine System.
   2Brooklyn                            NY   SCIP 2015                  Install Secondary Main Water           1,540       1,400                 1,400
                                                                         Supply Line.
   2Brooklyn                            NY   SCIP 2017                  Renovate Outpatient Pharmacy(SA)       1,040         950       950
   2Brooklyn                            NY   SCIP 2017                  Upgrade Elevators...............       3,000       3,000                 3,000
   2Brooklyn                            NY   SCIP 2017                  Bldg 2 Replace Pressure Relief         1,200       1,080                 1,080
                                                                         Valve and Condensate Pumps.
   2Brooklyn                            NY   SCIP 2015                  Upgrade Life Safety/Critical           7,260       7,260                 7,260
                                                                         Branch Electrical Distribution.
   2Brooklyn                            NY   BT                         Replace Air & Vacuum Compressor.         935         850       850
   2Brooklyn                            NY   BT                         Laundry Plant Storm Disposal....         805         750       750
   2Brooklyn                            NY   Pending OOC                Renovate C3 and D3 Ward(SA).....       6,545       5,950                 5,950
   2Brooklyn                            NY   OOC                        Laundry Mechanical Room Upgrade        2,100       1,910     1,910
                                                                         (SA).
   2Buffalo                             NY   SCIP 2016                  Replace High Pressure Water            1,600           2                     2
                                                                         Risers, Bldg #1.
   2Buffalo                             NY   SCIP 2017                  Fuel Oil Tanks Replacement......       1,095         975       975
   2Buffalo                             NY   Pending OOC                Improve Potable Water Systems...       2,420       2,200                 2,200
   2Buffalo                             NY   Pending OOC                Upgrade HVAC SPS................       1,320       1,200                 1,200
   2Buffalo                             NY   BT                         Sub-Basement Safety Improvements         275         250       250
   2Buffalo                             NY   SCIP 2018                  Renovate 9th Floor B Wing.......       4,650         465                   465
   2Canandaigua                         NY   BT                         Upgrade HVAC B3.................         250         200                   200
   2Canandaigua                         NY   BT                         Heating Upgrades for B7 and B8..         475         400                   400
   2Canandaigua                         NY   BT                         Design and Install Backflow              950         800                   800
                                                                         prevention on campus.
   2Canandaigua                         NY   BT                         Provide Electrical Upgrades.....         800         800                   800
   2Canandaigua                         NY   SCIP 2017                  Replace Roofs Stationwide.......       1,350       1,350                 1,350
   2Canandaigua                         NY   BT                         Fire Department Upgrades........         860         750       750
   2Canandaigua                         NY   BT                         Renovations to Support Swing              50          50                    50
                                                                         Space Development.
   2Canandaigua                         NY   BT                         Relocate Grounds and                     595         500       500
                                                                         Transportation.
   2Canandaigua                         NY   OOC                        Renovate 6A for Member Services.       6,500       6,000     6,000
   2Canandaigua                         NY   SCIP 2018                  Replace Primary Electrical             2,500         250                   250
                                                                         Distribution System.
   2Castle Point                        NY   SCIP 2016                  Renovate STP Replace Trinkling         1,480       1,200                 1,200
                                                                         Filter.
   2Castle Point                        NY   SCIP 2018                  Upgrade Central Air Conditioning       4,400         440                   440
                                                                         Plant Chilled Water Units and
                                                                         Distribution Main.
   2Montrose                            NY   SCIP 2014                  Install Elevator Building 29....       1,800       1,500                 1,500
   2Montrose                            NY   SCIP 2013                  Replace aging steam distribution       3,795       3,450     3,450
                                                                         equipment for Buildings 3. 4 &
                                                                         12.
   2Montrose                            NY   SCIP 2016                  Correct Deficiencies with SPS          1,285       1,090                 1,090
                                                                         Area in Building 7 FDR.
   2Montrose                            NY   SCIP 2018                  Install new Temperature, pH, and       2,465         247                   247
                                                                         Flow measuring devices on
                                                                         Domestic Water Systems at FDR.
   2New York                            NY   Pre-SCIP                   Admitting Area/ ER Expansion           3,850       3,500     3,500
                                                                         Phase 2.
   2New York                            NY   SCIP 2017                  Replace Chiller Phase II........       3,800       3,430                 3,430
   2New York                            NY   SCIP 2015                  Renovate Research Area/ Animal         5,500       4,090                 4,090
                                                                         Lab.
   2New York                            NY   SCIP 2017                  Correct Accessibilities Ph I....       5,375       3,400                 3,400
   2New York                            NY   SCIP 2018                  Correct Accessibility                  5,375         538                   538
                                                                         Deficiencies PH1.
   2Northport                           NY   SCIP 2015                  Replace Primary Electrical             9,971       9,063                 9,063
                                                                         Distribution Phase 1.
   2Northport                           NY   OOC                        Upgrade Sewage Treatment Plant,        2,860       1,230     1,230
                                                                         Phase 1.
   2Northport                           NY   SCIP 2015                  Renovate Roads Project 4........       4,695       4,268                 4,268
   2St. Albans                          NY   SCIP 2013                  Laundry Heat Recovery SA........       1,975       1,800     1,800
   2Syracuse                            NY   BT                         Demolish Abandoned Piping in Sub         295         265                   265
                                                                         Basement.
   2Syracuse                            NY   OOC                        Upgrade Chiller Plant Switchgear       2,525       2,300     2,300
   2Syracuse                            NY   SCIP 2015                  Laboratory Renovations..........       3,510       3,150                 3,150
   4Wilmington                          DE   SCIP 2017                  Replace AHU's Serving Nuclear          1,100       1,000                 1,000
                                                                         Medicine and the Lab.
   4Wilmington                          DE   SCIP 2017                  Correct ICU Heat and Facility-         2,200       2,000                 2,000
                                                                         Wide Humidification.
   4Wilmington                          DE   SCIP 2017                  Renovate Building 13............       3,850       3,500                 3,500
   4Wilmington                          DE   Pending OOC                Renovate the Auditorium.........       1,100       1,000                 1,000
   4Wilmington                          DE   Pending OOC                Renovate 2 East.................       2,200       2,000                 2,000
   4Wilmington                          DE   SCIP 2017                  Provide Chiller Plant Redundancy       2,200       2,000                 2,000
   4Wilmington                          DE   SCIP 2016                  Convert the Special Procedures         4,400       4,000                 4,000
                                                                         Room to an Operatory.
   4Wilmington                          DE   Pending OOC                Evaluate and Replace Roofs             2,200       2,000                 2,000
                                                                         Throughout the Facility.
   4Wilmington                          DE   SCIP 2014                  Study and Correct Domestic Water       5,540       4,200                 4,200
                                                                         Storage.
   4Wilmington                          DE   SCIP 2014                  Renovate the First Floor of            6,600       6,000                 6,000
                                                                         Building 1 for Primary Care.
   4Wilmington                          DE   SCIP 2017                  Assess and Replace Steam and           3,300       3,000                 3,000
                                                                         Condensate Distribution Piping.
   4Altoona                             PA   BT                         Make Fire Safety Improvements...         356         324       324
   4Altoona                             PA   BT                         Correct Air Conditioning                 160         146       146
                                                                         Deficiencies in Biomedical Shop
                                                                         & Mailroom.
   4Altoona                             PA   SCIP 2017                  Replace Keying System For              1,745       1,587                 1,587
                                                                         Outbuildings.
   4Altoona                             PA   BT                         Provide For Green Environmental          500         455       455
                                                                         Management (GEM), Phase 1.
   4Altoona                             PA   BT                         Facility Chlorination System....         300         270       270
   4Altoona                             PA   BT                         Provide Security Upgrades, Phase         605         550       550
                                                                         2.
   4Altoona                             PA   BT                         Replace Space Signage...........         622         566       566
   4Altoona                             PA   BT                         Provide Electronic Signage......         398         362       362
   4Altoona                             PA   BT                         Paint Walls.....................         242         220       220
   4Altoona                             PA   SCIP 2017                  Correct Retro-commissioning            3,722       3,384                 3,384
                                                                         Discrepancies Phase 2.
   4Butler                              PA   SCIP 2015                  Renovate Building 6.............       3,045       1,750                 1,750
   4Coatesville                         PA   Pending OOC                Renovate Building 58............       8,800       8,000                 8,000
   4Coatesville                         PA   BT                         Update Campus Water Lines.......         490         190       190
   4Coatesville                         PA   SCIP 2018                  Correct Electrical Deficiencies        2,225       2,000                 2,000
                                                                         (PH2).
   4Coatesville                         PA   BT                         Remove Fuel storage tanks.......         470         400       400
   4Coatesville                         PA   Pending OOC                Hospice Oxygen System...........       1,100         900                   900
   4Coatesville                         PA   BT                         FCA Repairs Bldg 14.............         485         425       425
   4Coatesville                         PA   BT                         Tree Management & Sidewalks Oval         495         450       450
                                                                         1.
   4Coatesville                         PA   Pending OOC                SPS Satellite Storage Rooms.....       1,100         900                   900
   4Coatesville                         PA   SCIP 2015                  Replace Steam & Condensate             3,000       2,700                 2,700
                                                                         Mains--Oval 2 & Outlying
                                                                         Branches.
   4Coatesville                         PA   SCIP 2017                  Upgrade HVAC System B/57........       2,200       1,690                 1,690
   4Coatesville                         PA   BT                         Correct FCA Deficiencies                 350         300       300
                                                                         Building 10.
   4Coatesville                         PA   BT                         Roof Fall Protection Systems             600         500       500
                                                                         Evaluation & Upgrades.
   4Coatesville                         PA   SCIP 2017                  Exterior Signage & Wayfinding          1,870       1,750                 1,750
                                                                         Campus Wide.
   4Coatesville                         PA   SCIP 2018                  Renovate Building 58--A Floor...       4,950         495                   495
   4Coatesville                         PA   SCIP 2018                  Correct Electrical Deficiencies--      2,225       2,002                 2,002
                                                                         Phase 2.
   4Erie                                PA   SCIP 2016                  Renovate Exterior Building--           2,200       2,000                 2,000
                                                                         Masonry, Windows, Sunshades.
   4Erie                                PA   Pending OOC                Replace Roofs...................       1,815       1,650                 1,650
   4Erie                                PA   SCIP 2015                  New Central Chiller Plant.......       9,680       8,800                 8,800
   4Erie                                PA   SCIP 2013                  Renovate Fourth Floor (Design)..       4,950       4,500     4,500
   4Erie                                PA   SCIP 2015                  Correct Retro-Commissioning            1,100         100       100
                                                                         Project Findings.
   4Lebanon                             PA   SCIP 2015                  Renovate 1-4C for Multi-purpose        2,200       2,200                 2,200
                                                                         Area.
   4Lebanon                             PA   OOC                        Replace Electrical Substation...       4,500       4,000     4,000
   4Lebanon                             PA   Pending OOC                Correct Physical Security Issues       3,300       3,000                 3,000
   4Lebanon                             PA   OOC                        Renovate Food Service Kitchen...       3,830       3,500     3,500
   4Lebanon                             PA   SCIP 2015                  Renovate Primary Care/Specialty        1,950       1,750                 1,750
                                                                         Clinic Building 17.
   4Lebanon                             PA   SCIP 2017                  Replace Chillers................       3,850       3,500                 3,500
   4Lebanon                             PA   SCIP 2017                  Renovate Bldg. 22...............       5,000       4,500                 4,500
   4Lebanon                             PA   SCIP 2015                  Renovate 1-4C for Patient              2,200       1,900                 1,900
                                                                         Activity Area.
   4Lebanon                             PA   SCIP 2015                  Renovate for MOVE! program......       3,300       3,000                 3,000
   4Lebanon                             PA   SCIP 2018                  Correct Physical Security Issues       3,300       2,970                 2,970
                                                                         Phase 1.
   4Lebanon                             PA   SCIP 2018                  Correct Facade Issues Phase 3...       3,300         330                   330
   4Lebanon                             PA   SCIP 2018                  Retro-Commissioning Corrections.       3,300         330                   330
   4Philadelphia                        PA   SCIP 2017                  Modernize Dental Exam Rooms.....       1,884       1,713                 1,713
   4Philadelphia                        PA   BT                         Relocate On-Call Rooms..........         550         500       500
   4Philadelphia                        PA   Pre-SCIP                   Correct Building Facade                8,000       7,800     7,800
                                                                         Deficiencies.
   4Philadelphia                        PA   SCIP 2017                  Architectural Improvements for         2,973       2,543                 2,543
                                                                         Wards 5 and 6.
   4Philadelphia                        PA   BT                         Upgrade Toilets 1st Floor.......         225         200       200
   4Philadelphia                        PA   CSI                        Upgrade CLC Unit C Ph 2.........       4,400       4,000     4,000
   4Philadelphia                        PA   SCIP 2017                  Correct FCA for Lightning              1,100         737       737
                                                                         Protection.
   4Philadelphia                        PA   SCIP 2017                  Renovate Building 1 7th Floor          3,190       2,900                 2,900
                                                                         for Mental Health.
   4Philadelphia                        PA   SCIP 2017                  Address EmergencyPower0                4,600       4,200                 4,200
                                                                         Deficiencies in Building 1.
   4Philadelphia                        PA   CSI                        Women's Imaging Center..........       2,200       2,000     2,000
   4Philadelphia                        PA   BT                         Install Security Fencing at              278         216       216
                                                                         Parking Garage Bldg 28.
   4Philadelphia                        PA   SCIP 2016                  Renovate Specialty Clinics......       3,500       3,300                 3,300
   4Philadelphia                        PA   OOC                        Upgrade Patient Environment NHCU       1,700       1,200     1,200
   4Philadelphia                        PA   CSI                        Replace Catheterization Lab.....       1,100       1,000     1,000
   4Philadelphia                        PA   SCIP 2017                  Upgrade Halls and Wall Phase 1..       2,200       2,000                 2,000
   4Philadelphia                        PA   BT                         Radiology Rooms.................         563         500       500
   4Pittsburgh                          PA   SCIP 2018                  Renovate Building One-10 East          5,250         525                   525
                                                                         for Architectural, Mechanical
                                                                         and Electrical Deficiencies.
   4Pittsburgh                          PA   SCIP 2018                  Replace Elevators in Building 51       3,420         342                   342
                                                                         and Building 50 at Heinz
                                                                         Division.
   4Pittsburgh                          PA   SCIP 2018                  Replace Air Handling Units             9,600         960                   960
                                                                         serving Operating Rooms (AC12 &
                                                                         AC13).
   4Pittsburgh (UD)                     PA   SCIP 2015                  Install Wayfinding Signage at UD       5,500       5,000                 5,000
                                                                         and HZ Campuses.
   4Pittsburgh (UD)                     PA   SCIP 2017                  Replace Domestic Water Branch         22,000      20,000                20,000
                                                                         Piping at UD and HZ.
   4Wilkes-Barre                        PA   OOC                        Replace Exterior Windows........       4,800       4,400     4,400
   4Wilkes-Barre                        PA   SCIP 2015                  Improve Wayfinding and Signage..       1,650       1,500                 1,500
   4Wilkes-Barre                        PA   SCIP 2015                  Renovate 2 West Rehab...........       5,600       5,000                 5,000
   4Wilkes-Barre                        PA   SCIP 2017                  Correct FCA Electrical                 4,400       4,000                 4,000
                                                                         Deficiencies.
   4Wilkes-Barre                        PA   SCIP 2015                  Construct New Chiller Plant.....       6,000       5,000                 5,000
   4Wilkes-Barre                        PA   SCIP 2013                  Renovate 8 East for Nursing            3,800       3,455     3,455
                                                                         Administration.
   4Wilkes-Barre                        PA   Pending OOC                Building 1 HVAC, Phase 2........       4,950       4,500                 4,500
   4Wilkes-Barre                        PA   OOC                        Improve Landscaping.............       1,000         900       900
   4Wilkes-Barre                        PA   SCIP 2017                  Install Fence and Gates.........       2,200         180       180
   4Wilkes-Barre                        PA   SCIP 2017                  Renovate 2 North- Radiology.....       3,300         300       300
   5Washington                           DC  SCIP 2018                  Correct FCA Infrastructure             4,295         430                   430
                                                                         Deficiencies and Functional
                                                                         Deficiencies in Research B4 ,
                                                                         Phase IV.
   5Washington                           DC  SCIP 2018                  Replace Walk-In Refrigerators          2,765         277                   277
                                                                         and Freezers in Patient
                                                                         Kitchen, Morgue, Pharmacy, Lab
                                                                         and Research.
   5Washington                           DC  SCIP 2018                  Replace and Upgrade Room Air           1,962         196                   196
                                                                         Distribution Terminal Devices
                                                                         and Controls to Correct FCA
                                                                         deficiency.
   5Washington                           DC  SCIP 2018                  Renovate MICU 4B for Patient           9,617         962                   962
                                                                         Privacy and Correction of FCA
                                                                         Deficiencies.
   5Washington                           DC  SCIP 2018                  Correct Seismic, Structural, and       2,745         275                   275
                                                                         Facility Condition Deficiencies
                                                                         in Building 1.
   5Washington                           DC  SCIP 2016                  Correct NFPA 70 (NEC) Code             3,028       2,750                 2,750
                                                                         Deficiencies in all Secondary
                                                                         Distribution Panels and
                                                                         Separate Branch Circuits for
                                                                         Critical, Life Safety and
                                                                         Equipment Branches.
   5Washington                           DC  SCIP 2014                  Renovate Research Labs, Phase 3.       2,691       2,427                 2,427
   5Washington                           DC  SCIP 2016                  Replace and Upgrade Outside            3,700       3,400                 3,400
                                                                         Distribution for Site Storm and
                                                                         Sanitary Sewer System.
   5Washington                           DC  SCIP 2016                  Upgrade Sprinkler System for           2,462       2,262                 2,262
                                                                         Building #6.
   5Washington                           DC  SCIP 2016                  Upgrade Chiller Plant and              8,800       8,000                 8,000
                                                                         Cooling Tower.
   5Baltimore                           MD   BT                         Upgrade and Repair CLC Heating           450         450                   450
                                                                         Boilers.
   5Baltimore                           MD   OOC                        Upgrade Emergency Switchgear and         200       1,800     1,800
                                                                         Distribution.
   5Baltimore                           MD   BT                         Replacement of Exterior                  715         650       650
                                                                         Breezeway Precast Concrete
                                                                         Paver Sidewalk System.
   5Baltimore                           MD   SCIP 2013                  Convert Semi-Private Beds to           8,800       8,000     8,000
                                                                         Private 3A.
   5Baltimore                           MD   BT                         Upgrade SPD Closet HVAC.........         770         700       700
   5Baltimore                           MD   BT                         Loch Raven Drainage Corrections.         770         700       700
   5Baltimore                           MD   SCIP 2017                  Upgrade and Renovate OR Suite...       6,710       6,100                 6,100
   5Baltimore                           MD   SCIP 2016                  Convert 6A Semi-Private Mental         8,290       7,461                 7,461
                                                                         Health Beds to Private.
   5Baltimore                           MD   SCIP 2018                  Upgrade Building Air Handler           5,170         517                   517
                                                                         Units and Improve Heating,
                                                                         Ventilating, and Air
                                                                         Conditioning Systems.
   5Baltimore                           MD   SCIP 2018                  Convert 3B Semi Private Beds to        7,040         704                   704
                                                                         Private.
   5Perry Point                         MD   BT                         Expand Fire House for EMS.......         330         300       300
   5Perry Point                         MD   SCIP 2016                  Upgrade Fire Alarm System Campus       7,416       6,674                 6,674
                                                                         Wide--Phase 1--Patient
                                                                         Buildings.
   5Perry Point                         MD   BT                         Emergency Steam Condensate               550         500       500
                                                                         System Repairs.
   5Perry Point                         MD   Pending OOC                Improvements to Bldg 361 Urgent        5,060       4,600                 4,600
                                                                         Care Clinic (UCC).
   5Perry Point                         MD   BT                         PP Enhanced Dining..............         660         600       600
   5Perry Point                         MD   SCIP 2014                  Convert Bldg 364B for                  2,640       2,400                 2,400
                                                                         Residential Rehabilitation
                                                                         Treatment Program.
   5Perry Point                         MD   BT                         Waterproof Tunnel to Bldg 364...         880         800       800
   5Perry Point                         MD   SCIP 2016                  Replace Boiler No. 2 at Perry          1,484       1,336                 1,336
                                                                         Point.
   5Perry Point                         MD   SCIP 2016                  Upgrade Medical Gas Systems.....       1,912       1,721                 1,721
   5Perry Point                         MD   SCIP 2018                  Replace Main Transformers and          1,276         128                   128
                                                                         Switchgear at Perry Point
                                                                         Substation.
   5Perry Point                         MD   SCIP 2018                  Renovate Building 15H for Mental       4,040         404                   404
                                                                         Health Homeless Staff and
                                                                         Voluntary Service.
   5Perry Point                         MD   SCIP 2018                  Replace Chilled Water along            4,796         480                   480
                                                                         Avenue D to Correct FCA
                                                                         Deficiency.
   5Perry Point                         MD   SCIP 2018                  Upgrade HVAC at Bldg 4H to             2,751         275                   275
                                                                         Correct FCA Deficiency.
   5Beckley                             WV   SCIP 2018                  Upgrade Boiler Plant System.....       3,850         385                   385
   5Beckley                             WV   SCIP 2018                  Correct High Voltage                   4,840         484                   484
                                                                         Deficiencies.
   5Beckley                             WV   SCIP 2018                  Corrections to Medical Gas             1,600         160                   160
                                                                         System.
   5Beckley                             WV   SCIP 2018                  Correct Domestic Water Supply          3,025         303                   303
                                                                         System.
   5Clarksburg                          WV   OOC                        Modernize Specialty Clinics.....       6,380       5,844     5,844
   5Clarksburg                          WV   OOC                        Construct Replacement Chiller          7,976       7,251     7,251
                                                                         Plant.
   5Clarksburg                          WV   SCIP 2018                  Replace Deficient Domestic Water       2,200         220                   220
                                                                         Riser Building 1.
   5Huntington                          WV   SCIP 2018                  Upgrade and Correct FCA                6,278         628                   628
                                                                         Deficiencies for Campus
                                                                         Building Management System.
   5Huntington                          WV   SCIP 2018                  Repair and Upgrade Buildings 23        7,069         707                   707
                                                                         and 23R to Correct FCA
                                                                         Deficiencies.
   5Huntington                          WV   SCIP 2018                  Improve Facility Safety and            2,700         270                   270
                                                                         Security.
   5Huntington                          WV   SCIP 2015                  Construct Secondary Access Road.       2,905       2,600                 2,600
   5Huntington                          WV   SCIP 2016                  Correct Boiler Plant Steam             3,005       2,705                 2,705
                                                                         Deficiencies.
   5Huntington                          WV   SCIP 2016                  Replace Mechanical Systems Bldg        4,235       3,850                 3,850
                                                                         4.
   5Huntington                          WV   SCIP 2015                  Replace Air Handling Units Bldgs       2,109       1,900     1,900
                                                                         1&1S.
   5Huntington                          WV   BT                         Improve Signage and Wayfinding..         999         850       850
   5Huntington                          WV   CSI                        Construct RRTP Building.........       4,840       4,400     4,400
   5Huntington                          WV   SCIP 2015                  Replace Windows Bldg 1S.........       1,500       1,500                 1,500
   5Martinsburg                         WV   SCIP 2018                  Relocate Electrical Feeder for         2,785         279                   279
                                                                         Physical Security Compliance.
   5Martinsburg                         WV   SCIP 2018                  Repair Steam Piping from               1,534         153                   153
                                                                         Buildings 217, 318 & 328 to
                                                                         Boiler Plant.
   5Martinsburg                         WV   OOC                        Renovate Building 305 for Fiscal       1,540       1,400     1,400
   5Martinsburg                         WV   BT                         Construct Internet Cafe Healing          710         600       600
                                                                         Garden.
   5Martinsburg                         WV   BT                         Renovate 217 for Veterans' Music         890         800       800
                                                                         Room.
   5Martinsburg                         WV   OOC                        Renovate Building 317, Post            2,075       1,900     1,900
                                                                         Theater.
   6Durham                               NC  Pending OOC                Correct High Priority FCA              3,850       3,500                 3,500
                                                                         Deficiencies.
   6Durham                               NC  Pending OOC                Install Security Fence..........       1,100       1,050                 1,050
   6Durham                               NC  BT                         Renovate Utility Space in                545         500       500
                                                                         Basement.
   6Durham                               NC  BT                         Renovate Access Improvement              570         570                   570
                                                                         Spaces.
   6Durham                               NC  Pending OOC                Expand PACU.....................       2,870       2,600                 2,600
   6Durham                               NC  BT                         Correct Life Safety Deficiencies         395         350       350
   6Durham                               NC  Pending OOC                Pharmacy Processing Renovation..       1,925       1,925                 1,925
   6Durham                               NC  BT                         Install Lightning and Fall               700         700                   700
                                                                         Protection.
   6Durham                               NC  BT                         Renovate OR Locker Rooms........         715         650       650
   6Durham                               NC  Pending OOC                Replace Roofs Phase II..........       2,300       2,150                 2,150
   6Fayetteville                         NC  SCIP 2018                  Renovate Intensive Care Unit....       5,028       4,528                 4,528
   6Fayetteville                         NC  SCIP 2017                  Renovation of 1A corridor and            790         700       700
                                                                         offices.
   6Fayetteville                         NC  SCIP 2017                  Renovate Nursing Area 1A........       1,114       1,000                 1,000
   6Fayetteville                         NC  SCIP 2014                  Replace AHUs in A-wing Basement.       2,500       2,250                 2,250
   6Fayetteville                         NC  SCIP 2014                  Replace Windows Bldg 1..........       2,400       2,160                 2,160
   6Fayetteville                         NC  SCIP 2013                  Renovate Lab, Radiology and            3,520       3,200     3,200
                                                                         Pharmacy High Traffic Areas.
   6Salisbury                            NC  SCIP 2018                  Renovate Building 2 for Medical        6,002       5,402                 5,402
                                                                         Surgical Modernization.
   6Salisbury                            NC  SCIP 2014                  Install New Steam Control Valves       1,665       1,498                 1,498
                                                                         at Existing Convectors
                                                                         Buildings 2, 3, and 4.
   6Salisbury                            NC  SCIP 2014                  Replace Chilled Water Lines            2,080       1,872                 1,872
                                                                         Building 3.
   6Salisbury                            NC  SCIP 2016                  Replace Campus Fire Alarm System       4,285       3,900                 3,900
   6Salisbury                            NC  SCIP 2013                  Construct Water Tower...........       3,250       2,925     2,925
   6Salisbury                            NC  SCIP 2018                  Renovate Building 2 for Medical        6,002       5,452                 5,452
                                                                         Surgical Modernization.
   6Salisbury                            NC  BT                         Resurface Station Roadways and           992         992                   992
                                                                         Repair Sidewalks.
   6Salisbury                            NC  BT                         Road Access Modifications at             300         300                   300
                                                                         Building 3.
   6Salisbury                            NC  SCIP 2016                  Correct Information Technology         3,500       3,100                 3,100
                                                                         FCA Deficiencies.
   6Hampton                             VA   BT                         Access Control Prime Clinics....         165         150       150
   6Hampton                             VA   SCIP 2013                  Implement Master Plan Design and       8,900       8,091     8,091
                                                                         Building Systems Upgrade,
                                                                         Building 110.
   6Hampton                             VA   SCIP 2016                  Improve Data Distribution/             1,650       1,500                 1,500
                                                                         Security/Infrastructure.
   6Hampton                             VA   OOC                        Replace Natural Gas Line and           1,730       1,655     1,655
                                                                         Initial ESPC Pay Down.
   6Hampton                             VA   CSI                        Construct New MRI Facility......         900         819       819
   6Hampton                             VA   BT                         Renovate Prime Clinics for PACT          153         140       140
                                                                         Alignment.
   6Richmond                            VA   SCIP 2018                  Upgrade Pharmacy to USP 800.....       1,045         105                   105
   6Richmond                            VA   BT                         Pharmacy Giant Omni-Cell........          15          15                    15
   6Richmond                            VA   BT                         Parking Access Improvement......         550         500       500
   6Richmond                            VA   SCIP 2016                  Renovate for Operating Rooms....       8,725       7,900                 7,900
   6Richmond                            VA   BT                         Secure 3D with PACS.............          75          75                    75
   6Richmond                            VA   BT                         Radiology Mobile MRI Awning.....         150         150                   150
   6Richmond                            VA   BT                         Roof Replacement................         750         750                   750
   6Richmond                            VA   OOC                        Replace Air Handlers SCI........       2,725       2,450     2,450
   6Richmond                            VA   BT                         Canteen Renovations.............         550         500       500
   6Richmond                            VA   BT                         Remodel Admin Space.............         996         905       905
   6Richmond                            VA   BT                         Remodel Support Spaces..........         945         900       900
   6Richmond                            VA   BT                         Fisher House Exterior Painting..          15          15                    15
   6Richmond                            VA   SCIP 2014                  Improve Patient Privacy 4B......       3,700       3,370                 3,370
   6Richmond                            VA   OOC                        Renovate Spinal Cord Injury Unit       5,720       5,200     5,200
                                                                         for Privacy.
   6Richmond                            VA   Pending OOC                Replace HVAC Systems 2 and 5....       1,980         180                   180
   6Richmond                            VA   Pending OOC                SPS/OR Vertical Transportation..       1,650         150                   150
   6Salem                               VA   SCIP 2016                  Replace Roofs and Tuckpoint.....       6,000       5,480                 5,480
   6Salem                               VA   BT                         Renovate Basement Building 8....         750         675       675
   6Salem                               VA   BT                         Construct Simulation Center              938         900       900
                                                                         Building 4.
   6Salem                               VA   BT                         Replace Finishes Various                 550         550                   550
                                                                         Buildings.
   7Birmingham                          AL   SCIP 2018                  Correct Critical Mechanical and        5,500         550                   550
                                                                         Plumbing Deficiencies by
                                                                         Replacing Aging and
                                                                         Deteriorating Steam
                                                                         Distribution Systems.
   7Birmingham                          AL   SCIP 2014                  Install New Interior Finishes--        3,850       3,500                 3,500
                                                                         Blind Rehabilitation Center.
   7Birmingham                          AL   SCIP 2016                  Replace Information Technology         2,200       1,980                 1,980
                                                                         Cabling Infrastructure.
   7Birmingham                          AL   SCIP 2016                  Replace/Upgrade Pressure Piping        6,600       5,940                 5,940
                                                                         and Hot Water Distribution
                                                                         System.
   7Birmingham                          AL   SCIP 2016                  Replace Air Handling Units--           4,400       3,960                 3,960
                                                                         Phase IV.
   7Birmingham                          AL   BT                         Upgrade Negative Pressure Rooms.         830         750       750
   7Montgomery                          AL   BT                         Renovate Building 90 Therapeutic         330         300       300
                                                                         Pool for Fitness Center.
   7Montgomery                          AL   BT                         Replace Air Handling Equipment           825         750       750
                                                                         and add Generator, Bldg. 1.
   7Montgomery                          AL   BT                         Upgrade Restrooms with Water             820         734       734
                                                                         Conservation Measures, Phase 2.
   7Montgomery                          AL   SCIP 2018                  Renovate Inpatient Medicine Unit       9,290         929                   929
                                                                         for privacy--Building 1, floor
                                                                         4..
   7Tuscaloosa                          AL   SCIP 2018                  Masonry Restoration.............       5,960         596                   596
   7Tuscaloosa                          AL   BT                         Improve Building 12 (Warehouse).         239         206                   206
   7Tuscaloosa                          AL   SCIP 2016                  Replace HVAC Systems............       2,807       2,359                 2,359
   7Tuscaloosa                          AL   SCIP 2017                  Improve in Building 3...........       2,580         862       862
   7Tuscaloosa                          AL   BT                         Improve Courtyard Building 1....         283         265       265
   7Tuscaloosa                          AL   BT                         Install Legionella Precautions..         858         780       780
   7Tuscaloosa                          AL   SCIP 2016                  Electrical Upgrades.............       1,664       1,498                 1,498
   7Tuscaloosa                          AL   OOC                        A/E Legionella Survey/Assessment       6,700       6,200     6,200
                                                                         Design Phase II Tuscaloosa.
   7Tuskegee                            AL   BT                         Improve Facility Condition               985         895       895
                                                                         Assessment Findings-Plumbing
                                                                         Upgrades.
   7Tuskegee                            AL   SCIP 2018                  Repair the Roof on Buildings           2,204         220                   220
                                                                         #3,#3A,#4A,#65,#83,#88,#97,#120
                                                                         and #129.
   7Tuskegee                            AL   SCIP 2018                  Repair FCA Electrical                  1,795         180                   180
                                                                         Deficiencies in Buildings
                                                                         #5,#12,#14.
   7Tuskegee                            AL   SCIP 2018                  Repair Electrical FCA                  2,260         226                   226
                                                                         Deficiencies in Buildings #65
                                                                         and #68.
   7Tuskegee                            AL   SCIP 2018                  Replace Refrigeration Equipment        1,426         143                   143
                                                                         for Building #120 and #97.
   7Atlanta                             GA   SCIP 2018                  Correct Infrastructure, Patient        9,930         993                   993
                                                                         Safety, and FCA Deficiencies in
                                                                         Mechanical, Electrical, and
                                                                         Architectural in Research and
                                                                         the Medical Center.
   7Atlanta                             GA   SCIP 2018                  Replace Campus Fire Alarm System       2,370         237                   237
   7Atlanta                             GA   BT                         Bariatric Bedroom...............         350         290       290
   7Atlanta                             GA   OOC                        Correct Emergency Care                 7,145       6,255     6,255
                                                                         Deficiencies.
   7Atlanta                             GA   BT                         Correct Piping Deficiencies,             810         736       736
                                                                         Phase II.
   7Atlanta                             GA   SCIP 2016                  Renovate and Expand Oncology           3,350       3,015                 3,015
                                                                         Medical Specialty Services.
   7Atlanta                             GA   SCIP 2016                  Renovate and Expand Medical/           6,576       5,918                 5,918
                                                                         Surgical Inpatient Services on
                                                                         6th Floor Building 1C Nursing
                                                                         Tower.
   7Atlanta                             GA   OOC                        Upgrade Elevators Building 1A &        3,700       3,350     3,350
                                                                         1B.
   7Augusta                             GA   OOC                        Renovate and Upgrade Operating         9,995       9,086     9,086
                                                                         Rooms, Phase 1.
   7Augusta                             GA   SCIP 2016                  Replace Emergency Generator            2,814       2,558                 2,558
                                                                         Systems Uptown.
   7Dublin                              GA   SCIP 2014                  Implement Retro Commissioning          1,815       1,650                 1,650
                                                                         Recommendations.
   7Dublin                              GA   SCIP 2016                  Correct Information Technology         1,814       1,656                 1,656
                                                                         Infrastructure Deficiencies.
   7Dublin                              GA   SCIP 2016                  Install Emergency Power                3,780       3,500                 3,500
                                                                         Generator.
   7Dublin                              GA   SCIP 2016                  Renovate 26A for Swing Space           2,354       2,150                 2,150
                                                                         Functions.
   7Charleston                           SC  SCIP 2018                  Replace E&F Buildings and              9,887         989                   989
                                                                         Building Frame Seismic.
   7Charleston                           SC  SCIP 2018                  Fire alarm Ph 2 /life safety           9,977         998                   998
                                                                         improvements removal fire
                                                                         dampers, quick response head
                                                                         replacement, dry system
                                                                         replacement.
   7Charleston                           SC  SCIP 2018                  Expand/Replace Direct Digital          5,486         549                   549
                                                                         Control.
   7Charleston                           SC  SCIP 2018                  Address Potential Legionella           9,991         999                   999
                                                                         Issues (Phase II).
   7Charleston                           SC  SCIP 2018                  Correct Structural Seismic             9,901         990                   990
                                                                         Deficiencies to the Medical
                                                                         Center (Building 1).
   7Charleston                           SC  SCIP 2018                  Renovate electrical/telephone          9,890         989                   989
                                                                         closet upgrades (separation of
                                                                         ENG and IT).
   7Charleston                           SC  SCIP 2018                  Update Mechanical Systems.......       9,842         984                   984
   7Charleston                           SC  SCIP 2016                  Renovate Canteen Kitchen........       1,000         900       900
   7Charleston                           SC  SCIP 2016                  Construct Patient Surgical             2,500       2,250                 2,250
                                                                         Elevator.
   7Charleston                           SC  SCIP 2017                  Correct/Repair External                6,380       5,800                 5,800
                                                                         Architectural Barriers and
                                                                         Structures.
   7Charleston                           SC  SCIP 2016                  Renovation of Common and Support       5,000       4,500                 4,500
                                                                         Areas in Building 1.
   7Charleston                           SC  SCIP 2016                  Overhaul/Replace Elevators......       2,500       2,250                 2,250
   7Charleston                           SC  SCIP 2017                  Remove ACM throughout VAMC......       1,128       1,000                 1,000
   7Charleston                           SC  SCIP 2015                  Correct Security Deficiencies...       3,195       2,700                 2,700
   7Columbia                             SC  SCIP 2018                  Replace Hot Water Piping........       2,182         218                   218
   7Columbia                             SC  SCIP 2016                  Upgrade Elevator Systems........       1,685       1,450                 1,450
   7Columbia                             SC  BT                         Implement Lab Energy                     660         600       600
                                                                         Conservation Measures.
   8Bay Pines                           FL   SCIP 2014                  Replace Air Conditioning System        1,764       1,210                 1,210
                                                                         B-102 PH I (Multi-Phase).
   8Bay Pines                           FL   SCIP 2014                  Replace Roof Building 102.......       1,221       1,221                 1,221
   8Bay Pines                           FL   SCIP 2012                  Renovate Patient Wards B100, 3C        8,262       7,511     7,511
                                                                         & 4A.
   8Bay Pines                           FL   SCIP 2017                  Resolve SPS Temp, Humidity, Air        3,513       3,193                 3,193
                                                                         Change and Air Flow
                                                                         Deficiencies.
   8Bay Pines                           FL   SCIP 2018                  Replace Domestic Water Mains....       3,839         384                   384
   8Gainesville                         FL   OOC                        Install Parking Garage Fall            2,210         714       714
                                                                         Protection.
   8Gainesville                         FL   OOC                        Renovate Ambulatory Care Area...       6,300       5,670     5,670
   8Gainesville                         FL   SCIP 2018                  Replace Air Handler Unit No. 3..       9,950         995                   995
   8Gainesville                         FL   SCIP 2018                  Replace Air Handler Unit No. 2..       9,900         990                   990
   8Lake City                           FL   SCIP 2018                  Renovate Common Area Restrooms..       2,750         275                   275
   8Lake City                           FL   SCIP 2018                  Replace Windows and Weather            9,900         990                   990
                                                                         Protection.
   8Lake City                           FL   SCIP 2018                  Expand Electrical Distribution..       9,900         990                   990
   8Lake City                           FL   SCIP 2018                  Replace Site Water Distribution.       7,000         700                   700
   8Miami                               FL   SCIP 2018                  Replace pneumatics with direct         9,079       5,530                 5,530
                                                                         digital control.
   8Miami                               FL   BT                         Renovate locker and rest rooms           901         901                   901
                                                                         for staff.
   8Miami                               FL   SCIP 2017                  Replace coolers and                    2,020       1,087                 1,087
                                                                         refrigerators.
   8Miami                               FL   SCIP 2018                  Replace Duct work and piping and       8,346       7,199                 7,199
                                                                         conduct duct cleaning building
                                                                         1.
   8Miami                               FL   SCIP 2017                  Renovate Ambulatory surgery.....       1,418         882       882
   8Miami                               FL   SCIP 2017                  Renovate inpatient Mental Health       6,104       5,535                 5,535
                                                                         4th Floor A & B.
   8Miami                               FL   BT                         Renovate Room B1023.............          32          32                    32
   8Miami                               FL   BT                         Update spinal cord injury                352         317       317
                                                                         outdoor rehabilitation area.
   8Orlando                             FL   BT                         Add Variable Air Volume and              864         786       786
                                                                         Environmental Controls at Viera
                                                                         OPC.
   8Orlando                             FL   BT                         Correct Access and Stormwater            925         836       836
                                                                         Deficiencies--Viera.
   8Orlando                             FL   SCIP 2017                  Renovate Building 500 for              4,400       4,000                 4,000
                                                                         Administration Space.
   8Orlando                             FL   SCIP 2014                  Renovate Building 500 for              3,962       3,660                 3,660
                                                                         Veterans Benefit Administration
                                                                         Space.
   8Tampa                               FL   SCIP 2017                  Upgrade Facility Security.......       4,600       4,000                 4,000
   8Tampa                               FL   SCIP 2017                  Replace and Consolidate Domestic       6,112       5,557                 5,557
                                                                         Water Distribution, Bldg 1.
   8Tampa                               FL   BT                         Contractor Area Renovation......          45          31        31
   8Tampa                               FL   SCIP 2018                  Replace Air Handler Units 12,          8,600         860                   860
                                                                         20, 65 and 66, Building 1.
   8Tampa                               FL   SCIP 2018                  Replace Chilled Water System for       9,100         910                   910
                                                                         Building #1.
   8West Palm Beach                     FL   BT                         Replace Air Cooled Chillers in           669         669                   669
                                                                         Operating Rooms.
   8West Palm Beach                     FL   SCIP 2017                  Provide Return Ducts and               1,090         990       990
                                                                         Controllers on Air Handler
                                                                         Units (AHU).
   8San Juan                            PR   SCIP 2012                  Provide New Environmental              3,610       3,310     3,310
                                                                         Integrated Waste Center.
   8San Juan                            PR   BT                         Replace Air Handling Units at            946         880       880
                                                                         Various Sites.
   8San Juan                            PR   SCIP 2017                  Upgrade Perimeter Fence Upgrade.       2,300       1,414                 1,414
   8San Juan                            PR   BT                         Repair Paver System and Add              507         461       461
                                                                         Canopy at Administrative
                                                                         Building.
   8San Juan                            PR   BT                         Replace Reheat System...........         890         800       800
   8San Juan                            PR   BT                         Replace Exhaust Fans............         739         688       688
   8San Juan                            PR   CSI                        Site Prep for New Linear               2,209       2,008     2,008
                                                                         Accelerator.
   8San Juan                            PR   BT                         Install Non Structural                   955         875       875
                                                                         Components and Equipment
                                                                         Seismic Correction and Remove
                                                                         Asbestos at Basement Area.
   8San Juan                            PR   SCIP 2018                  Correct Nonstructural Components       3,800         380                   380
                                                                         at OPA.
   9Lexington--Leestown                 KY   SCIP 2018                  Renovate B29, 2nd Flr, for             7,400       6,730                 6,730
                                                                         Women's Health, C&P and Primary
                                                                         Cary.
   9Lexington--Leestown                 KY   BT                         Chiller Plant Improvements......         310         310                   310
   9Lexington--Leestown                 KY   SCIP 2016                  Renovate Building 28 for               9,474       8,641                 8,641
                                                                         Specialty Care.
   9Lexington--Leestown                 KY   BT                         Construct Additional Parking B28         561         510       510
   9Lexington (CD)                      KY   BT                         Replace Boiler Controls and              437         378       378
                                                                         Burners.
   9Lexington (CD)                      KY   BT                         Repair Pkg Garage Deck..........         880         800       800
   9Lexington (CD)                      KY   SCIP 2013                  Upgrade Physical Access Control        7,124       4,577     4,577
                                                                         System (PACS) and Site Security.
   9Lexington (CD)                      KY   BT                         Activate OR for CT Surgery......         550         500       500
   9Lexington (CD)                      KY   BT                         Renovate Chemo Infusion Ante-            446         401       401
                                                                         Room.
   9Louisville                          KY   BT                         Install Closed Circuit Security          500         500                   500
                                                                         at Louisville Community Based
                                                                         Outpatient Clinics.
   9Louisville                          KY   BT                         Upgrade Motors Project..........          78          78                    78
   9Louisville                          KY   BT                         Renovate Area for Emergency              374         340       340
                                                                         Department Fast Track.
   9Louisville                          KY   BT                         Renovate Building 3 for PRRC....         494         450       450
   9Louisville                          KY   SCIP 2016                  Replace AHUs, Ph 5..............       2,500       2,250                 2,250
   9Louisville                          KY   SCIP 2016                  Replace Fire Alarm System.......       5,500       5,000                 5,000
   9Louisville                          KY   BT                         Replace TIP Units in 23 IT               354         354                   354
                                                                         Closets.
   9Louisville                          KY   OOC                        OR Anesthesia Supply Head              1,328       1,195     1,195
                                                                         Replacement Rooms 1--6.
   9Louisville                          KY   BT                         Replace Steam Traps.............          90          90                    90
   9Louisville                          KY   BT                         Upgrade 6 South Reheats.........         440         400       400
   9Memphis                             TN   SCIP 2018                  Correct Plumbing Piping and            9,185         919                   919
                                                                         Replace Fixtures.
   9Memphis                             TN   SCIP 2018                  Renovate Clinical Lab...........       7,409         741                   741
   9Memphis                             TN   BT                         Renovate Surgical Service.......         619         619                   619
   9Memphis                             TN   BT                         Install Equipment Pad for                 30          30                    30
                                                                         Voluntary Service Carts.
   9Memphis                             TN   Pending OOC                Renovate Building 1 for Primary        9,879       8,989                 8,989
                                                                         Care.
   9Memphis                             TN   Pending OOC                Renovate Building 1 Clinical Lab       9,945       9,050                 9,050
   9Memphis                             TN   BT                         Replace Building 10 Rooftop AC            55          55                    55
                                                                         Units.
   9Memphis                             TN   BT                         Upgrade Elevators for Oil                189         189                   189
                                                                         Coolers and UV.
   9Memphis                             TN   BT                         Replace Automatic Doors.........         978         978                   978
   9Memphis                             TN   BT                         Renovate Physical Medicine &             871         785       785
                                                                         Rehabilitation Pool Area.
   9Memphis                             TN   OOC                        Upgrade Spinal Cord Injury             1,678       1,526     1,526
                                                                         Patient Bathrooms.
   9Memphis                             TN   BT                         Replace Building 1 and 1A                250         225       225
                                                                         Medical Vacuum Pump.
   9Memphis                             TN   BT                         Replace Finishes for Halls and           950         950                   950
                                                                         Walls.
   9Memphis                             TN   BT                         Replace Flooring and Ceilings            964         877       877
                                                                         for Safety and Infection
                                                                         Control.
   9Mountain Home                       TN   BT                         Replace Building 200 Roof.......         950         893       893
   9Mountain Home                       TN   OOC                        Replace AHU 3 For SPD Building         1,672       1,520     1,520
                                                                         77.
   9Mountain Home                       TN   BT                         Renovate Building 160 Main Lobby         901         825       825
   9Mountain Home                       TN   BT                         Replacement of Signs Bldg 200/           900         895       895
                                                                         204/205/77/160.
   9Mountain Home                       TN   SCIP 2015                  Correct Bldg 20 Condition &            1,439       1,316                 1,316
                                                                         Environment Deficiencies for
                                                                         Clinical/Support Staff
                                                                         Recruitment & Training.
   9Mountain Home                       TN   BT                         Modify Pharmacy HVAC System for          825         750       750
                                                                         USP 800 & USP 797 Compliance.
   9Mountain Home                       TN   BT                         Replace Facility Condition               935         935                   935
                                                                         Assessment Deficient Elevators,
                                                                         Building 160.
   9Mountain Home                       TN   BT                         Renovate CLC Dining Room........         968         880       880
   9Mountain Home                       TN   BT                         Renovate Halls & Walls, Building         929         851       851
                                                                         200 Phase I.
   9Mountain Home                       TN   BT                         Correct Facility Condition               988         899       899
                                                                         Assessment Exterior and
                                                                         Structural Deficiencies for
                                                                         Historic Chapel, Bldg 13.
   9Mountain Home                       TN   BT                         Implementation of Electrical             948         862       862
                                                                         Infrastructure Upgrades--Phase
                                                                         2.
   9Mountain Home                       TN   BT                         Replace AHU and Upgrade Duct             957         870       870
                                                                         System in Primary Care, Bldg.
                                                                         160.
   9Murfreesboro                        TN   BT                         Renovate Bathrooms..............         896         800       800
   9Murfreesboro                        TN   BT                         Replace Air Handling Unit 12....         840         750       750
   9Murfreesboro                        TN   BT                         Replace Nuclear Medicine Air             728         650       650
                                                                         Handling Unit 4.
   9Murfreesboro                        TN   BT                         Upgrade Elevator Building 5.....         840         750       750
   9Murfreesboro                        TN   SCIP 2016                  Upgrade Security Measures.......       1,760       1,600                 1,600
   9Murfreesboro                        TN   SCIP 2016                  Upgrade Corridors and Waiting...       1,980       1,800                 1,800
   9Murfreesboro                        TN   BT                         Replace Flooring and Abatement..         658         658                   658
   9Murfreesboro                        TN   SCIP 2016                  Abate Asbestos..................       1,000         900       900
   9Murfreesboro                        TN   SCIP 2018                  Renovate Ward 1A................       8,330         833                   833
   9Nashville                           TN   BT                         Cardiology Improvements.........         762         680       680
   9Nashville                           TN   BT                         Replace AHU-3A for Sterile               840         750       750
                                                                         Processing Supply.
   9Nashville                           TN   BT                         Reconfigure Sterile Processing           358         300       300
                                                                         Supply Scope Processing.
   9Nashville                           TN   BT                         Improvements for Surgical Clinic         909         810       810
   9Nashville                           TN   BT                         Expand Clinical Support.........         498         464       464
   9Nashville                           TN   SCIP 2016                  Upgrade Public Corridors and           1,980       1,710                 1,710
                                                                         Waiting Rooms.
   9Nashville                           TN   SCIP 2016                  Install Boiler System Condensing       1,205       1,105                 1,105
                                                                         Economizer.
   9Nashville                           TN   SCIP 2016                  Upgrade Energy Management System       1,100         990       990
                                                                         Infrastructure.
   9Nashville                           TN   SCIP 2016                  Upgrade Electrical Distribution.       3,300       3,000                 3,000
  10Fort Wayne                          IN   BT                         Increase Fort Wayne Site                 775         705       705
                                                                         Accessibility.
  10Fort Wayne                          IN   SCIP 2018                  Remodel West Wing, 3rd Floor....       4,035         404                   404
  10Indianapolis                        IN   SCIP 2018                  Modify Water Systems for               2,750         275                   275
                                                                         Legionella Prevention.
  10Indianapolis                        IN   SCIP 2015                  Replace Air Handling Units and         9,240       8,400                 8,400
                                                                         Correct Deficiencies.
  10Indianapolis                        IN   BT                         Install Entrance Gate System....         200         175       175
  10Indianapolis                        IN   BT                         Install A-Wing Reheat Victaulic          687         625       625
                                                                         Fittings.
  10Indianapolis                        IN   BT                         Upgrade Fire Suppression System.         990         900       900
  10Indianapolis                        IN   BT                         Reconfigure Waiting Rooms.......         990         900       900
  10Indianapolis                        IN   SCIP 2015                  Upgrade Building 1 for                 9,900       9,000     9,000
                                                                         Accessibility.
  10Indianapolis                        IN   Pending OOC                Renovate Space for Veteran             1,045         950                   950
                                                                         Centered Care.
  10Marion                              IN   SCIP 2017                  Renovate 4th Floor, Building 138       9,600       8,640                 8,640
  10Marion                              IN   BT                         Improve Infrastructure Building          990         990                   990
                                                                         65.
  10Marion                              IN   SCIP 2015                  Demolish Buildings 7, 10, 11,          8,800       8,000                 8,000
                                                                         18, 24, 60, 75, CC-2.
  10Marion                              IN   BT                         Renovate Atrium, Building 172...         620         564       564
  10Marion                              IN   BT                         Remodel Medication Rooms,                307         279       279
                                                                         Building 185.
  10Marion                              IN   BT                         Replace Roof, Building 138......         770         700       700
  10Marion                              IN   SCIP 2018                  Demolish Buildings 25, 42 and          4,537         454                   454
                                                                         122, Marion.
  10Ann Arbor                           MI   SCIP 2018                  Upgrade Electrical Switchgear          2,200         220                   220
                                                                         and Distribution.
  10Ann Arbor                           MI   SCIP 2016                  Renovate Intensive Care Units...       8,672       7,805                 7,805
  10Ann Arbor                           MI   BT                         Renovate Outpatient Pharmacy for         885         770                   770
                                                                         Ambulatory Care Clinics.
  10Ann Arbor                           MI   BT                         Upgrade HVAC for SPS............         945         850       850
  10Ann Arbor                           MI   BT                         Chiller Plant Optimization......         885         800       800
  10Ann Arbor                           MI   BT                         Renovate Lab Service............         900         750       750
  10Ann Arbor                           MI   BT                         Install Gypboard Ceiling in SPS.         475         402       402
  10Battle Creek                        MI   BT                         Repair Gutters and Downspouts...         705         624       624
  10Battle Creek                        MI   SCIP 2015                  Install ADA Access, Various            1,971       1,760                 1,760
                                                                         Buildings.
  10Battle Creek                        MI   BT                         Replace Water Heaters Various            666         555       555
                                                                         Buildings.
  10Battle Creek                        MI   BT                         Install Energy Efficient HVAC,           621         550       550
                                                                         B84.
  10Battle Creek                        MI   BT                         Install Water Monitoring System.         572         500       500
  10Battle Creek                        MI   SCIP 2016                  Replace Windows, Various               2,528       2,257                 2,257
                                                                         Buildings.
  10Battle Creek                        MI   SCIP 2015                  Renovate B83--2 for Patient            5,577       4,979                 4,979
                                                                         Privacy.
  10Battle Creek                        MI   SCIP 2018                  Replace Roofs, Various Buildings       2,750         275                   275
  10Battle Creek                        MI   SCIP 2018                  Correct Water Distribution             4,950         495                   495
                                                                         Deficiencies for Legionella.
  10Detroit                             MI   SCIP 2018                  Upgrade Fire Alarm Notification        2,750         275                   275
                                                                         System.
  10Detroit                             MI   SCIP 2018                  Replace Poz Loc Fire Sprinkler         2,240         224                   224
                                                                         Piping, Phase II.
  10Detroit                             MI   SCIP 2016                  Install Electrical Switchgear          6,700       6,000                 6,000
                                                                         Enclosures.
  10Detroit                             MI   BT                         Installation of Simulation Lab           500         450       450
                                                                         for Education.
  10Detroit                             MI   BT                         Renovate Hallway A4 and B4......         390         350       350
  10Saginaw                             MI   SCIP 2016                  Renovate 3rd Floor Building 1...       6,225       5,600                 5,600
  10Saginaw                             MI   SCIP 2015                  Pharmacy Renovation.............       1,500       1,390                 1,390
  10Saginaw                             MI   Pending OOC                Medical Center Security and            3,292       3,000                 3,000
                                                                         Controls Upgrades.
  10Saginaw                             MI   Pending OOC                Building 22 Sprinkler                  1,600       1,500                 1,500
                                                                         Replacement.
  10Saginaw                             MI   SCIP 2015                  Electrical Deficiencies and            1,000         875       875
                                                                         Improvements.
  10Chillicothe                         OH   SCIP 2018                  Improve Water System to Reduce         9,999       1,000                 1,000
                                                                         Risk of Legionella
                                                                         Contamination and Patient
                                                                         Injury.
  10Chillicothe                         OH   BT                         Renovate Student Housing                 988         889       889
                                                                         Buildings 15 and 16.
  10Chillicothe                         OH   BT                         Sanitary Sewer inspection and            500         425       425
                                                                         Repair.
  10Chillicothe                         OH   BT                         Upgrade IT Infrastructure to             550         484       484
                                                                         Support VoIP Phone System.
  10Chillicothe                         OH   OOC                        Demolish Buildings 2, 6, 10 & 11       1,300       1,170     1,170
  10Chillicothe                         OH   SCIP 2016                  Renovate Building 25 to Improve        3,720       3,348                 3,348
                                                                         Efficiency.
  10Chillicothe                         OH   SCIP 2016                  Address and Resolve Hazmat             2,860       2,540                 2,540
                                                                         Deficiencies.
  10Cincinnati                          OH   SCIP 2018                  Improve Exhaust System..........       4,875         488                   488
  10Cincinnati                          OH   SCIP 2018                  Replace Hospital Steam Heating         3,355         336                   336
                                                                         Systems, Phase II.
  10Cincinnati                          OH   SCIP 2017                  Relocate PM&R to Basement of           1,200       1,072                 1,072
                                                                         Building #2.
  10Cincinnati                          OH   SCIP 2017                  Upgrade Water Systems for              1,200       1,056                 1,056
                                                                         Legionella and Improve Water
                                                                         Efficiency.
  10Cincinnati                          OH   BT                         Upgrade UPS and AC in Computer           605         550       550
                                                                         Room.
  10Cincinnati                          OH   BT                         Replace Operating Room Chillers.         880         795       795
  10Cincinnati                          OH   BT                         Install PA Systems in Trailers..         242         220       220
  10Cleveland                           OH   SCIP 2018                  Replace Air Handling Unit AC-          6,900         690                   690
                                                                         17&18.
  10Cleveland                           OH   SCIP 2018                  Upgrade Fire Alarm System.......       4,000         400                   400
  10Cleveland                           OH   SCIP 2018                  Replace CARES Tower Roof and           5,950         595                   595
                                                                         Repair Overhangs.
  10Cleveland                           OH   BT                         Renovate Boiler Plant Heat               385         325       325
                                                                         Recovery System.
  10Cleveland                           OH   BT                         Replace Automatic Transfer               250         225       225
                                                                         Switch 15 in Energy Center.
  10Cleveland                           OH   BT                         Provide Chiller Plant Automatic          275         250       250
                                                                         Transfer Switch.
  10Cleveland                           OH   BT                         Consolidate Chaplain Services...         440         400       400
  10Cleveland                           OH   BT                         Expand Emergency Department              440         400       400
                                                                         Parking Area.
  10Columbus                            OH   BT                         Remodel Pharmacy IV Prep Room-           915         800       800
                                                                         FCA.
  10Columbus                            OH   BT                         Add Domestic Water Pressure              208         190       190
                                                                         Booster.
  10Columbus                            OH   BT                         Construct temporary chiller              510         464       464
                                                                         connection.
  10Columbus                            OH   SCIP 2015                  Construct Chiller Plant.........       9,100       8,190                 8,190
  10Columbus                            OH   BT                         Increase Size of Smoking Shelter         100          90        90
  10Columbus                            OH   BT                         Expand Existing Emergency                783         712       712
                                                                         Distribution Panel Board and
                                                                         Add Cooling to Substation Room.
  10Dayton                              OH   SCIP 2018                  Renovate Laboratory, Building          8,602         860                   860
                                                                         310.
  10Dayton                              OH   SCIP 2018                  Renovate Infrastructure for            4,400         440                   440
                                                                         National Historical Archives,
                                                                         Building 116.
  10Dayton                              OH   SCIP 2018                  Renovate TCU/ICU Space..........       4,950         495                   495
  10Dayton                              OH   SCIP 2016                  Improve Campus Access and              4,500       4,100                 4,100
                                                                         Security.
  10Dayton                              OH   BT                         Correct Arc Flash Deficiencies..         438         393       393
  10Dayton                              OH   SCIP 2017                  Renovate B410 East Wing.........       4,400       3,660                 3,660
  12Chicago                             IL   BT                         Renovate Sterile Processing.....         970         900       900
  12Chicago                             IL   SCIP 2016                  Remodel Patient Admitting.......       3,750       3,500                 3,500
  12Chicago                             IL   BT                         Replace Fire Pump Controller in          210         185       185
                                                                         Building #1-Damen.
  12Chicago                             IL   BT                         Replace ATS for Elevators in             185         135       135
                                                                         Building #1-Damen.
  12Danville                            IL   SCIP 2017                  Remediate Legionella Station           4,087       3,700                 3,700
                                                                         Wide Phase 1.
  12Danville                            IL   BT                         Building 98 Exterior Ductwork            178         178                   178
                                                                         Insulation.
  12Danville                            IL   SCIP 2014                  Renovate 58-5 Endoscopy Suite...       1,871       1,750                 1,750
  12Danville                            IL   BT                         Legionella Continuous                    160         160                   160
                                                                         Temperature Monitoring System.
  12Danville                            IL   BT                         Demolish Quarters 31, 32, 33....         600         450       450
  12Hines                               IL   BT                         Remodel Resident Kitchen, Bldg.           56          50        50
                                                                         221.
  12Hines                               IL   SCIP 2017                  Legionella Suppression--Task           3,450       3,000                 3,000
                                                                         Order #1.
  12Hines                               IL   BT                         Install Patient Lifts, Multiple          522         381       381
                                                                         Locations.
  12Hines                               IL   BT                         Correct HVAC Central Supply and          598         500       500
                                                                         Storage Rooms.
  12Hines                               IL   Pending OOC                Upgrade Chilled Water System,          9,914       9,013                 9,013
                                                                         Bldg. 200.
  12North Chicago                       IL   SCIP 2018                  Upgrade Water Distribution             6,500         650                   650
                                                                         System.
  12North Chicago                       IL   SCIP 2018                  Improve Facility Accessibility..       4,815         482                   482
  12North Chicago                       IL   BT                         Construct Hemodialysis Area              275         250                   250
                                                                         Building 133.
  12North Chicago                       IL   BT                         Renovate Occupational Health             330         300       300
                                                                         Bldg 133.
  12North Chicago                       IL   BT                         Oncology Renovation USP 800              330         300       300
                                                                         Requirement.
  12North Chicago                       IL   BT                         Building 135 HR Renovation......         165         150       150
  12North Chicago                       IL   SCIP 2017                  Facility Roofs..................       3,300       3,300                 3,300
  12North Chicago                       IL   BT                         Chilled Water Efficiency Part 2.         900         900                   900
  12North Chicago                       IL   BT                         Prosthetics Renovation..........         550         500       500
  12North Chicago                       IL   SCIP 2017                  Renovate Building 131-4 ``A''          1,100       1,100                 1,100
                                                                         Wing.
  12North Chicago                       IL   OOC                        Renovate Audiology..............       1,320       1,200     1,200
  12North Chicago                       IL   OOC                        Replace Chiller #5..............       1,650       1,500     1,500
  12North Chicago                       IL   CSI                        Construct Space for 1.5T MRI....       3,969       3,500     3,500
  12North Chicago                       IL   BT                         Modify Chilled Water System              500         500                   500
                                                                         Valves.
  12North Chicago                       IL   BT                         Construct Misc Catwalks.........         120         120                   120
  12North Chicago                       IL   BT                         Repair Misc. Fire Suppression             50          50                    50
                                                                         Systems in Various Bldgs.
  12North Chicago                       IL   OOC                        ATFP Measures--Gates and Fencing       3,000         300       300
  12North Chicago                       IL   BT                         Expand Police Area Bldg. 133....         220          20        20
  12Iron Mountain                       MI   BT                         Install Server Room AHU.........         170         150       150
  12Iron Mountain                       MI   BT                         Upgrade OPC Heat Exchangers.....         255         225       225
  12Iron Mountain                       MI   BT                         HVAC Pressurization Study.......         638         600       600
  12Iron Mountain                       MI   SCIP 2017                  Install Potable Water Mixing           1,330       1,250                 1,250
                                                                         Valves and Control Upgrades.
  12Iron Mountain                       MI   Pending OOC                Renovate 5 West.................       2,000       1,850                 1,850
  12Madison                             WI   OOC                        Renovate 3B for Inpatient Ward..       4,918       4,500     4,500
  12Madison                             WI   SCIP 2015                  Renovate 3A/3C..................       6,146       5,246                 5,246
  12Madison                             WI   SCIP 2018                  Renovate 4B.....................       6,550         655                   655
  12Milwaukee                           WI   Pending OOC                112 Replace (3) Boilers.........       9,900       9,000                 9,000
  12Milwaukee                           WI   SCIP 2016                  Upgrade HVAC V9, S1, S4 in Bldg        7,260       6,600                 6,600
                                                                         111.
  12Milwaukee                           WI   BT                         Replace Refrigerant Units                285         285                   285
                                                                         Various Locations.
  12Milwaukee                           WI   SCIP 2015                  Correct FCA Sanitary                   3,300       3,000                 3,000
                                                                         Deficiencies Grounds Phase 1.
  12Milwaukee                           WI   BT                         Upgrade Elevators Buildings 5            748         680       680
                                                                         and 6 A Wing.
  12Milwaukee                           WI   SCIP 2016                  Replace Security Card Readers          1,552       1,384                 1,384
                                                                         and Upgrade Security.
  12Milwaukee                           WI   BT                         Repair Campus Steam Tunnel and           500         450       450
                                                                         Structural Supports.
  12Milwaukee                           WI   BT                         Replacement of Structural Floor          485         425       425
                                                                         Slab for Building 43 Dining
                                                                         Room Mental Health.
  12Tomah                               WI   SCIP 2016                  Renovate South End of Building         2,783       2,530                 2,530
                                                                         406, 2nd Floor.
  12Tomah                               WI   CSI                        Construct Warehouse.............       4,600       4,250     4,250
  15Marion                              IL   BT                         Install Ventilation Corrections          150         130       130
                                                                         for Sterile Processing.
  15Leavenworth                         KS   SCIP 2018                  Renovate Infrastructure of             5,000         500                   500
                                                                         Laundry Building 153.
  15Leavenworth                         KS   SCIP 2018                  Replace Steam/Condensate Lines         2,650         265                   265
                                                                         throughout the facility.
  15Topeka                              KS   SCIP 2017                  Renovate Bldg 6, Wing B of             4,990       4,456                 4,456
                                                                         Existing CLC.
  15Topeka                              KS   OOC                        Renovate Space For VA Call             9,000       8,100     8,100
                                                                         Center At Fort Riley For VHA
                                                                         Member Services.
  15Topeka                              KS   BT                         Upgrade Oncology For Pharmacy--          390         350       350
                                                                         Topeka.
  15Topeka                              KS   BT                         Relocate Gastrointestinal                899         800       800
                                                                         Laboratory.
  15Topeka                              KS   BT                         Repair Boiler Plant Chimney.....         360         320       320
  15Topeka                              KS   BT                         Repair Surgery Ventilation               625         550       550
                                                                         System and Connect to Emergency
                                                                         Power.
  15Wichita                             KS   CSI                        Construct Substance Abuse              4,730       4,300     4,300
                                                                         Residential Rehabilitation
                                                                         Treatment Building 59.
  15Wichita                             KS   BT                         Correct Mechanical Deficiencies,         500         450       450
                                                                         Building 26.
  15Columbia                            MO   BT                         Replace Air Handler (AC -S2)....         880         800       800
  15Columbia                            MO   BT                         Renovate Vacated Surgery, Ward 6         890         800       800
  15Kansas City                         MO   BT                         Replace Central Boiler Plant             900         800       800
                                                                         Control System.
  15Kansas City                         MO   BT                         Replace Building 26 Roof........         500         475       475
  15Kansas City                         MO   BT                         Extend Chilled Water Loop                900         800       800
                                                                         Building 15 and 26.
  15Kansas City                         MO   CSI                        Expand Outpatient Mental Health        2,200       2,000     2,000
                                                                         Clinic.
  15Poplar Bluff                        MO   OOC                        Replace Boilers, Building 7.....       3,000       2,700     2,700
  15Poplar Bluff                        MO   SCIP 2017                  Replace Station 518,000 Volt           1,315       1,206                 1,206
                                                                         Amps Electrical Life Safety
                                                                         Generator.
  15Poplar Bluff                        MO   BT                         Create Exterior Secure Storage           250         200       200
                                                                         Area.
  15Poplar Bluff                        MO   BT                         Correct Legionella Deficiencies          900         810       810
                                                                         Phase 1.
  15St. Louis                           MO   OOC                        Renovate Operating Rooms and           6,120       5,943     5,943
                                                                         Support Spaces.
  15St. Louis                           MO   CSI                        Demolish Sextro Warehouse, John        4,100       4,000     4,000
                                                                         Cochran Division.
  15St. Louis                           MO   BT                         Prepare Site for X-Ray Units....         640         640                   640
  16Fayetteville                        AR   SCIP 2018                  Renovate B9 Laundry.............       1,925         193                   193
  16Fayetteville                        AR   SCIP 2018                  Replace Eaves, Soffit, Integral        1,855         186                   186
                                                                         Gutters and Fascia, Multiple
                                                                         Buildings.
  16Fayetteville                        AR   BT                         Replace Primary Care Elevator             80          80                    80
                                                                         Controls.
  16Little Rock                         AR   SCIP 2016                  Provide 100% Emergency Power....       9,900       9,000                 9,000
  16Little Rock                         AR   SCIP 2018                  Develop Private/Semi-Private Bed       8,360         836                   836
                                                                         Spaces.
  16Alexandria                          LA   SCIP 2016                  Emergency Generator Replacement.       4,950         600       600
  16Shreveport                          LA   SCIP 2018                  Correct Electrical Deficiencies,       7,300         730                   730
                                                                         Building 1.
  16Shreveport                          LA   SCIP 2018                  Abate Central Chase/Replace Fire       1,320         132                   132
                                                                         Main Risers.
  16Shreveport                          LA   BT                         Renovate Morgue, Building 1.....         407         370       370
  16Shreveport                          LA   SCIP 2017                  Replace Primary Switch Gear.....       1,557       1,410                 1,410
  16Jackson                             MS   OOC                        Renovate Ground Floor Community        8,505       7,667     7,667
                                                                         Living Center--Bldg. 7.
  16Jackson                             MS   BT                         Continuous Monitoring of Potable         200         200                   200
                                                                         Water Engineering Controls.
  16Jackson                             MS   BT                         Replace Cable TV System.........         150         150                   150
  16Jackson                             MS   BT                         Repair Employee Parking Lot Area         550         550                   550
                                                                         I.
  16Jackson                             MS   OOC                        Upgrade HVAC System 9B..........       5,335       4,850     4,850
  16Jackson                             MS   BT                         Upgrade Auto Transfer Switches/          935         850       850
                                                                         Emergency Generator Control
                                                                         Units.
  16Oklahoma City                       OK   SCIP 2018                  Renovate Pharmacy for Chapter          1,760         176                   176
                                                                         797/800 Compliance.
  16Oklahoma City                       OK   SCIP 2018                  Correct Domestic Hot Water             1,980         198                   198
                                                                         Distribution System
                                                                         Deficiencies.
  16Oklahoma City                       OK   SCIP 2018                  Renovate to Separate OIT and           1,878         188                   188
                                                                         Engineering Closets.
  16Oklahoma City                       OK   SCIP 2018                  Renovate 6 North for Patient           2,715         272                   272
                                                                         Privacy.
  16Houston                             TX   SCIP 2018                  Renovation of Pathology and            6,000         600                   600
                                                                         Laboratory- Phase 1.
  16Houston                             TX   Pending OOC                Replace Elevators B-100.........       6,000       5,250                 5,250
  16Houston                             TX   SCIP 2017                  Renovate/Expand ER Building 100.       6,500       1,800                 1,800
  17Amarillo                            TX   SCIP 2016                  Replace HVAC Components for            3,800       3,500                 3,500
                                                                         Energy Savings Building 28.
  17Amarillo                            TX   SCIP 2016                  Replace HVAC Components for            2,750       2,000                 2,000
                                                                         Energy Savings Building 1.
  17Amarillo                            TX   BT                         Repair Medical Air & Vacuum              150         150                   150
                                                                         Systems.
  17Amarillo                            TX   OOC                        Renovate Building 28 Medical           3,372       3,322     3,322
                                                                         Ward for Privacy.
  17Big Spring                          TX   BT                         Renovate fifth floor Nursing             825         700                   700
                                                                         Station and Corridor.
  17Big Spring                          TX   BT                         Relocate & Expand Audiology.....         599         544                   544
  17Big Spring                          TX   BT                         Replace Deficient HVAC Fan Coil          975         850       850
                                                                         Units.
  17Big Spring                          TX   BT                         Renovate Street Entrance........         455         400       400
  17Big Spring                          TX   OOC                        Replace Roofs on Building 1.....       3,350       3,200     3,200
  17Big Spring                          TX   BT                         Construct Restrooms for                  375         300       300
                                                                         Education Training Center.
  17Big Spring                          TX   BT                         Replace Flag Pole...............         410         350       350
  17Big Spring                          TX   OOC                        Renovate Administration for            2,530       2,300     2,300
                                                                         Physical Therapy and
                                                                         Prosthetics.
  17Big Spring                          TX   BT                         Correct Facade Deficiencies.....          95          50        50
  17Big Spring                          TX   OOC                        Install Perimeter Fencing Around       2,700       2,500     2,500
                                                                         Campus.
  17Big Spring                          TX   OOC                        Upgrade Electrical Panels.......       2,250       2,000     2,000
  17Big Spring                          TX   BT                         Replace HVAC in Bldg 4 & 7......         800         725       725
  17Big Spring                          TX   SCIP 2015                  Remove Dead Leg Water Lines in         1,150       1,035     1,035
                                                                         the Facility.
  17Bonham                              TX   SCIP 2016                  Replace HVAC Bldg 1 & 2.........       2,170       2,000                 2,000
  17Bonham                              TX   OOC                        Replace Pipe Support Stands.....       2,303       2,100     2,100
  17Bonham                              TX   SCIP 2015                  Replace Bonham Fire Alarm System       3,200       3,000                 3,000
  17Dallas                              TX   BT                         Roof Top Chiller Pressurized             874         800                   800
                                                                         System.
  17Dallas                              TX   OOC                        Renovate Building #60 Bed & Bath       3,600       3,500     3,500
                                                                         Rooms B Wing.
  17Dallas                              TX   BT                         Correct B.70 Deficiencies.......         990         900       900
  17Dallas                              TX   BT                         Replacing Bldg. 6 & 8 AHU System         550         500       500
  17Dallas                              TX   BT                         Replace/Repair Roof Bldg.60.....         550         500       500
  17Dallas                              TX   OOC                        Replace Patient Exterior and           3,000       3,000     3,000
                                                                         Interior Signage.
  17El Paso                             TX   OOC                        Repair FCA Deficiencies.........       1,650       1,500     1,500
  17Harlingen                           TX   OOC                        Upgrade HVAC....................       2,750       2,500     2,500
  17Harlingen                           TX   OOC                        Repair Parking Lot Corpus                550         500       500
                                                                         Christi Outpatient Clinic.
  17San Antonio                         TX   BT                         Activate Emergency Well Water @          666         600       600
                                                                         ALMD.
  17San Antonio                         TX   BT                         Conduct Legionella Study........         440         400       400
  17San Antonio                         TX   SCIP 2016                  Replace 1000kw Generator and           2,200       2,000                 2,000
                                                                         Fuel Storage Tank.
  17San Antonio                         TX   SCIP 2018                  Replace main switch gear........       2,200         220                   220
  17Temple                              TX   Pending OOC                Reconfigure Specialty Clinics          2,838       2,580                 2,580
                                                                         4th Floor Teague Tower.
  17Temple                              TX   SCIP 2018                  Relocate Mental Health to Dom C-       9,686       4,860                 4,860
                                                                         Wing.
  17Temple                              TX   SCIP 2018                  Relocate Mental Health to Dom D-       7,578       4,440                 4,440
                                                                         Wing.
  17Temple                              TX   BT                         Construct 2nd Cardiac Cath......         491         450       450
  17Temple                              TX   OOC                        Replace Air Handler Units Bldg         4,075       3,705     3,705
                                                                         163 Tower.
  17Temple                              TX   SCIP 2017                  Convert Bldg 44W to Admin.......       1,650       1,500                 1,500
  17Temple                              TX   OOC                        Prevention of Legionella--Temple       3,377       3,070     3,070
  17Temple                              TX   OOC                        Replace Medium Voltage                 3,232       3,000     3,000
                                                                         Switchgear.
  17Waco                                TX   SCIP 2017                  Relocate Canteen Bldg 202.......       2,299       2,090                 2,090
  17Waco                                TX   OOC                        Upgrade Electrical Secondary           2,200       2,000     2,000
                                                                         Distribution System.
  17Waco                                TX   BT                         Replace Building 1 HVAC.........         817         777       777
  17Waco                                TX   OOC                        Prevention of Legionella--Waco..       2,742       2,493     2,493
  19Denver                                CO OOC                        Replace CBS West AHU............       2,321       2,121     2,121
  19Grand Junction                        CO Pending OOC                Energy Audit Finding Corrections       1,118       1,026                 1,026
  19Grand Junction                        CO BT                         Correct Building 33 FCA                  229         208       208
                                                                         Deficiencies.
  19Grand Junction                        CO SCIP 2016                  Replace AHU 9 AND 10............       1,680       1,500                 1,500
  19Grand Junction                        CO Pending OOC                Ventilate and Expand IT Closets.       1,090       1,000                 1,000
  19Grand Junction                        CO SCIP 2017                  Replace Boilers and Controls,          7,616       7,201                 7,201
                                                                         Phase 2.
  19Grand Junction                        CO Pending OOC                Renovate 4E/4W and Upgrade             2,150       1,980                 1,980
                                                                         Mechanical AHU.
  19Grand Junction                        CO SCIP 2013                  Elimination of Substandard Beds        3,740       3,400     3,400
                                                                         on 3rd Floor.
  19Grand Junction                        CO BT                         DR Site Prep....................         175         160       160
  19Ft Harrison                         MT   SCIP 2017                  Replace Penthouse HVAC Systems..       2,420       2,150                 2,150
  19Ft Harrison                         MT   BT                         Digital Security Enhancements...         935         850       850
  19Ft Harrison                         MT   OOC                        LED Lighting Phase I............       1,100         990       990
  19Ft Harrison                         MT   SCIP 2017                  Building 141 Heating............       1,452       1,280                 1,280
  19Muskogee                            OK   BT                         Replace & Upgrade DW1 Cart               375         375                   375
                                                                         Elevator.
  19Muskogee                            OK   Pending OOC                Replace Surveillance System.....       2,050       1,900                 1,900
  19Muskogee                            OK   SCIP 2015                  Install Energy Retrofits for Air       5,445       4,901                 4,901
                                                                         Handling Units, Controls, and
                                                                         Lighting.
  19Muskogee                            OK   BT                         Upgrade Roofing Systems Phase 2.         800         800                   800
  19Oklahoma City                       OK   CSI                        Remodel Cath Labs...............       1,450       1,300     1,300
  19Oklahoma City                       OK   SCIP 2016                  Renovate 7 East for Patient            3,215       2,700                 2,700
                                                                         Privacy.
  19Oklahoma City                       OK   SCIP 2016                  Renovate Canteen Food Court and        1,628       1,480                 1,480
                                                                         Office Suite.
  19Oklahoma City                       OK   SCIP 2016                  Increase Electrical Capacity to        1,540       1,400                 1,400
                                                                         9th Floor Server Room.
  19Oklahoma City                       OK   OOC                        Upgrade Interior Fixed Equipment       2,075       1,850     1,850
  19Oklahoma City                       OK   CSI                        Site Prep for New 80 Slice CT...         660         500       500
  19Salt Lake City                      UT   SCIP 2017                  Upgrade Public Address Mass            4,750       4,300                 4,300
                                                                         Notification System (PAMNS).
  19Salt Lake City                      UT   BT                         B.7, B.35, B.37 Research                 880         800       800
                                                                         Renovation.
  19Salt Lake City                      UT   OOC                        Legionella--Mixing Valves,             1,870       1,700     1,700
                                                                         Schematics, Controls.
  19Salt Lake City                      UT   SCIP 2017                  Chilled Water Distribution Line        1,980       1,800                 1,800
                                                                         Ph. 6.
  19Salt Lake City                      UT   SCIP 2017                  Upgrade Fire Alarms.............       1,527         153       153
  19Salt Lake City                      UT   SCIP 2016                  Site Electrical Replacement.....       1,000         100       100
  19Salt Lake City                      UT   SCIP 2016                  Solar PV Parking Garage.........       4,180         380       380
  19Cheyenne                            WY   SCIP 2016                  Improve Facility Security Phase        1,000         988       988
                                                                         1.
  19Cheyenne                            WY   BT                         FCA Improve Wayfinding..........         135         135                   135
  19Cheyenne                            WY   BT                         Potable Water Improvements......         990         900       900
  19Cheyenne                            WY   Pending OOC                Renovate Pharmacy & SPS, Phase 2       1,090          90                    90
  19Sheridan                            WY   BT                         Demo 30,34,39 & 83..............         700         700                   700
  19Sheridan                            WY   BT                         Replace O2 Tanks................         580         580                   580
  19Sheridan                            WY   Pending OOC                Site Prep Sheridan MRI..........       1,700       1,700                 1,700
  19Sheridan                            WY   BT                         Porch and Roof Corrections......         682         592                   592
  19Sheridan                            WY   BT                         Boiler Upgrade Ph3..............         960         850       850
  19Sheridan                            WY   Pending OOC                IT Comm Closet Upgrades Ph 1....       2,080       1,900                 1,900
  19Sheridan                            WY   BT                         Replace B64 Parking Lots........         958         860       860
  19Sheridan                            WY   SCIP 2018                  IT Communication Closets Upgrade       2,180         218                   218
                                                                         Phase I.
  20Anchorage                           AK   BT                         Surgical Suite Steam                     600         520       520
                                                                         Humidification System.
  20Anchorage                           AK   BT                         Building 100 Site Improvements..         440         400       400
  20Boise                               ID   BT                         Replace Officer's Row Road......         335         300       300
  20Portland                            OR   SCIP 2017                  Upgrade and Replace condensate         2,750       2,500                 2,500
                                                                         and steam infrastructure (V).
  20Portland                            OR   BT                         Upgrade Building 18 TLU HVAC....         880         800       800
  20Portland                            OR   BT                         Simulation Lab Relocation.......         335         300       300
  20Roseburg                            OR   SCIP 2016                  Upgrade Campus Security.........       3,300       3,000                 3,000
  20Roseburg                            OR   SCIP 2017                  Renovate Building 1 to Relocate        1,936       1,760                 1,760
                                                                         Short Stay.
  20Roseburg                            OR   BT                         Replace Campus PA System........         715         650       650
  20Roseburg                            OR   BT                         Update Wayfinding Signage campus         980         900       900
                                                                         wide.
  20Roseburg                            OR   BT                         Replace Nurse Call System                275         250       250
                                                                         Building 81.
  20Roseburg                            OR   BT                         Replace Quonset Huts T6, T7, T8,         832         772       772
                                                                         T15 & T19.
  20White City                          OR   SCIP 2016                  Renovate Space, Building 210           2,200       1,980                 1,980
                                                                         Upper South for Clinical Areas.
  20White City                          OR   SCIP 2016                  Retrofit Campus Wide                   7,900       7,200                 7,200
                                                                         Infrastructure Systems--Water,
                                                                         Sewer, & Storm.
  20American Lake                       WA   BT                         Replace Building 148 Boiler.....         550         500       500
  20American Lake                       WA   BT                         VCS Coffee Shop in Building 2...         198         143       143
  20American Lake                       WA   OOC                        Expand Blind Rehabilitation            1,485       1,376     1,376
                                                                         Building 2.
  20American Lake                       WA   SCIP 2016                  Am Lake Replace Boilers for            3,300       2,970                 2,970
                                                                         Energy Efficiency.
  20Seattle                             WA   BT                         Replace Flooring in B100 First           220         200       200
                                                                         Floor Core/Lobby.
  20Seattle                             WA   BT                         Renovate Main Entrance Canopy            275         250       250
                                                                         and Demo Smoking Shelter/Canopy.
  20Seattle                             WA   BT                         Replace Ceiling and Flooring in          165         150       150
                                                                         Bldg 23.
  20Seattle                             WA   BT                         Replace Flooring in Bldg 11 OR           115         100       100
                                                                         Rooms and Corridor.
  20Seattle                             WA   BT                         Renovate Rooms in Bldg 34 for            286         260       260
                                                                         Veterinary Treatment.
  20Seattle                             WA   BT                         Replace Flooring in Bldg 34               65          50        50
                                                                         First Floor.
  20Seattle                             WA   BT                         Building 1 Sterilizer                    385         350       350
                                                                         Installation.
  20Seattle                             WA   BT                         Renovate SCI Bathrooms..........         660         600       600
  20Seattle                             WA   BT                         OR Mechanical Upgrades..........         550         500       500
  20Seattle                             WA   SCIP 2015                  Renovate and Expand Seattle            7,797       7,019     7,019
                                                                         Sterile Processing Service.
  20Seattle                             WA   BT                         Replace 2 West Corridor Flooring         115         100       100
  20Seattle                             WA   SCIP 2016                  Renovate Seattle B37 First Floor       1,654       1,489                 1,489
                                                                         for VA Police.
  20Seattle                             WA   SCIP 2017                  4W Surgical Specialty Care             4,686       4,296                 4,296
                                                                         Clinic Expansion.
  20Seattle                             WA   BT                         Install Wi-Fi in Patient Areas..         825         750       750
  20Seattle                             WA   SCIP 2018                  Replace Roofs--Seattle VA.......       4,675         468                   468
  20Spokane                             WA   CSI                        Site Prep for Nuke Med SPECT/CT.         660         630       630
  20Spokane                             WA   BT                         Demolish Building 32............          60          50        50
  20Spokane                             WA   CSI                        Site Prep for MRI Replacement...         250         200       200
  20Spokane                             WA   SCIP 2015                  Correct Electrical and                 3,900       3,510     3,510
                                                                         Communication Infrastructure
                                                                         Deficiencies.
  20Spokane                             WA   BT                         Install Hot Water Recirculation          495         450       450
                                                                         Loop for Acute Psychiatric Unit.
  20Spokane                             WA   BT                         CLC Remodel and Portico.........         714         650       650
  20Spokane                             WA   BT                         Replace Elevators in Bldg 1 and          990         900       900
                                                                         27.
  20Spokane                             WA   SCIP 2016                  Replace Boiler Plant............      11,000       9,900                 9,900
  20Walla Walla                         WA   BT                         Replace Steam Traps.............         440         400       400
  21Fresno                                CA BT                         Repair Mechanical Systems,               755         700                   700
                                                                         Building 1 Sub-Basement.
  21Fresno                                CA BT                         Remodel ED for Observation Beds.         550         200       200
  21Fresno                                CA CSI                        Expand Mental Health Center,           4,950       4,540     4,540
                                                                         Building 27.
  21Fresno                                CA SCIP 2016                  Expand Chilled Water Capacity...       9,600       8,800                 8,800
  21Fresno                                CA BT                         Install Skytron Ceiling Mount            375         300       300
                                                                         Booms in Surgical Suite, 3rd
                                                                         Floor, Building 1.
  21Fresno                                CA BT                         Install USP800 Chemo Compounding         410         360       360
                                                                         Room, 3rd Floor, Building 24.
  21Fresno                                CA BT                         Remodel Building 24, 1st Floor..         990         800       800
  21Fresno                                CA SCIP 2018                  Renovate Outpatient Clinic             5,010         501                   501
                                                                         Basement for Emergency
                                                                         Department Observation Bed
                                                                         Suite.
  21Livermore                             CA BT                         Repair Main Water Line, LVD.....          65          65                    65
  21Martinez                              CA BT                         Renovate Outpatient Clinic               880         800       800
                                                                         Office Space, Building 778,
                                                                         Fairfield.
  21Martinez                              CA SCIP 2014                  Correct Campus Security                2,000       1,800                 1,800
                                                                         Deficiencies and Renovate for
                                                                         Sterile Storage Supply.
  21Martinez                              CA Pending OOC                Investigate Seismic Capacity           3,100         100                   100
                                                                         Building 21.
  21Menlo Park                            CA BT                         Renovate Tele radiology, Bldg            870         800       800
                                                                         334.
  21Palo Alto                             CA OOC                        Create 60kV Substation and            30,000      30,000    30,000
                                                                         Infrastructure.
  21Palo Alto                             CA BT                         Expand Emergency Preparedness            550         500       500
                                                                         Capabilities, PAD Campus.
  21Palo Alto                             CA BT                         Construct Bump Out for Major             550         500       500
                                                                         Construction Team.
  21Palo Alto                             CA BT                         Create Surface Parking at                800         750       750
                                                                         Stockton.
  21Palo Alto                             CA SCIP 2017                  Construct Consolidated Fisher          3,575       2,300                 2,300
                                                                         House Central Reception
                                                                         Building.
  21Palo Alto                             CA SCIP 2015                  Replace Chillers in Building 100       4,824       4,000                 4,000
  21Palo Alto                             CA SCIP 2013                  Improve Emergency Sustainment          2,788       2,600     2,600
                                                                         capabilities -South Campus
                                                                         Generator.
  21Palo Alto                             CA BT                         Create Additional Patient &              950         850       850
                                                                         Staff Parking at PAD.
  21Sacramento                            CA BT                         Renovate for Clean Room                  560         500       500
                                                                         Expansion, Building 652.
  21San Francisco                         CA BT                         Upgrade Sanitary System on East          990         890                   890
                                                                         Side of Campus.
  21San Francisco                         CA Pending OOC                Replace Building 3, 200                2,076       1,750                 1,750
                                                                         Chillers, insulate ductwork.
  21San Francisco                         CA OOC                        Replacement of Bldg. 200 Roof          1,500       1,500     1,500
                                                                         System.
  21San Francisco                         CA SCIP 2015                  Renovate and Consolidate               3,685       3,500                 3,500
                                                                         Clinical Programs on the Ground
                                                                         Floor of the Main Hospital.
  21San Francisco                         CA OOC                        Renovate and Upgrade Patient           1,500       1,200     1,200
                                                                         Restrooms in Bldgs 200 and 203.
  21San Francisco                         CA BT                         Correct Non-structural                   700         700                   700
                                                                         Components of B. 200 and 203.
  21San Francisco                         CA CSI                        Site Preparation for Bi-Plane...       1,000       1,000                 1,000
  21Honolulu                            HI   BT                         Renovate Pharmacy...............         700         600       600
  21Honolulu                            HI   BT                         Finish Parking Structure                 558         475       475
                                                                         Basement.
  21Honolulu                            HI   BT                         Replace Fire Alarm Panels.......         575         575                   575
  21Honolulu                            HI   BT                         Upgrade Center For Aging HVAC            990         990                   990
                                                                         System.
  21Honolulu                            HI   BT                         Install Real-time Water                  235         175       175
                                                                         Monitoring System--Legionella.
  21Las Vegas                           NV   Pending OOC                CLC Patient Lift Installation...       1,757       1,757                 1,757
  21Las Vegas                           NV   SCIP 2017                  Modify Main Entrances in               1,841       1,690                 1,690
                                                                         Building 1.
  21Las Vegas                           NV   BT                         Back Up Cooling System for               879         790       790
                                                                         Critical Care Areas.
  21Las Vegas                           NV   BT                         Environmental Controls and               572         520       520
                                                                         Monitoring.
  21Las Vegas                           NV   SCIP 2017                  Water Line Improvement/Bypass...       1,950         960       960
  21Las Vegas                           NV   OOC                        Radiology and Surgical UPS......       2,114       1,995     1,995
  21Las Vegas                           NV   OOC                        Stairwell Safeguards............       1,540       1,400     1,400
  21Reno                                NV   BT                         MRI Upgrade Site Prep...........         400         400                   400
  21Reno                                NV   BT                         Upgrade Mental Health                    253         200       200
                                                                         Interlocking Doors (Study).
  21Reno                                NV   BT                         Demolish Buildings 15, 138, F            646         600       600
                                                                         and K.
  21Reno                                NV   BT                         Convert Room for Blood Draw.....          15          15                    15
  21Reno                                NV   SCIP 2017                  Expand Emergency Power Capacity        1,390       1,300                 1,300
                                                                         at the Boiler Plant.
  21Reno                                NV   SCIP 2018                  Replace damaged piping in              5,500         550                   550
                                                                         clinical Building 1D..
  21Reno                                NV   SCIP 2018                  Repair critical electrical             3,850         385                   385
                                                                         deficiencies in Clinical
                                                                         Building 1D.
  22Phoenix                             AZ   CSI                        Renovate and Expand Women's            4,400       4,000     4,000
                                                                         Health Clinic.
  22Phoenix                             AZ   SCIP 2018                  Replace AHUs at CLC and Main           3,300         330                   330
                                                                         Building.
  22Phoenix                             AZ   SCIP 2016                  Renovate Inpatient Ward 2C......       4,504       4,104                 4,104
  22Phoenix                             AZ   OOC                        Renovate 6D for Inpatient Ward..       4,000       3,600     3,600
  22Phoenix                             AZ   BT                         OI&T Electrical Upgrades........         990         900       900
  22Phoenix                             AZ   Pending OOC                Remodel Dietetics Kitchen.......       3,411       3,029                 3,029
  22Phoenix                             AZ   SCIP 2016                  Site Stormwater Correction......       1,760       1,600                 1,600
  22Prescott                            AZ   SCIP 2014                  Perform Retro-commissioning and          825         750       750
                                                                         Repair of Building Control
                                                                         Systems.
  22Prescott                            AZ   SCIP 2016                  Repair/Resurface Roads, Ph 4....       1,107         992       992
  22Prescott                            AZ   Pending OOC                Renovate Buildings 12-17               1,400       1,300                 1,300
                                                                         (Thermal Envelope).
  22Prescott                            AZ   BT                         Replace Heating Systems for              940         880       880
                                                                         Outer Buildings, Phase 1.
  22Prescott                            AZ   OOC                        Repair/Replace Main Steam Riser        1,050         900       900
                                                                         from Boiler Plant.
  22Tucson                              AZ   BT                         Replace Air Handlers (B60)......         990         900       900
  22Tucson                              AZ   BT                         Correct Safety Deficiencies, B4.         401         350       350
  22Tucson                              AZ   SCIP 2017                  Legionella DOM Water Loop              1,200         950       950
                                                                         Repairs, B-30 & B-67.
  22Tucson                              AZ   OOC                        Renovate for Pathology Morgue          2,420       2,200     2,200
                                                                         and IT, B-38 Basement.
  22Tucson                              AZ   OOC                        Replace Air Handling Units for         3,300       3,000     3,000
                                                                         Critical Care and Sterile
                                                                         Processing.
  22Tucson                              AZ   OOC                        Upgrade Information Technology         1,815       1,650     1,650
                                                                         Server Room.
  22Tucson                              AZ   OOC                        Replace Ancillary Boiler Plant         1,430       1,345     1,345
                                                                         Equipment & Controls.
  22Tucson                              AZ   BT                         Replace SPS and Logistics                655         600       600
                                                                         Dumbwaiters (B-57).
  22Loma Linda                            CA BT                         Renovate 4SW Bathrooms..........         880         800       800
  22Loma Linda                            CA BT                         Correct Steam Distribution               801         720       720
                                                                         Deficiencies.
  22Loma Linda                            CA BT                         Renovate Stairwells.............         600         550       550
  22Loma Linda                            CA SCIP 2016                  Replace Main Stormwater, Waste &       3,000       2,700                 2,700
                                                                         Vent Piping.
  22Loma Linda                            CA SCIP 2018                  Correct Environmental Controls &       2,500         250                   250
                                                                         Security Deficiencies in IT
                                                                         rooms.
  22Long Beach                            CA SCIP 2015                  Physical Security Access Control       1,650         880       880
  22Long Beach                            CA OOC                        Correct Carpet-Wall Finish             3,960       3,600     3,600
                                                                         Deficiency B150 SCI.
  22Long Beach                            CA SCIP 2012                  Install Emergency Management           5,498       5,000     5,000
                                                                         Generator, Phase 2.
  22Long Beach                            CA OOC                        B126OP Basement-Correct FCA            4,015       3,650     3,650
                                                                         Deficiencies and Remodel.
  22Long Beach                            CA SCIP 2016                  B126 Renovate & Upgrade                4,950       4,455                 4,455
                                                                         Hemodialysis Infrastructure.
  22Long Beach                            CA BT                         Metasys System..................         800         720       720
  22Long Beach                            CA SCIP 2018                  Correct Legionella Deficiencies--      4,400         440                   440
                                                                         Bldg 1.
  22Long Beach                            CA SCIP 2018                  Correct Electrical Site Security       5,203         520                   520
                                                                         Deficiencies.
  22Long Beach                            CA SCIP 2018                  Renovate ICU Bldg 126 3rd Floor.       6,600         660                   660
  22Long Beach                            CA SCIP 2018                  Renovate Bldg 126 8th Floor            9,200         920                   920
                                                                         North for Private/Semi Private
                                                                         Beds.
  22Los Angeles                           CA BT                         Replace Fire Alarm System in             910         821       821
                                                                         LAACC.
  22Los Angeles                           CA SCIP 2018                  Replace Water Main and Valves...       3,795         380                   380
  22San Diego                             CA SCIP 2016                  Bldg 2 Remodel- Emergency Bus          9,020       8,200                 8,200
                                                                         &Switchgear Modifications.
  22San Diego                             CA SCIP 2017                  Emergency Department Exterior          2,310       2,100                 2,100
                                                                         Access & Signage.
  22Sepulveda                             CA SCIP 2016                  Upgrade Information Technology         1,650       1,500                 1,500
                                                                         Closets Sepulveda.
  22West Los Angeles                      CA BT                         Replace B158 Fire Alarm.........         770         700       700
  22West Los Angeles                      CA SCIP 2016                  Upgrade Information Technology         1,500       1,350                 1,350
                                                                         Closets WLA North Campus Six
                                                                         Buildings.
  22Albuquerque                         NM   OOC                        Abate Asbestos B-41.............       1,760       1,600     1,600
  22Albuquerque                         NM   OOC                        Install Legionella Corrections..       2,500       2,250     2,250
  23Des Moines                          IA   SCIP 2015                  Design/Construct Security Gates.       1,660       1,500                 1,500
  23Des Moines                          IA   BT                         Repair Roads/Walks for Safety...         820         672       672
  23Des Moines                          IA   SCIP 2016                  Upgrade OR Chilled Water Cooling       1,756         800       800
                                                                         System.
  23Des Moines                          IA   SCIP 2016                  Install New Emergency Generator        1,900       1,750                 1,750
                                                                         System.
  23Des Moines                          IA   CSI                        Site Prep to Replace Two CTs....       1,080         930       930
  23Des Moines                          IA   SCIP 2015                  Upgrade Existing and Construct         3,990       3,600                 3,600
                                                                         New Elevators.
  23Des Moines                          IA   SCIP 2018                  Renovate and Expand Primary Care       1,240         124                   124
                                                                         Infusion and Oncology Center.
  23Iowa City                           IA   Pending OOC                Replace Deficient Mechanical           2,200       2,000                 2,000
                                                                         Systems (AHU).
  23Iowa City                           IA   SCIP 2017                  Modernize Existing Chillers.....       3,850       3,450                 3,450
  23Iowa City                           IA   SCIP 2015                  Replace Defective Steam Traps          6,100       5,500                 5,500
                                                                         and Correct Condensate Over
                                                                         pressurization.
  23Iowa City                           IA   OOC                        Upgrade and Expand Hospital            2,250       2,050     2,050
                                                                         Security Systems.
  23Iowa City                           IA   OOC                        Correct Life Safety Deficiencies       9,900       9,000     9,000
  23Minneapolis                         MN   SCIP 2018                  Renovate Outpatient Mental             4,300         430                   430
                                                                         Health (1L).
  23Minneapolis                         MN   SCIP 2018                  Recommission of Main Hospital          1,000         100                   100
                                                                         HVAC Systems.
  23Minneapolis                         MN   CSI                        Site Prep--Multi-Site DR Rooms..       5,000       4,000     4,000
  23Minneapolis                         MN   SCIP 2017                  Construct Clinical Research            3,300       3,000                 3,000
                                                                         Wings.
  23Minneapolis                         MN   CSI                        Upgrade Cath Labs 2 and 3.......       2,200       2,000     2,000
  23Minneapolis                         MN   SCIP 2016                  Renovate Inpatient Mental Health       2,600       2,300                 2,300
  23St Cloud                            MN   SCIP 2018                  Renovate Primary Care Clinic           8,203         820                   820
                                                                         Building 4.
  23St. Cloud                           MN   SCIP 2016                  Renovate Building 4 Basement for       7,150       6,500                 6,500
                                                                         Sterile Processing Services and
                                                                         Sterile Processing and
                                                                         Distribution.
  23St. Cloud                           MN   SCIP 2017                  Relocate Rehab Functions........       6,204         564       564
  23St. Cloud                           MN   SCIP 2016                  Upgrade Information Technology         4,965       4,500                 4,500
                                                                         Closets for Security.
  23St. Cloud                           MN   OOC                        Install Ground Source Heat Pump        5,433       5,000     5,000
                                                                         System for Building 28.
  23St. Cloud                           MN   SCIP 2016                  Renovate Building 4 East Side          2,900       2,636                 2,636
                                                                         for Women's Clinic.
  23St. Cloud                           MN   SCIP 2015                  Renovate Building 2, First Floor       4,987       4,545                 4,545
                                                                         for Residential Rehabilitation
                                                                         Therapy Program.
  23St. Cloud                           MN   SCIP 2014                  Replace Windows, Buildings 4, 8        1,580       1,500                 1,500
                                                                         & 9.
  23Fargo                               ND   CSI                        Perform Site Prep for Urology            316         287       287
                                                                         Equipment in OR #4.
  23Fargo                               ND   BT                         Install Instrument Air and RO            202         182       182
                                                                         Water in SPS.
  23Fargo                               ND   BT                         Replace N&FS Ceiling System.....         220         200       200
  23Fargo                               ND   SCIP 2015                  Renovate 2nd Floor Bldg 46 for         2,640       2,400                 2,400
                                                                         Medical Specialties.
  23Fargo                               ND   SCIP 2017                  Replace Boiler Plant............       8,250       7,500                 7,500
  23Fargo                               ND   SCIP 2017                  Renovate Bldg 1 First Floor for        4,840       4,400                 4,400
                                                                         PT/OT and Prosthetics.
  23Omaha                               NE   BT                         Construct SPS Scope Processing           206         186                   186
                                                                         Area.
  23Omaha                               NE   SCIP 2016                  Construct Central Energy Plant..      36,027      35,640                35,640
  23Omaha                               NE   BT                         Replace Overhead Paging Systems--         30          30                    30
                                                                         Omaha and Grand Island.
  23Fort Meade                          SD   BT                         Upgrade Boiler Plant Automation          330         300                   300
                                                                         Equipment.
  23Fort Meade                          SD   SCIP 2016                  Renovate and Consolidate               7,490       6,590                 6,590
                                                                         Inpatient Function Building 113.
  23Fort Meade                          SD   SCIP 2016                  Relocate Sterile Processing            5,265       4,778                 4,778
                                                                         Service and Endoscopy.
  23Hot Springs                         SD   BT                         Canteen Entry Upgrades Design...         175         150                   150
  23Sioux Falls                         SD   BT                         Electrical and Fire Suppression          700         500       500
                                                                         Upgrades.
  23Sioux Falls                         SD   SCIP 2015                  Renovate 5th Floor Surgery......       3,909       3,519     3,519
  23Sioux Falls                         SD   Pending                    Mechanical Upgrades.............       2,200         200                   200
    Various                                  Various                    Below Threshold/Urgent Projects.                 121,374               121,374
                                                                                                         -----------------------------------------------
                                                                              Total VHA Planned NRM        2,549,939   1,870,000   600,000   1,270,000
                                                                         Projects.
--------------------------------------------------------------------------------------------------------------------------------------------------------


    Question 17. Please provide a list of the projects and their 
associated funding levels included in the $862 million for the 
activation of new and enhanced health care facilities. Specifically 
break out the additional projects included in the $364 million ``second 
bite'' for 2018 advance appropriations.
    Response. See attached list of projects.

                                 Planned 2018 Non-Recurring Maintenance Projects
----------------------------------------------------------------------------------------------------------------
                                                                                                      Actual or
                                                                                                      Estimated
                                                                                                    Construction
 VISN                Project Name                   FY 2018             New or Replacement?          Completion/
                                                                                                        Lease
                                                                                                     Acceptance
                                                                                                        Date
----------------------------------------------------------------------------------------------------------------
   1Boston, MA--Community-Based Outpatient        $7,945,835  Replacement.......................    7/31/2018
     Clinic Lease
   2Syracuse, NY--Spinal Cord Injury                $986,452  Replacement.......................     6/1/2013
   2Brick, NJ--Community-Based Outpatient        $10,986,303  Replacement.......................     6/1/2020
     Clinic
   2Manhattan, NY--Hospital Restoration and       $1,819,563  Replacement.......................   10/31/2019
     Renovation
   2Canandaigua, NY--New Construction and         $3,890,735  Replacement.......................    1/31/2023
     Renovation Phase1
   2Rochester, NY--Health Care Center--Major     $13,614,553  Replacement.......................    9/30/2019
     Lease
   4Butler, PA--Health Care Center Lease          $1,398,248  New...............................    6/12/2017
   5Perry Point, MD--Replacement Long Term        $1,200,000  Replacement.......................    7/31/2021
     Care
   6Fayetteville, NC--Health Care Center         $12,489,421  New...............................    9/30/2016
     Lease
   6Charlotte, NC--Health Care Center Lease      $27,008,337  New...............................    2/28/2016
   6Winston-Salem, NC--Health Care Center        $28,702,513  New...............................   12/31/2015
     Lease
   7Expand Cobb City, AL--Community-Based         $7,599,157  New...............................     6/1/2020
     Outpatient Clinic
   7Birmingham, AL--Clinical Annex/               $4,884,076  New...............................    7/31/2015
     Outpatient Clinic Lease
   7Huntsville, AL--Outpatient Clinic Lease       $5,590,275  Replacement.......................   12/15/2015
   7Savannah, GA--Community-Based Outpatient      $9,058,563  Replacement.......................     2/1/2017
     Clinic Lease
   8New Port Richey, FL--Lease Consolidation      $2,311,438  Replacement.......................     6/1/2020
   8Bay Pines, FL--Mental Health/Inpatient-       $8,329,187  Replacement.......................    8/30/2020
     Outpatient Improvements
   8Tallahassee, FL--Outpatient Clinic Lease     $21,491,622  Replacement.......................    7/31/2016
   8Brandon (South Hillsborough), FL--           $20,946,907  New...............................    10/1/2018
     Outpatient Clinic (Tampa) Lease
   8Orlando, FL--New Medical Facility            $63,549,984  New...............................   11/30/2015
   8Tampa, FL--Polytrauma and New Bed Tower      $36,230,637  New...............................    1/31/2021
   9Louisville, KY--Replacement Med Center/       $1,195,634  Replacement.......................     1/6/2023
     Regional Office
  10Terre Haute, IN--Health Care Center             $200,000  Replacement.......................     2/1/2022
  10St Joseph County VA Clinic, IN--             $26,100,912  New...............................   10/31/2017
     Outpatient Clinic
  12Green Bay, WI--Health Care Center            $37,326,024  Replacement.......................    8/10/2015
  15St. Louis, MO--Med Facility Improve &         $5,951,843  Replacement.......................   11/15/2018
     Expansion
  15St. Louis, MO--Clinic                           $773,726  Replacement.......................   10/31/2017
  15Cape Girardeau, MO--Clinic Expansion            $773,726  Replacement.......................    5/31/2019
  16Mobile, AL--Outpatient Clinic Lease           $8,332,515  Replacement.......................    12/1/2018
  16Biloxi, MS--Building 1 & 2 Renovation         $3,240,933  Replacement.......................    5/31/2018
  16New Orleans, LA--Restoration/Replacement    $134,346,907  Replacement.......................    2/28/2018
     Medical Facility
  16Springfield, MO CBOC                         $23,256,953  New...............................    6/30/2018
  16Lafayette, LA--Outpatient Clinic Lease        $4,864,834  New...............................    9/30/2016
  17San Antonio, TX--Polytrauma Renovation        $6,931,830  Replacement.......................   12/31/2013
     Project
  17McAllen, TX--Outpatient Clinic               $17,059,566  New...............................    4/28/2014
  19Missoula, MT--CBOC Lease                         $95,736  Replacement.......................    1/31/2022
  19Denver, CO--Replacement Medical Center       $87,487,356  Replacement.......................     7/1/2018
     Facility
  20American Lake, WA--Seismic Corrections          $240,000  Replacement.......................     9/4/2023
     of Building81
  20Seattle, WA--B101 Mental Health               $1,857,268  Replacement.......................    3/22/2018
  20Walla Walla, WA--New OPC and Renovation       $1,100,000  Replacement.......................     1/6/2020
     86
  20East Portland, OR--Community Based            $3,074,444  Replacement.......................     8/1/2016
     Outpatient Clinic
  20Eugene, OR--Community-Based Outpatient        $6,541,941  Replacement.......................   12/31/2015
     Clinic Lease
  20Seattle, WA--Correct Seismic                     $80,000  Replacement.......................    5/19/2016
     Deficiencies B100
  20Honolulu, HI--ALOHA (459)                     $6,500,000  New...............................     5/1/2020
  21Las Vegas, NV--New Medical Facility          $43,565,383  Replacement.......................     3/7/2016
  21Chico, CA--Replace Lease for Expiring         $4,079,638  Replacement.......................     4/1/2020
     CBOC
  21Redding, CA--Replace Lease for Expiring      $15,421,608  Replacement.......................     6/1/2020
     CBOC
  21Reno, NV--Building 1 Seismic                    $200,000  Replacement.......................    4/26/2021
  21San Francisco, CA--Correct Seismic           $14,823,000  Replacement.......................     9/1/2022
     Deficiencies in Buildings 1,6,8 & 12
  21Livermore, CA--Livermore Realignment            $500,000  New...............................     7/4/2023
     (Palo Alto)
  21Palo Alto, CA--Polytrauma (Polytrauma-        $2,000,000  New...............................    6/30/2017
     Ambulatory Care Center)
  21Palo Alto, CA--Radiology (Polytrauma-           $500,000  Replacement.......................     7/2/2018
     Ambulatory Care Center)
  21Palo Alto, CA--Research (Polytrauma-          $4,300,000  Replacement.......................     4/1/2019
     Ambulatory Care Center)
  21Monterey, CA--Health Care Center Lease        $1,500,000  New...............................    2/28/2017
  21San Jose, CA--Outpatient Clinic Lease        $15,700,000  Replacement.......................   12/31/2017
  21Mission Valley, CA--Clinic                   $21,365,246  New...............................     6/1/2020
  22San Diego, CA--Spinal Cord Injury/Long       $31,959,139  Replacement.......................    9/15/2025
     Term Care
  22Chula Vista, CA--Clinic                       $7,483,329  Replacement.......................    5/31/2019
  22Loma Linda, CA--Health Care Center Lease      $5,140,552  New...............................    6/30/2016
  22Long Beach, CA--Out Patient 126               $7,104,443  Replacement.......................    11/1/2019
  22Long Beach, CA--Seismic Correction--          $1,871,545  Replacement.......................    7/13/2021
     Mental Health & Community Living Center
  22Los Angeles, CA--Seismic Corrections--12      $6,571,450  Replacement.......................   12/24/2024
     Buildings
  22West Los Angeles, CA--New Bed Tower           $1,581,592  Replacement.......................    2/15/2030
  22Bakersfield, CA--Community-Based              $5,018,194  Replacement.......................     5/1/2021
     Outpatient Clinic Lease
                                             -----------------
        Subtotal                                $858,051,072    ................................
    VA Central Office Direct Field Support        $4,115,722    ................................
     (PCAC/VACASE)
                                             -----------------
        Grand Total                             $862,166,794    ................................
----------------------------------------------------------------------------------------------------------------
    Note 2: Activation Funding (AF) covers multiple requirements to bring these projects into full operational
      status; i.e., furniture, fixtures, equipment, and support to plan and outfit each health care facility.
      Additionally, AF is utilized to cover additional clinical and administrative staff to provide new and
      expanded services, and supports other operating expenses; i.e., utilities, maintenance, etc. Based on the
      scope and complexity of the project, AF typically is allocated 2-3 years prior to the construction start
      date, and 2-3 years post construction completion date based on the activation phasing schedule. Within the
      VHA portfolio of activation projects, there are some projects that require activation support and funding
      beyond the typical period of activation funding allocation. These are activation funding estimates and may
      require adjustments based on changes in the construction and activation schedules.


    Question 18. Please provide the weights assigned to the criteria 
and sub-criteria in the Strategic Capital Investment Planning Process 
Decision Model contained on Page 10-3 of Volume IV of the Budget 
Justification.
    Response. Below are the definition and weights associated with the 
criteria and sub-criteria of the SCIP 2018 Decision model.
    strategic capital investment planning process decision criteria
    Improve Safety, Compliance, and Security: VA is dedicated to 
ensuring its Clients (Veterans) and Customers (VA Staff) are being 
served and/or work in a safe and secure environment. Mitigating the 
destruction and injury caused by natural or manmade disasters 
(including seismic, hurricane, flooding, blast, etc.); ensuring 
problems or injuries caused by the potential failure of critical 
building systems are avoided; improving compliance with safety and 
security laws, Federal Information Security Management Act (FISMA) 
standards, building codes, and regulations (including operating room, 
supply processing and distribution, inpatient privacy standards, PACT, 
and Research functional deficiencies for VHA; counselor offices, 
hearing rooms, and public/non-public separation for VBA and equipment 
rooms for OIT); mitigating threats to persons (physical security) on a 
VA facility (duress alarms for VBA); and ensuring VA mission critical 
buildings are able to provide service in the wake of a catastrophic 
event are of paramount importance.
    The three sub-criteria that projects are measured against with 
respect to Improving Safety and Security are:

     Safety/Compliance (Excludes Seismic)
     Physical and Building Security/Emergency Preparedness
     Seismic

    Fixing What We Have (making the most of current infrastructure/
extending useful life): VA is committed to managing its buildings in 
order minimize the extent to which deficiencies in infrastructure 
(including IT infrastructure) and other areas impact the delivery of 
benefits and services to Veterans, such as Central Office rent 
reduction efforts, depletion dates for National Cemeteries and VBA's 
Transformation Initiative. For infrastructure deficiencies, facility 
condition assessments (FCA) evaluate the condition of VA buildings 
using scores A through F and the criticality of building sub-systems.
    The three sub-criteria projects are measured against with respect 
to Fixing What We Have are:

     Reduce Facility Condition Assessment Deficiencies 
(critical)
     Reduce Facility Condition Assessment Deficiencies (non-
critical)
     Other Self-Identified Gaps (gaps not defined in existing 
criteria)

    Increasing Access: Serving Veterans is at the core of VA's mission. 
We strive to increase access for Veterans (our Clients) by reducing the 
time and distance a Veteran must travel to receive the best quality 
services and benefits; ensuring Veterans have access to National 
Cemeteries, providing virtual access to benefits); providing adequate 
supporting structures at VA facilities, such as parking facilities and 
gravesite locators; by increasing our ability to handle workload; and 
by enabling VA staff (our Customers) to work more efficiently.
    The four sub-criteria that projects are measured against with 
respect to increasing access are:

     Client (Veteran) Access to Services
     Customer (Internal) Access to Services
     Support Structures (includes parking deficiencies)
     Utilization/Workload

    Right-Sizing Inventory: In order to provide the highest quality 
service to Veterans at the right time and in the right place, VA is 
managing its space inventory by removing excess VA-owned space via 
demolition, sale or transfer, building new space, collocating (VHA, 
VBA, NCA, and Staff Offices using the vacant or underutilized space of 
another office), leasing new space, converting underutilized space of 
one type to another type, to better suit its mission, and using space 
efficiency strategies such as but not limited to teleworking, cubicle 
reconfiguration, converting to new space standards, and expanded office 
hours to reduce the need for space.
    The four sub-criteria projects are measured against with respect to 
Right-Sizing Inventory are:

     Space--New Construction/Renovation/Conversion/Lease
     Space--Disposal (via demolition, sale, or transfer only)
     Space--Collocation
     Space--Space Efficiency Strategies

    Ensure Value of Investment: As a steward of the public's trust VA 
is responsible for making capital investments in the most cost-
effective way possible by ensuring new capital investments optimize 
operating and maintenance costs, in order to create the best value.
    The two sub-criteria that projects are measured against with 
respect to Ensure Value of Investment are:

     Cost Saving Strategies--identification, quantification, 
and description any cost savings realized with the implementation of 
this project.
     Best Value Solution--completion of a cost-effectiveness 
analysis (CEA) on the Status Quo and required alternatives is mandatory 
for Major Construction, Minor Construction, and Lease projects; if the 
chosen option does not have the best net present value (NPV) an explain 
for why the chosen option is the better value is also required

    Departmental Initiatives: For improved management and performance 
across the Department, capital projects should contribute to 
performance goals from the Department's strategic plan, including DOD 
collaboration and complying with energy standards established in law 
and Executive Orders.
    The five sub-criteria that projects are measured against with 
respect to Strategic Requirements are:

     Empower Veterans to Improve Their Well-being
     Enhance and Develop Trusted Partnerships
     Manage and Improve VA Operations to Deliver Seamless and 
Integrated Support
     DOD Collaboration
     Energy Standards

    
    
          office of transition, employment and economic impact
    Question 19. Please provide the number of Direct and Management 
Direction and Support FTE for the Office of Transition, Employment, and 
Economic Impact (OTEEI) for fiscal year 2017 and the request for fiscal 
year 2018.
    Response. For FY 2017, OTEEI was allocated 40 full-time employees 
(FTE) with 10 slots designated as supervisors or program managers. On 
November 1, 2016, OTEEI was realigned under VBA's Benefits Assistance 
Service (BAS) and the Office of Economic Opportunities (OEO). Of this 
total, 23 FTE were realigned under BAS, 7 FTE were realigned under OEO, 
and the remaining FTE were realigned to other mission essential 
functions. No FTE was allocated for FY 2018 as OTEEI no longer exists.

    Question 20. Please provide the total administrative costs for 
OTEEI for fiscal year 2017 and the request for fiscal year 2018.
    Response. OTEEI was provided $199,000 in operating budget for FY 
2017. These funds were reallocated to BAS and OEO, to support mission 
functions. In FY 2018, there was not a separate budget submission for 
OTEEI as those duties have been dispersed between other business lines 
in VBA.

    Question 21. Please provide a list of the programs and other 
functions for which OTEEI is responsible, including the annual cost or 
expenditure per program, for fiscal year 2017 and the request for 
fiscal year 2018.
    Response. OTEEI is no longer an existing organization. BAS assumed 
responsibilities for the Transition Assistance Program while OEO 
continues to collaborate with Department of Labor (DOL), non-profits, 
and the private sector with the goal of helping Veterans reach their 
full economic potential.
                           education service
    Question 22. The Budget Justification noted that Education Service 
has indefinitely delayed implementation of the Veterans Approval, 
Certification, Enrollment, Reporting, and Tracking System (VA-CERTS) 
due to funding constraints.

    a. What functions would VA-CERTS provide to Education Service and 
to school certifying officials?
    Response. VA-CERTS would provide a modernized way for schools to 
send enrollment information to VA. Training institutions would be able 
to access VA data to include chapter 33 eligibility percentages, which 
is not currently available in the existing legacy system. With the 
completion of VA-CERTS, it would allow VA to consolidate two legacy 
systems into one agile and accessible system.

    b. How would VA-CERTS improve the administration of education 
benefits compared to the current system?
    Response. Improvements would allow for schools to have the ability 
to see VA data in order to verify that schools were paid the correct 
tuition and fees rates. VA-CERTS would also incorporate the ability to 
certify multiple enrollments for students at one time, as opposed to 
entering one enrollment at a time. In addition, a newer system would 
eliminate the need for duplication of work for VA employees by 
combining the Web Enabled Approval Management System and VA-ONCE. 
Currently, VA employees have to enter similar information into both 
systems.

    c. What is the cost to complete and fully implement VA-CERTS, and 
when will VA make a decision on completing it?
    Response. The cost to implement VA-CERTS is not known at this time. 
When initially conceived in 2014 its estimated cost of completion was 
$39M. Currently, the Office of Information and Technology is in the 
process of re-engineering education systems--eliminating the Business 
Delivery Network (BDN), a 51-year-old COBOL-based mainframe system and 
consolidating all education processing and payments into Long Term 
Solution (LTS) and VETSNET/FAS (Financial Accounting Services). This 
elimination of a critical legacy system and the resulting consolidation 
of capabilities, beginning now and running through 2018, will greatly 
facilitate VA's ability to conduct system enhancements going forward. 
Due to the aggressive timeline for accomplishing this work, it is 
vitally important to not introduce additional changes or enhancements 
during this period to avoid additional complexity and risk. 
Implementation of VA-CERTS capabilities could begin once this initial 
effort is complete. VA will be in a better position to estimate costs, 
timing and how to best implement the capabilities conceived for VA-
CERTS at the end of this calendar year once the engineering plan for 
the initial effort is solidified and implementation well underway.

    Question 23. The Budget Justification stated VA is working toward 
``a fully automated system for all education claims.''

    a. What is Education Service's goal for automating original claims 
in the Long Term Solution?
    Response. The current average processing time for original claims 
is 22 days. By fully automating original claims, VA would be able to 
provide even faster service for some beneficiaries. VA's long-term goal 
is for a beneficiary to be able to obtain an eligibility determination 
electronically, as opposed to waiting until VA manually adjudicates a 
claim and then mails a letter regarding the eligibility determination. 
By full automating the original claims process, there would be a 
savings to the government because it would eliminate the costs of 
paper, postage, envelopes, and mail handling.

    b. What is the cost to complete development of the Long Term 
Solution in order to fully automate all education claims?
    Response. The cost to complete development of LTS is not known at 
this time. We have, however, included projections of $37.5M in our 
budget planning for FY19-21. Currently, the Office of Information and 
Technology is in the process of re-engineering education systems--
eliminating the BDN, a 51-year-old COBOL-based mainframe system and 
consolidating all education processing and payments into LTS and 
VETSNET/FAS. This elimination of a critical legacy system and the 
resulting consolidation of capabilities, which is beginning now and 
will run through 2018, will greatly facilitate VA's ability to conduct 
system enhancements going forward. Due to the aggressive timeline for 
accomplishing this work, it is vitally important to not introduce 
additional changes or enhancements during this period to avoid 
additional complexity and risk. Implementation of LTS enhancements 
could begin once this initial effort is complete. VA will be in a 
better position to estimate costs, timing and how to best implement LTS 
enhancements at the end of this calendar year once the engineering plan 
for the initial effort is solidified and implementation well underway.

    c. How many man hours were spent processing original claims in 
fiscal year 2016 and how many are expected to be spent in fiscal year 
2017 and fiscal year 2018? What is the average cost of a man hour to 
process original claims?
    Response. VA does not track the specific number of man hours that 
are spent processing various types of claims. However, we track the 
number of claims that are processed, and in 2016, we processed 356,756 
``original'' claims of all benefit types combined. Our current time to 
process an original claim is approximately 22 days.
    Prior to automating supplemental claims in September 2012, the 
average timeframe for processing a claim was 21 days for supplemental 
and 36 days for originals; presently we are operating at 8 days for 
supplemental and 22 days for original claims. We would expect a similar 
benefit to our timeliness if we automate original claims.

    Chairman Isakson. Thank you, Dr. Shulkin. We appreciate 
your attendance today.
    I want to start off with my questions on the appeals 
process. I have consistently said that any change in the 
process to improve it must include an acceleration in dealing 
with the 470,000 veterans whose claims are pending today at the 
VA. Would you agree with that?
    Secretary Shulkin. I would like to see that happen.
    Chairman Isakson. Well, I am going to give you the same 
question, once we give you a chance to make a commitment on 
that.
    If both appeals reform and budget requests are adopted in 
this budget, would VA be able to begin accelerating decisions 
for those 470,000 appeals that are pending?
    Secretary Shulkin. The appeals that are in the Board of 
Appeals are the ones that we are most concerned about. If the 
Senate votes to move the appeals modernization forward, as I 
think you are saying, Mr. Chairman, we will have a process to 
expedite those from the time that the law passes moving 
forward.
    You are asking about the legacy claims----
    Chairman Isakson. Right.
    Secretary Shulkin [continuing]. And appeals. We do not have 
a plan to make significant progress on those. We are going to 
have to whittle away at them. The budget this year will add 142 
more staff to the board. That will allow us to make incremental 
progress, but I think to deal with the backlog, we would be 
looking at 2026 before we dealt with the backlog.
    The one hope that I have, Mr. Chairman, rather than adding 
a large number of staff to deal with the backlog, is that we 
will give current veterans who are in the appeals process the 
option of opting into the new process, and if they choose to 
opt in--but it is going to have to be their choice--they would 
be able to have their appeal dealt with in the expedited 
fashion, in the faster fashion.
    It is my hope to be able to accelerate the backlog, to 
encourage veterans, who unfortunately right now would have to 
wait years to get decisions, to opt into the new process.
    Chairman Isakson. Well, first of all, let me commend you 
because you just gave a patently honest answer to my question, 
not that I had expected anything else.
    Secretary Shulkin. Mm-hmm.
    Chairman Isakson. But it is easy for a department head 
sometimes to talk department-ese----
    Secretary Shulkin. Mm-hmm.
    Chairman Isakson [continuing]. Where we think we heard one 
thing and we heard something else, but what I heard you say, in 
effect, as far as those legacy appeals are concerned, this 
really is not going to do much, even if it is adopted, to take 
those legacy claims and move them forward.
    Secretary Shulkin. Yes.
    Chairman Isakson. Which means we will still have 470,000 
veterans claims out there that are old. One of them is 25 years 
old. I know that.
    Secretary Shulkin. At least. At least.
    Chairman Isakson. That is the oldest legacy claim.
    Secretary Shulkin. Yes.
    Chairman Isakson. Eventually, he will die, and we will get 
that one solved, but we have got 469,999 more we have got to.
    I hate to--I am going to quote now what I have heard 
secondhand, and I will say up front this is secondhand. I have 
been told that the VA recently told the Congressional Budget 
Office that VA's plan is to, ``very gradually,'' address the 
470,000 legacy appeals if appeals reform is passed. Is that the 
plan, and how long would that take? I heard your answer being 
yes, it is probably going to be very gradual, and yes, it would 
be 2026 before we got to it?
    Secretary Shulkin. Yes, yes. Mr. Chairman, let me just add 
that we share that frustration. I find it really difficult to 
tell people who have submitted into the appeals process that 
they have 6 years to wait on average to get a response.
    So, I have asked the question: how much more would it take 
to get that backlog address?
    Chairman Isakson. And the answer is?
    Secretary Shulkin. I am not sure you want to know because I 
was astounded by how much it was.
    Chairman Isakson. I want to know.
    Secretary Shulkin. Around $800 million.
    Chairman Isakson. Senator Sanders, Senator Tester, Senator 
Heller, Senator Boozman, Senator Moran, everything we do as a 
Committee--Senator Manchin--will pale in comparison to the hell 
we are going to catch if it is going to cost $800 million to 
handle those claims before 2026. The appeals, we are going to 
clean up appeals prospectively in the future with what this 
budget proposes, but for the legacy appeals that sit out there, 
they are going to still be out there.
    Secretary Shulkin. Yes.
    Chairman Isakson. The anger is going to get louder and the 
frustration deeper. So, we really need--you need to know the 
number--$800 million will do it--and we need to be prepared to 
try to find some way to do that because all that--all that is 
going to happen is there are a lot of people that are going to 
get worse, more and more anguish, less and less service, and it 
is going to cause us more and more problems with our new 
programs we try to bring in place.
    Thank you for being candid about that. I want all of us to 
be aware as Members of this Committee what we are dealing with, 
and we have got to make the hard decisions. One of them is 
going to be to get those legacy claims done and not let them 
build up in the future because when you do put your new program 
in that is going to solve all the problems prospectively--it 
sure as hell better!--because if we fix the ones that are back 
there and then we have another buildup, we are going to be 
madder than a wet hornet. Is that not right, Jon?
    Senator Tester. That is a fact.
    Secretary Shulkin. Mm-hmm.
    Chairman Isakson. Now, very quickly--I took much time on 
that, but I thought that ought to be out on the table.
    When a veteran, when an American citizen signs up in the 
United States military and commits themselves to a period of 
service, carries out that service, and it meets the 
qualification necessary for them to go for VA health care in 
their retirement or when they leave the service, then we are 
obligated as a nation to pay for those benefits. Is that not 
correct?
    Secretary Shulkin. That is correct.
    Chairman Isakson. Does anybody up here at the dais disagree 
with that? [No response.]
    This is not a trick, by the way. I am just trying to get 
everybody engaged.
    We did Choice, and Senator Sanders and Senator McCain did a 
great job of leadership 36 months ago on that. We did Choice to 
address the appointment backlog, the wait time periods, and 
things of that nature. We did some good things, which brought 
about some problems, which we have illuminated and have begun 
to solve.
    We are now in a situation--and you alluded to it in your 
remarks--where you need to find some money to finish out Choice 
in this current budget period by moving some money from one 
part of the VA budget to the other.
    I just want to make sure I am right on this. You have seven 
accounts that fund health care benefits; is that correct?
    Secretary Shulkin. Community Care.
    Chairman Isakson. Community Care, but there are seven 
accounts?
    Secretary Shulkin. Yeah, seven. Right.
    Chairman Isakson. One of those is Choice. One of those is 
Community Care, care in the community. So, you have enough 
money; you are not asking for new money to be given to you by 
appropriators or by the Congress. You are asking to move 
existing appropriated money for health care benefits under one 
stovepipe in the VA to another stovepipe to achieve balance, 
but there is no new appropriation. Am I correct?
    Secretary Shulkin. That is correct. We have enough money to 
be able to make sure that all veterans will get the care that 
they need.
    We need your help to figure out the best solution about how 
to get more money into the Choice account.
    Chairman Isakson. I am raising this only as a good talking 
point for all of us on the Committee to have a discussion, 
which I am sure we will have on this, but I want to get that 
point also. We sometimes get bogged down in legi-speak, words 
like ``mandatory'' and ``discretionary'' and this acronym and 
that acronym, when it is all the same money in the case you are 
talking about. It is for veterans health care benefits. It is 
in your current appropriations. It is not any new money. We are 
not raising any expenditure to the taxpayer. We are just trying 
to meet our obligation to our veterans.
    So, we need to find the way to do that on not just a stop-
gap manner but permanently, and one of those ways might be to 
see to it that all the veterans benefits for health care are 
paid out of one account and is under the Secretary of the VA. 
Is that not correct?
    Secretary Shulkin. That would make sense to me, Mr. 
Chairman.
    Chairman Isakson. Senator Tester.
    Senator Tester. Thank you, Mr. Chairman.
    Once again, thank you for being here, Dr. Shulkin.
    You talked about--and I want to just follow up on the 
Chairman's questions. You talked about in your opening 
statement Choice being down to $821 million and the fact that 
there was additional dollars in Community Care that you wanted 
to transfer over.
    You had put out a rule or edict. I do not know what you 
want to call it. What is it called?
    Secretary Shulkin. A directive?
    Senator Tester. A directive. That is better. A few days ago 
that directive said you wanted to go to the original intent on 
Choice, which would dry up a lot of how the dollars were spent. 
Then, a day or two later, you rescinded that.
    Thank you for the breakfast yesterday. We had a great 
breakfast, and we talked yesterday about potentially doing a 
fix legislatively.
    I was told today that another directive was put out today 
that reinstated that rule to go back to the initial. Is that 
correct?
    Secretary Shulkin. Let me try to be accurate about what 
happened. We noticed that there was an imbalance in our two 
checking accounts.
    Senator Tester. Yes.
    Secretary Shulkin. On Friday, we sent out a directive 
saying----
    Senator Tester. Right.
    Secretary Shulkin [continuing]. Stop spending from this 
account.
    Senator Tester. Right.
    Secretary Shulkin. OK. Start spending from this account.
    Senator Tester. Correct.
    Secretary Shulkin. We were afraid after seeing that 
directive that we were going to confuse the field----
    Senator Tester. Bingo.
    Secretary Shulkin [continuing]. And so we rescinded that 
memo.
    Senator Tester. That is correct. Right.
    Secretary Shulkin. The field, once we rescinded the memo, 
said, ``OK. We get it. You are rescinding the memo, but will 
you give us some direction about how we should spend out of 
both of these accounts? because we still do have money in the 
Choice account. We have more money in Community Care.''
    So, we sent out four principles about the appropriate use 
of Choice and the appropriate use of Community Care funds, 
while we are working with you to figure out the best solution 
about how to get the appropriate money in each of those 
checking accounts.
    Senator Tester. Did those four principles--I do not have a 
problem here.
    Secretary Shulkin. Yeah.
    Senator Tester. All I want is predictability because I 
think it is important.
    Did those four principles tell the folks to go back to the 
original use of Choice?
    Secretary Shulkin. It told them--it told them to use Choice 
for the appropriate use of Choice, which is clearly as you 
legislated, which is 40 miles, 30 days, and to use Community 
Care for the original use that they were using it for.
    Senator Tester. OK. With all due respect, the directive was 
put back in place, and by the way, I do not have a problem with 
the first directive. I do not have a problem with staying the 
way it was. It has got to be driving your folks on the ground 
and it is going to be driving our veterans crazy if it is yes, 
no, yes. Then, in a week, when we fix this, it will be no 
again, so that is all I ask.
    That uncertainty, by the way--and I will not speak for 
everybody on this Committee, but I have a notion that it will 
be this way for everybody on the Committee--does not add 
confidence to the VA moving forward. I will just tell you. Do 
you get my drift?
    Secretary Shulkin. Absolutely. Let me just say and----
    Senator Tester. Yes.
    Secretary Shulkin. Listen, I would not disagree or argue 
with you.
    Senator Tester. Yes.
    Secretary Shulkin. The Choice Program has been difficult to 
administer----
    Senator Tester. Yeah, yeah.
    Secretary Shulkin [continuing]. Difficult to understand----
    Senator Tester. Yep.
    Secretary Shulkin [continuing]. And very complex.
    The first memo was rescinded----
    Senator Tester. Yeah.
    Secretary Shulkin [continuing]. And remains rescinded 
because what it said is ``Do not go to Choice.'' We do not mean 
that. What we have tried to do is provide guidance to say, 
``You can use choice, and we want you to use Choice 
appropriately, but we have Community Care funds. We want you to 
use those.''
    We understand----
    Senator Tester. OK.
    Secretary Shulkin [continuing]. But it is different than 
the first memo.
    Senator Tester. OK. I would just say this, communication is 
a very good thing, we need to have communication. The breakfast 
we had yesterday was very, very important.
    Secretary Shulkin. Mm-hmm.
    Senator Tester. I think everybody who was at that breakfast 
will do it, and hopefully, we can have more of them. But, there 
was never an indication of this happening at the breakfast 
yesterday, or we could have talked about it some more. I do not 
want to micromanage the VA.
    Secretary Shulkin. Mm-hmm.
    Senator Tester. It is your baby. You would hang me out to 
dry if I tried to do that, and rightfully so. We just need 
predictability, that is all.
    By the way--when I say we, I mean this Committee--but more 
importantly are the people sitting behind you who need that 
predictability.
    Secretary Shulkin. Mm-hmm. Absolutely.
    Senator Tester. Otherwise things are going to go upside-
down pretty quick.
    I have got a bunch more questions, but I will refer to the 
next person in line.
    Secretary Shulkin. OK.
    Chairman Isakson. Senator Moran.

           HON. JERRY MORAN, U.S. SENATOR FROM KANSAS

    Senator Moran. Chairman, thank you. I want to be in the 
position agreeing with Senator Tester and disagreeing with 
Senator Tester.
    Senator Tester. Uh-oh.
    Senator Moran. The memos are different, and there is a 
significant consequence to the difference.
    Secretary Shulkin. Yes.
    Senator Moran. When we visited about the first memo, the 
consequence of that would be that the third-party 
administrators would have no role to play, and the networks 
potentially could go away. Lie dormant?
    Secretary Shulkin. Exactly.
    Senator Moran. The second memo says Choice is alive and 
well----
    Secretary Shulkin. Absolutely.
    Senator Moran [continuing]. And it is to be used in these 
circumstances, which are the ones that were defined by the 
original Choice Act.
    Secretary Shulkin. Right.
    Senator Moran. I do not actually know what--why that is 
different than how it was being used. How is Choice being used 
different than 40 miles and 30 days?
    Secretary Shulkin. Because we were also putting everything 
that we could through Choice, especially services that were not 
being offered at the VA.
    So, Senator Moran, you have it correct. That was exactly 
what we tried to do between the first and second memos. Senator 
Tester is pointing out that we have some work to do in getting 
our communications a little bit better.
    Senator Moran. That is the part I was going to agree with 
Senator Tester.
    Secretary Shulkin. Yes. I agree with him too.
    Senator Moran. Because on that point----
    Secretary Shulkin. Yes.
    Senator Moran [continuing]. I would make the case on behalf 
of Senator Tester that----
    Secretary Shulkin. Right.
    Senator Moran [continuing]. We had a hearing on Wednesday 
on Choice.
    Secretary Shulkin. Yes.
    Senator Moran. Your first memo goes out on Thursday or 
Friday.
    Secretary Shulkin. Friday.
    Senator Moran. This conversation never occurred with people 
who care a lot about Choice but care a lot about veterans.
    Secretary Shulkin. I will say everything that both of you 
have said is accurate, and I will tell you--and I hope that 
you----
    Senator Sanders. You are quite the politician, I must 
confess. [Laughter.]
    Secretary Shulkin. Yeah.
    I will tell you that, look, my integrity is very important. 
On Wednesday, Senator, I did not know this information. I 
learned about it on Thursday.
    Senator Moran. I assumed that was the case.
    Secretary Shulkin. Yes. Thank you.
    Senator Moran. Let me then again try to highlight why 
keeping Choice in existence--and it is not just a matter of 
transferring. How we transfer the money or what pot of money it 
comes from is an important issue, and that revolves around 
whether or not Choice has a future today and again when we 
potentially reauthorize its existence into the future.
    When I say that it matters, because if Choice is not being 
used, then our intermediaries are not being paid, the network 
that has been established under Choice goes away, and you have 
Community Care but no Choice and no network, no third-party 
intermediary. It is not just a matter of transferring money 
back and forth. It is a matter of making sure that Choice is 
viable so that the network stays in place. Does that make 
sense?
    Secretary Shulkin. Yes. We worked very hard to do that, and 
I agree with you. We want to keep that in place.
    Senator Moran. A part of this that I still am confused 
about, because your response in regard to Chairman Isakson was 
that we just need transfer authority. I certainly have been in 
these hearings enough to know that you have said that more than 
once, and I think that is something that we are interested in. 
It makes no sense to have unneeded barriers.
    Secretary Shulkin. Mm-hmm.
    Senator Moran. We also need to make certain that this issue 
of mandatory is handled in a way that, again, Choice is 
mandatory, and that money has to stay available so that the 
program stays viable.
    Here is what I wonder, is that just--and, again, in 
response to the Chairman, I think you said, ``We are not asking 
for any new money.''
    Secretary Shulkin. Right.
    Senator Moran. My understanding is that you have about $2 
billion in the Community Care account. Is that an accurate 
number?
    Secretary Shulkin. Unobligated, yes.
    Senator Moran. Unobligated. So, at some point in time--and 
I do not know how soon that is, maybe the VA does--that money 
becomes scarce. The fix can only last so long before both the 
Choice account and the Community Care account are insufficient 
to meet the community, the health care needs through Community 
Care. Is that true?
    Secretary Shulkin. We have enough money to get us through 
the end of the fiscal year in both--if we could balance the 
accounts correctly, we could make it through till the end of 
the year to get Community Care paid for in both Choice and 
internal Community Care.
    Senator Moran. So, the $2.9 billion in the fiscal year 2018 
Budget Request is not needed until fiscal year 2018?
    Secretary Shulkin. I am going to defer to my CFO, but I 
would have said yes.
    Mr. Yow. Yes, sir. That is a requirement that is for next 
year. Now, the one caveat is in the budget, we assumed we were 
going to carry over $626 million of this year's Choice money 
into next year. Our actual requirement for 2018 is $3.5 
billion. We are going to consume that $626 million, we think 
now, before the end of this year, so we will have a hole next 
year of about $600 million.
    Senator Moran. That hole exists in mandatory dollars, not 
discretionary dollars?
    Mr. Yow. Yes, sir.
    Senator Moran. Which then means this Committee has to act 
to authorize additional mandatory spending for whatever the 
account is then called.
    Mr. Yow. Yes, sir.
    Senator Moran. Is that true?
    Mr. Yow. Unless we were to find some other offset somewhere 
in our direct appropriated discretionary funds.
    Senator Moran. I guess my takeaway is, assuming that your 
budget numbers are right, Mr. Yow and Mr. Secretary, that there 
is no emergency is what you are telling us? That Choice will 
continue between now and the end of the fiscal year without any 
additional input of money as long as there can be a transfer 
of, I suppose, discretionary spending into the mandatory 
account.
    Secretary Shulkin. Yeah.
    Senator Moran. Is that true?
    Secretary Shulkin. The last part that you said is true, but 
if there is no action at all by Congress, then the Choice 
Program will dry up by mid-August.
    Senator Moran. You have no ability, in your view, to fix 
the transfer issue, the discretionary and the mandatory, two 
components, to combine those into an account without 
legislative authorization?
    Secretary Shulkin. That is correct.
    Senator Moran. So, the emergency is not more money.
    Secretary Shulkin. Right.
    Senator Moran. The emergency is changing the law to allow 
you to spend money that you have, although it certainly sounds 
like it creates a likelihood of fiscal shortfall, dollar 
shortfall in fiscal year 2018, even if we appropriate the $2.8 
billion in the President's request.
    Secretary Shulkin. I think everything you said is correct, 
and as Mr. Yow said, we are not seeking, though, additional 
monies. If we needed to, we will identify the offset to the 
$600 million for 2018.
    Senator Moran. The Chairman has his finger on the----
    Chairman Isakson. No.
    Senator Moran. I think I have had my fair shot. We may have 
another chance. Thank you.
    Chairman Isakson. Well, that is very helpful, and I 
apologize, Senator Sanders. I am going to take 1 minute just to 
clarify a couple of points.
    Dr. Shulkin, I am a veteran. I served in the military in 
Afghanistan. I served my years to necessarily make me eligible 
for VA health care. I am a veteran. I am in VA health care. If 
I go to the VA hospital for a medical need related to my 
service or to just regular health care, you are obligated as 
head of the VA to pay for it and deliver that health care to me 
the best possible way possible. Is that not right?
    Secretary Shulkin. Yes.
    Chairman Isakson. So, it is mandatory that you do that. You 
do not have the discretion as director of the VA to not provide 
me with health care because you did not get enough money?
    Secretary Shulkin. Correct.
    Chairman Isakson. You have the obligation to manage the 
money you have, and if you need more come to get more money 
appropriated. Is that not correct?
    Secretary Shulkin. Yes.
    Chairman Isakson. That is why when we talk about mandatory 
and discretionary; I do not think it is a matter of discretion 
if a veteran's health care is at risk for not having enough 
money. We have got to find the money, and it is mandatory that 
we provide that money.
    Secretary Shulkin. I would agree.
    Chairman Isakson. What you are talking about in 
transferability is after we decide to put X number of dollars 
in however many accounts that are in the VA, you want to be 
able to take money out of any of those accounts to pay for the 
benefit of that veteran without having to go to a secondary 
step within the VA to get money removed--moved by somebody else 
because something is named ``mandatory'' or named 
``discretionary.''
    Secretary Shulkin. Correct.
    Chairman Isakson. Is that correct?
    Secretary Shulkin. Yes.
    Chairman Isakson. I just want to make sure I had that 
right. I am not sure I said it right, but----
    Secretary Shulkin. You said it perfectly.
    Chairman Isakson. It is clear to me now. Clear as mud, 
anyway.
    Secretary Shulkin. OK.
    Chairman Isakson. Senator Sanders.

         HON. BERNIE SANDERS, U.S. SENATOR FROM VERMONT

    Senator Sanders. Thank you very much, Mr. Chairman.
    Dr. Shulkin, great to see you.
    On page 3 of your testimony, you point out, I think, what 
most veterans organizations and veterans know, by and large, 
the VA has a pretty good health care system. You quote a study 
published by the Journal of the American Medical Association 
(JAMA), where researchers compared hospital-level quality care 
on 129 VA hospitals with over 4,000 non-VA hospitals, and you 
found that you have better outcomes in the VA on six of nine 
patient safety indicators, and the other three were about the 
same. That is pretty good. I mean, that speaks pretty well for 
the system that you are running, despite all of the criticism 
we hear every day. True?
    Secretary Shulkin. Yes. Yes, sir.
    Senator Sanders. Let me ask you a question that has always 
fascinated me. Maybe you can give me an answer. I held a 
hearing a few years ago on the Health Committee talking about 
preventable deaths in American hospitals. According to--I am 
looking at an article right now in the New England Journal of 
Medicine, and they say that hospital medical errors are the 
third leading cause of death in the United States. 700 people 
every single day die in this country from hospital medical 
errors. How is the VA doing compared to non-VA hospitals on 
that issue?
    Secretary Shulkin. Well, as the article in JAMA suggested, 
the VA is actually performing better on patient safety--and 
patient safety is defined by medical errors--than, on average, 
the private sector. Of course, every hospital in America, 
including VA, are always looking for ways to get better, but 
the VA has systems in place that help it perform better than 
many of the private-sector hospitals.
    Senator Sanders. Well, congratulations for that. I know 
that the veterans appreciate that, which takes me to the point 
that Senator Tester made a moment ago, and that is what we hear 
every time there is a hearing with veterans, they like VA 
health care.
    Secretary Shulkin. Mm-hmm.
    Senator Sanders. What I do not want to see--and I think 
Senator Tester--many of us do not want to see the shifting of 
funds that go to traditional VA health care moved to the Choice 
Program. Regarding the Choice Program, we have had long 
discussions. We will continue to discuss that.
    I am a little bit distressed that a significant amount of 
money in President Trump's budget is going to Choice, not quite 
so much going to traditional VA.
    Another question. You mention on page 9 what is obvious. 
You say that VHA is the largest health care system in the U.S. 
in an industry where there is a national shortage of health 
care providers. We have a major doctors crisis, especially in 
certain areas: primary health care relief, maybe psychiatry/
psychology.
    Secretary Shulkin. Those are the two biggest, yes.
    Senator Sanders. OK. A couple of years ago when I helped 
work on the major veterans bill, we put--we expanded a program 
for medical education. It was the Section 302 of the Health 
Professionals Educational System Program. What that does, 
essentially, Mr. Chairman, is--what it does is help. As you 
know, medical school is now outrageously expensive, which is a 
very serious problem.
    I talk to young doctors who are $3-400,000 in debt. OK? 
They are probably not going to go to work at the VA. They are 
going to go work where the money is. I would like to see that 
program expanded. What it does is provides debt forgiveness. 
You want to work for the VA for X number of years; we will 
forgive the debt that you have incurred at medical school. Is 
that an idea that makes sense to you?
    Secretary Shulkin. Senator Sanders, both of the ideas that 
you said and that the Ranking Member talked about make a great 
deal of sense to me. I do not want to see VA care diluted 
because we are getting more veterans treated in the community. 
I want to see more veterans treated in the community because 
they need the care and VA cannot provide it right now.
    So, what we are proposing and hoping to work with you in 
this new Choice Program are the two things you have talked 
about. Right now, we are restricted to a 1 percent transfer 
from care in the community back into the VA or vice versa. We 
would like to see that aperture open so that we could actually 
take money that was in the budget for sending veterans out and 
reinvesting more of it into the VA. We think that is very 
important. It should be done at the local level when every 
local VISN makes its decision about what services the VA needs 
to strengthen in.
    On the GME issue, graduate medical education, I could not 
agree with you more. The program that you were helpful in 
crafting was a great success.
    Senator Sanders. Is it working well?
    Secretary Shulkin. It is. It is. We need to do more of it. 
We are proposing exactly what you are saying, which is creating 
more GME spots. The country needs them. VA would pay for them, 
and in exchange, it would be like the military or public health 
service.
    Senator Sanders. Or the National Health Service Corps.
    Secretary Shulkin. Or the National Health Service Corps. 
Afterwards, they would give 5 years back to the VA.
    Senator Sanders. Right.
    So, Mr. Chairman, this is an issue where I think we can go 
a long way in attracting excellent physicians and nurses, 
perhaps----
    Secretary Shulkin. Yeah.
    Senator Sanders [continuing]. Into the VA by doing a debt--
expanding the debt forgiveness program, which I understand is 
already working well. I would look forward to working with you 
on that.
    Last question is--I am quoting from a publication called 
Families USA: ``Cutting Medicaid would hurt veterans. Efforts 
in Congress to cut Medicaid jeopardize a critical source of 
health coverage for veterans. Approximately 1.75 million 
veterans, nearly 1 in 10, have Medicaid as a source of 
coverage.''
    If the Republican health care plan goes through--and I am 
going to do everything I can to see that it does not, but if it 
does go through and Medicaid is cut by over $800 billion in a 
10-year period, I assume that means that a lot more veterans 
are going to be flocking into the VA. Am I correct on that?
    Secretary Shulkin. I would think so. We are a safety-net 
organization, and we tend to have veterans without other health 
access come to the VA. I do not want to sound like a 
politician, but, you know, as the Chairman said, our role is to 
provide that care. We would need to do that.
    Senator Sanders. So, if veterans lost their Medicaid, there 
is a reasonable possibility, many of them would turn to the VA 
for care.
    Secretary Shulkin. I believe so.
    Senator Sanders. And you need additional health to 
accommodate that large number of veterans?
    Secretary Shulkin. Yes.
    Senator Sanders. Thank you very much.
    Chairman Isakson. Thank you, Senator Sanders.
    Senator Rounds.

        HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA

    Senator Rounds. Thank you, Mr. Chairman.
    Mr. Secretary, last week, we had a rather--I guess I would 
call it a spirited discussion about the Emergency Care Fairness 
Act, and under the VA's Fiscal Year 2018 budget proposal, a 
budget line to pay for emergency care is still lacking. 
However, the VSOs' Independent Budget has included a 
recommendation of $1 billion for 2018.
    I guess my question, sir, would be, what is the status of 
the Staab appeal, which is the appeal on the Emergency Care 
Fairness Act, the way that it is being interpreted, and at what 
point will the VA formally request the necessary funds to pay 
for the emergency care for our veterans?
    Secretary Shulkin. Well, first of all, Senator, I 
appreciated the interchange that you and I had. I think that 
you were making excellent points, and you were actually on the 
right side of this issue.
    We have done two things since we talked last. First, we 
have completed all of the regulations to be able to move 
forward with payment of the Staab claims, and we have now 
transmitted them to the Office of Management and Budget. That 
part is complete, so that is moving forward.
    Senator Rounds. That is good news.
    Secretary Shulkin. The second thing is that after 
considering what you said and also I think Senator Blumenthal, 
I have decided to voluntarily withdraw the appeal to the Staab 
case.
    Senator Rounds. Oh, that is great news, Mr. Secretary. I 
think what that means is the last time we checked, there were 
370,000 claims outstanding that now can expect to receive 
payment for the emergency room care that they have expected 
since 2010?
    Secretary Shulkin. Well, we still have to go through the 
rulemaking process. That is why we transmitted those rules to 
OMB, and they need to go through the process. I do not want to 
set time expectations, but yes, we are moving in that direction 
to adhere to the judge's ruling on this.
    Senator Rounds. That is a very positive development. For 
those 370,000 individuals, this is great news. Any possibility 
of expediting that rulemaking process?
    Secretary Shulkin. We did. We got the rules over there very 
fast, and what happens now, we will certainly encourage the 
administration and be supportive of that.
    Senator Rounds. I cannot tell you how glad I am to hear 
that. I appreciate the fact that you have taken the time to get 
personally involved in this and to work through that issue. I 
think that is what veterans want to see coming from the VA, to 
be focused on what the veterans need, what the veterans care 
should be, and then when we make a promise, we honor that 
promise. I think that is what veterans are expecting from the 
VA, and I think this is a major first step in that. Thank you 
very, very much for your work on it, your attention to this, 
which I think will pay dividends for the entire organization 
for years to come, so thank you.
    Mr. Chairman, I would yield back time.
    Thank you, sir.
    Secretary Shulkin. Thank you.
    Senator Rounds. That is great news.
    Secretary Shulkin. Good.
    Senator Boozman [presiding]. Thank you, Senator.
    Senator Manchin.

     HON. JOE MANCHIN III, U.S. SENATOR FROM WEST VIRGINIA

    Senator Manchin. Thank you, Mr. Chairman.
    Secretary Shulkin, recently, you announced that you would 
be scrapping the current electronic health care record system 
(EMR) and adopting the same system that DOD uses from the 
Cerner Corporation based in St. Louis. While I am certainly in 
favor of making it easier on veterans transitioning from DOD to 
VA, my concern is that speed of this decision will have second- 
and third-order effects that could be detrimental. My questions 
to you are: are you concerned that there will be increased risk 
in having one company manage all these records? What if Cerner 
becomes the Health Net of electronic health records?
    Secretary Shulkin. Wow. Well, first of all, I think in 
making a decision of this magnitude, there are absolutely risks 
involved with it. I have to tell you, I thought the risks were 
greater to do nothing.
    Senator Manchin. OK.
    Secretary Shulkin. That considering the maintenance 
required on VistA, the expense that will be required, and our 
lack of ability to maintain qualified software developers 
within VA, the risk of doing nothing was worse.
    I think that DOD went through a strong due diligence 
process. I think that they selected a stable platform. We have 
benefited a lot from their due diligence and expertise, and 
that was one of the reasons why I went in that direction. There 
is always a risk, Senator, especially when you transfer 
systems, so----
    Senator Manchin. Here is another part.
    Secretary Shulkin. Yeah.
    Senator Manchin. I have got two more parts to this.
    Secretary Shulkin. Yeah.
    Senator Manchin. By waiving the bidding process, which you 
just spoke about, how are you guaranteeing Cerner is not taking 
the VA for what we would consider a little bit of a ride?
    Secretary Shulkin. Well, because all that I have done is 
start the process of negotiations. We have not committed to any 
funding. We have not committed to the contractual----
    Senator Manchin. How will you know if the price is 
competitive if you have nothing to compare it to?
    Secretary Shulkin. Well, we certainly know the price that 
DOD paid. We know the price that we are currently paying to 
maintain our systems, and we are going to be seeking the best 
way to do this for taxpayers.
    Now, most of the cost of a transfer of system is actually 
in internal change management, not in software licensing 
prices.
    Senator Manchin. I notice it is not in your budget right 
now.
    Secretary Shulkin. Right.
    Senator Manchin. I was going to ask, how are you going to 
absorb the cost?
    Secretary Shulkin. We are going to have to go to the 
appropriators and lay out a plan so that they could decide 
whether they believe this is also a good decision.
    Senator Manchin. Well, we know this hearing is about care 
in the community. While ensuring the records transfer between 
DOD and VA, it is important we must also ensure that records 
transfer and their operability between VA and non-VA providers 
is just as seamless. Will Cerner be undertaking that as well?
    Secretary Shulkin. Yes. What I said in the decision on the 
EMR is that while it is a decision to move forward with a 
common platform with DOD, this will not be the DOD system. VA's 
needs are much different in that we have to be interoperable 
with our community partners, and many, many--in fact, 80 
percent of our community partners are not necessarily on the 
Cerner platform. So, we are going to have to create a system 
that does several things that the DOD does not. We are not 
going to be scrapping VistA. We are going to have to connect 
into and maintain our 30-year database, and we are going to 
have to be interoperable with community partners.
    Senator Manchin. Very quickly, I have one more, and then I 
have a real quick question. There is no Assistant Secretary of 
IT, nor is there an Under Secretary for Health. So, how are you 
undertaking this without those positions filled?
    Secretary Shulkin. Well, fortunately, we have very 
competent acting people in those roles, but we look forward to 
getting those roles permanent.
    Senator Manchin. You feel like you have the personnel to do 
it?
    Secretary Shulkin. I feel like we are very lucky to have 
very competent acting people, but I need to have permanent 
people in those roles soon.
    Senator Manchin. My other question is concerning the opioid 
epidemic, which is the number 1 problem I have in my State----
    Secretary Shulkin. Yes.
    Senator Manchin [continuing]. Not just with the general 
population, but my veterans----
    Secretary Shulkin. Yeah.
    Senator Manchin [continuing]. With my veteran community. 
What I am concerned about, what the new non-VA care redesign 
looks like, I am looking for assurances that when we do new 
provider agreements on any contracts with non-VA care 
providers, we are going to be making sure that they understand 
that VA will not tolerate the over-prescription of opioids. 
More or less, we have a lot of pill mills; they get these 
people hooked, and they keep them hooked. How are you going to 
ensure or how--what is your oversight? Are you prepared for 
this?
    Secretary Shulkin. Well, I have to say I do not think we 
are doing a good enough job in this. I think the country needs 
to do a lot better.
    Senator Manchin. We have challenges within the VA ourself.
    Secretary Shulkin. Yes.
    Senator Manchin. We know that, and you all have been 
addressing that----
    Secretary Shulkin. Right, right.
    Senator Manchin [continuing]. And I appreciate it. A lot 
more needs to be done. You have very little control when you go 
out into the private sector.
    Secretary Shulkin. I think we have really made good 
progress in the VA on the oversight. We have seen the 33 
percent reduction in opioid use since 2010. We monitor patterns 
of prescribing. I have the concern about going out into the 
community that you have.
    Senator Manchin. What I am saying is the contracts that you 
write, if I am a provider----
    Secretary Shulkin. Yeah.
    Senator Manchin [continuing]. If I am a non-VA provider, 
where the new act lets that person come to me, I contract with 
the VA to take care of these people.
    Secretary Shulkin. Mm-hmm.
    Senator Manchin. Are there conditions on that if I 
prescribe? Do I have to follow prescription guidelines? Are you 
going to be monitoring that as far as opioid prescription 
guidelines?
    Secretary Shulkin. Today, there are not those requirements. 
I think this is a really good area for us to come back to you 
with some thoughts on.
    Senator Manchin. Sir, we need your help on this----
    Secretary Shulkin. I know. Yep.
    Senator Manchin [continuing]. Because you are on the front 
lines.
    Secretary Shulkin. Thank you.
    Senator Manchin. Thank you.
    Thank you, Mr. Chairman.
    Chairman Isakson [presiding]. Thank you, Senator Manchin.
    Senator Heller.

           HON. DEAN HELLER, U.S. SENATOR FROM NEVADA

    Senator Heller. Mr. Chairman, thank you.
    Mr. Secretary, thanks for being here.
    Secretary Shulkin. Thank you. Sure.
    Senator Heller. Glad to have you here.
    I want to talk about the budget for just a minute, if I 
may; specifically, I want to talk about the individual 
unemployability (IU) cuts.
    Secretary Shulkin. Yeah.
    Senator Heller. Can you explain the rationale of the 
thought process that reduced this?
    Secretary Shulkin. Yes, Senator Heller, my starting point 
on this is that we always have to do better for our veterans, 
and we have to deliver on our commitments that we have to our 
veterans. The President's budget includes significant increases 
in both discretionary and mandatory funds and makes Choice a 
permanent part of funding.
    But, we have a responsibility to use our current funds in a 
way that makes the best sense for veterans and for taxpayers. 
So, we proposed a part of the process that would revise the 
individual unemployability benefit.
    The budget is a process, and this was part of a menu of 
opportunities that we had for thinking how we could make the 
budget process better. As I began to listen to veterans and 
their concerns--VSOs in particular--it became clearer that this 
would be hurting some veterans and that this would be a 
takeaway from veterans who cannot afford to have those benefits 
taken away. I am really concerned about that.
    So, what I would like to say is that this is part of a 
process. We have to be looking at ways to do things better, but 
I am not going to support policies that hurt veterans. I would 
look forward to working you and all the Members of the 
Committee on figuring out how we can do this better. We have 
budget numbers and targets that we have to hit, but we should 
not be doing things that are going to be hurting veterans that 
cannot afford to lose these benefits.
    Senator Heller. I appreciate hearing that. Do you know how 
many veterans would have been affected by this change?
    Secretary Shulkin. Yes. We have 300,000, Jamie?
    Mr. Manker. Yes. There are 300,000 that are in receipt of 
IU, about 330,000. About 210,000 of those are over the age of 
60 and, therefore, would have been affected.
    Senator Heller. Would have been.
    Secretary Shulkin. Yeah.
    Mr. Manker. Correct.
    Senator Heller. It would not have been--it would have been 
retroactive?
    Mr. Manker. It would have been point forward, but to 
include all veterans in receipt of IU. So, when you say 
retroactive, I do not believe we would pull any benefits that 
we have distributed back. However----
    Senator Heller. Right. No, no. I am just saying that if you 
had the benefit, you could lose the benefits----
    Secretary Shulkin. Yes. Yes.
    Mr. Manker. Yes, sir. That is correct.
    Senator Heller [continuing]. Even if you are currently 
receiving it?
    Mr. Manker. That is correct.
    Secretary Shulkin. Yes. That was the proposal, and--but we 
do look forward to working with you to figure out how we could 
do this better.
    Senator Heller. I appreciate your concern for that.
    Do you know what the average is per veteran on this IU, 
what the average intake is?
    Mr. Manker. The average payment?
    Senator Heller. Yeah.
    Mr. Manker. It is roughly $1,600.
    Senator Heller. Roughly $1,600.
    Mr. Manker. Yes, sir. That is on top of--you have to be 
rated between 60 percent to 100 percent, and it takes you to a 
temporary 100 percent. Sixteen percent is--or beg your pardon--
60 percent is roughly $1,600.
    Senator Heller. All right.
    Mr. Manker. It is about 13 or more.
    Senator Heller. You can understand the financial burden 
that $1,600 may pose for an individual, and what I am more 
concerned about is, of course, their long-term retirement. They 
may have not prepared or been prepared if in believing that 
that $1,600 might be there is I think the concern.
    Secretary Shulkin. I think that is the issue, and this is 
why we had identified this as an opportunity. I think if we 
were designing this system from the beginning, we would not 
have used unemployment insurance to fund people's retirement. I 
think that was the conflict.
    The end result is that is the benefit, and to withdraw this 
benefit from people who rely on that money is something that 
would be very difficult to do.
    Senator Heller. Well, I appreciate your concern for this.
    Can I change topics for just minute----
    Secretary Shulkin. Mm-hmm.
    Senator Heller [continuing]. And make sure I understood 
this correctly? Did you say that you had a decision-ready claim 
in 3 days?
    Secretary Shulkin. We have had 12 of them so far, I think. 
Yes.
    Senator Heller. Twelve of them.
    Secretary Shulkin. Yes. So, on September 1 we are going to 
be rolling that out across the country.
    Senator Heller. I mean, that is big news.
    Secretary Shulkin. That is big news.
    Senator Heller. I am glad because I have been working with 
this issue for years; and to think that you could actually turn 
one around in 3 days is pretty incredible.
    Mr. Manker. That is a big deal. We are piloting in St. Paul 
right now, again, with a couple of our VSOs. If the VSO brings 
in the claim ready to be decided, we know----
    Senator Heller. Right. It has got to be ready. I get it.
    Mr. Manker. No further development and we decide the claim.
    Senator Heller. We had a previous Secretary who said that 
he could get the claims down to zero by--I think it was 2015. 
What is the status now? If this works as well as----
    Secretary Shulkin. I can tell you I will not say that. 
[Laughter.]
    No. I mean, so----
    Senator Heller. No predictions. No predictions----
    Secretary Shulkin. Yeah.
    Senator Heller [continuing]. On where the claims will be.
    Secretary Shulkin. No. We right now--we are at about 
90,000?
    Mr. Manker. As of this morning, it was 94,000 that we had.
    Senator Heller. Yeah. That is about what my notes say, too.
    Secretary Shulkin. Yeah.
    Senator Heller. There are about 1,200 of them in Nevada.
    Secretary Shulkin. Yeah, yeah. I think our goal, Jamie, is 
by the end of the calendar year to about 70,000?
    Mr. Manker. That is right. That is right.
    Secretary Shulkin. These decision-ready claims, we think 
will take 10 to 15 percent of them off. So, we will not start 
rolling them out till September, but that will begin to whittle 
that down. We hope in 2 years to be down below around half of 
where we are now.
    Senator Heller. OK, OK.
    Mr. Secretary, thank you, and, Mr. Chairman, thank you for 
the time.
    Chairman Isakson. Thank you, Senator Heller.
    Senator Murray.

        HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON

    Senator Murray. Thank you, Mr. Chairman, and thank you all 
for being here.
    Secretary Shulkin, in last year's budget request, the VA 
estimated that it would need $725 million in fiscal year 2017 
and $840 million in 2018 for the Veteran Caregiver Program, yet 
in the first budget of the Trump administration, you plan to 
only use $521 million in 2017 and $604 million in 2018. Those 
are cuts of about 30 percent. Meanwhile, I am hearing from so 
many of my constituents, as I am sure everybody is, of 
caregivers being dropped from the program with no explanation 
and no justification. An investigation by NPR found the 
Charleston Medical Center actually dropped 94 percent of its 
caregivers; 83 percent in Prescott, AZ; and 83 percent in 
Augusta, GA.
    It seems to me, watching this, that this is just another 
way the Administration is balancing its budget on the backs of 
veterans in need. How do you explain those numbers?
    Secretary Shulkin. Well, let us just talk about the three 
things quickly that you said. What was reported on in 
Charleston is completely unacceptable; 95 percent of revocation 
of caregiver benefits, unacceptable. That is why we suspended 
the program, and today, there are no revocations across the 
country going on until we get the guidelines better understood 
and in better shape.
    Senator Murray. That is the freeze that you are talking 
about?
    Secretary Shulkin. That is the--right, right. That is the 
freeze.
    Senator Murray. That is only a temporary measure----
    Secretary Shulkin. It is a temporary measure----
    Senator Murray [continuing]. And I think you did the right 
thing.
    Secretary Shulkin [continuing]. Until we revise policy, 
because I will not accept giving benefits and then taking 94 
percent of them away. That is ridiculous.
    The second thing is, is that on the right amount of money 
to request? We only spent--even though $750 million was in the 
budget, we only spent $521 million. So, in budget planning for 
next year, they requested $600 million, which is a modest 
increase from where we are.
    Our hope, as you know--and you have been a tireless 
advocate for this--is to expand caregiver benefits, and we do 
plan on working with you with that. We hope by expanding 
caregiver benefits, particularly to older veterans, who today 
are not getting the benefit the way that they should, that we 
actually find that that is going to be cost effective, because 
remember we pay for long-term care.
    Senator Murray. Right.
    Secretary Shulkin. My plan is to be responsible to 
taxpayers. I am going to seek to expand caregiver benefits to 
older veterans, but I am going to pay for it myself without 
asking the taxpayers to increase the bill.
    Senator Murray. OK. Well, the Ranking Member and I wrote to 
you a couple months ago suggesting a series of important 
reforms. Those issues have not been addressed, and I would just 
like to see the freeze extended until all of those issues in 
that letter were discussed. Can you do that?
    Secretary Shulkin. Yeah. Do you happen to have the date of 
the letter? If not, I will find it.
    Senator Murray. It was about 2 months ago.
    Secretary Shulkin. Two months ago. Of course, absolutely.
    Senator Murray. OK. Let me go to the shortfall in the 
Choice Program. I know that you wrote to TriWest and Health Net 
telling them to return referrals for care, including for 
veterans that are currently waiting for care. How many veterans 
are going to be affected by that?
    Secretary Shulkin. We ask--when they cannot appoint an 
appointment within a period of time in the contract, we ask 
them to return it. They are returning large numbers to us.
    Do you know, Mark?
    Mr. Yow. I do not. I am sorry.
    Secretary Shulkin. This is an ongoing process. Before, they 
would just wait until--it took weeks and weeks to give an 
appointment. We have said, ``If you cannot give an appointment 
within 5 business days for a routine appointment, return them 
to the VA so we can take care of the veteran.'' It is a big 
percent that we get back.
    Senator Murray. It is a big percent?
    Secretary Shulkin. Yeah.
    Senator Murray. Do you know how long care is going to be 
delayed for veterans as a result of that?
    Secretary Shulkin. Well, this is actually speeding up care. 
Rather than letting a veteran stay out there in the Choice 
Program, schedulers return them to the VA, and then the VA 
Community Care Program goes out and tries to find an 
appointment.
    Senator Murray. OK. Well, I am very concerned about where 
the money is going to come from, from this----
    Secretary Shulkin. Yeah.
    Senator Murray [continuing]. And how you are going to get 
the money to continue non-VA care. It seems to be two different 
stories here. Transfer authority is what I am hearing from this 
year? Correct? Well, if you transfer money from this year, then 
what you are doing is impacting what you thought----
    Secretary Shulkin. Yes.
    Senator Murray [continuing]. Was going to be a carryover 
for next year. So, will you not need additional money for next 
year?
    Secretary Shulkin. Yeah. Look, the problem of having these 
two separate checking accounts and predicting where you need 
the money is, frankly, impossible. That is why we want to work 
to get the program into a single Community Care account.
    We are going to--these guys are going to help make the best 
predictions possible. Mr. Yow is going to help us understand 
the right amount of money to transfer over to predict it, but--
--
    Senator Murray. But, it will impact 2018, so we need real 
numbers here. We cannot do our job if we do not know what the 
costs are.
    You know, I am already hearing from veterans in my State 
about the delays and burdens they are seeing as a result of 
this. I had veterans in Walla Walla who are being told they 
will have to drive 8 hours round-trip to Portland or Seattle 
just for some simple imaging tests as a result of this. I am 
hearing a lot more. We are happy to get those to you, but this 
is having an impact. I want you to know that and we want to 
know where this money is coming from. So, we will follow up 
with you on that, but I think this Committee needs to be aware 
of that.
    Secretary Shulkin. OK.
    Senator Murray. OK. I am running out of time--or I am way 
over time. I have other questions, Mr. Chairman, which I will 
submit for the record. But, I am deeply concerned about that.
    Secretary Shulkin. Yes.
    Chairman Isakson. Listening to all these questions about 
checking accounts and authorities reminds me of the question I 
was asked yesterday on my 49th wedding anniversary. Somebody 
asked my wife and I to what we would attribute 49 years 
together. I said we never had a joint checking account where 
both of us had to sign, so we never had those arguments. Let us 
not ever get in that situation with the VA either.
    Secretary Shulkin. OK.
    Chairman Isakson. Senator Boozman.

         HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Senator Isakson and Senator 
Tester.
    Thank you for being here, and we appreciate our veterans' 
advocates who are going to testify shortly for being here also.
    Senator Sanders talked to you about the problem with the 
fact of providers, and so many people are at the age now where 
a big group of baby boomers that are aging out, they practice 
because they like, and medicine has gotten more complicated and 
stuff. I think we are going to see a bunch of those actually 
decide to do something else or not do anything.
    The idea of increasing--well, first of all, I agree that 
the fact that we can reward people for going in is a great 
idea, and I think it actually would work. I think we have good 
evidence of that.
    The problem is actually creating new slots versus taking 
slots away for veterans. If you could work with some of your 
counterparts--and the VA is a huge entity.
    Secretary Shulkin. Mm-hmm.
    Senator Boozman. This is a huge problem for the country, 
besides the VA, but if you could craft a situation where you 
could actually increase the medical school classes and then 
also the residencies, which are a huge problem too, that would 
be a great deal.
    Secretary Shulkin. Yes.
    Senator Boozman [continuing]. With your relationship with 
the teaching hospitals----
    Secretary Shulkin. Right.
    Senator Boozman [continuing]. I think that could be done. 
It is going to take some work, but that truly could be a great 
legacy.
    Secretary Shulkin. Right. We are focused on the residency 
spots. The medical schools have actually increased the number 
of medical school spots because they have tuition that pays for 
it, so it is to their benefit.
    The residency spots, as you know, are capped by Medicare.
    Senator Boozman. Right.
    Secretary Shulkin. What you did in the Choice Program that 
Senator Sanders help lead was expand those graduate medical 
education spots. That is what we need desperately.
    Senator Boozman. Yeah, very much so.
    Secretary Shulkin. Yeah.
    Senator Boozman. And, again, we need to do that----
    Secretary Shulkin. Yes.
    Senator Boozman [continuing]. With whatever it takes in the 
future or we are going to get ourselves in trouble.
    $8.4 billion in mental health, 6 percent increase. That is 
great. Mental health has improved so much in the VA in the last 
years. We are not at the point where we are just writing 
prescriptions like so many providers, not just in the VA, but 
throughout the country giving a prescription. That simply does 
not work.
    On the other hand, we need to go farther. How are we going 
to prioritize that 6 percent as far as increasing our ability 
to provide good care?
    Secretary Shulkin. Well, we have targeted to hire a 
thousand mental health professionals. This year to date we are 
seeing 58,000 more mental health appointments than we did last 
year at this time.
    We are expanding our tele-mental health programs. We have 
just, as you know, this past year given full practice authority 
to our advanced practice nurses. Many of them will be putting 
their skills to work in behavioral health and expanding the 
training. As Senator Sanders said, psychiatry and psychology 
and nursing, all are areas of shortages that we can use more 
help in, not only in the VA, but the entire country, quite 
frankly.
    We need to do a lot more. I think you are right. We have 
prioritized mental health, but it is an area that needs a lot 
more help.
    Senator Boozman. You talked about the core mission of the 
VA, the foundational services that make the VA unique. Can you 
walk us through those or what you feel those are?
    Secretary Shulkin. Yes. These are the services that make me 
so strongly believe that a strong VA is essential for veterans 
and for the country, because I believe that without the types 
of services that the VA provides, you cannot find those in the 
private sector. If we just turned our veterans over to the 
private sector, they would really be lost.
    These are services that veterans have a high predilection 
for: post-traumatic stress, behavioral health issues, spinal 
cord injury, prostheses or orthotics, polytrauma. Comprehensive 
primary care and behavioral health care services are clearly 
foundational as well. Environmental exposures, blind rehab--I 
do not want to leave out a group because I know I will offend 
them, but these are things that the VA does extraordinarily 
well that you would not find easily, except in very specialized 
geographies where there are centers of excellence. So, it is 
important that we keep those strong.
    Senator Boozman. In your testimony also, you talked about 
Community Care and how doctors will make decisions on providing 
care in VA facilities versus in the community due to clinical 
need and what is best for the veteran. How do we--how do you do 
this? How do you make sure that with--we have an institution, 
somewhat of--well, we have a bureaucracy. How do you make sure 
that those decisions are based on what is best for the veterans 
as opposed to what is best for the facility?
    Secretary Shulkin. Well, I think--I wish that there was an 
easy answer to that.
    What we have to do as an organization is get out of the way 
of the doctor and the provider making those decisions together, 
so we need to get rid of the administrative rules and the third 
parties in between. That is what we saw in the Choice Program. 
We were having veterans call Call Centers of people who did not 
know them, and that was frustrating the veteran. What we have 
learned is to de-layer the process, get it back into the exam 
room or now, in more modern terms, you know, the tele-monitors. 
Let the doctor, the patient, the provider of the patient make 
the decisions together in a partnership about what is best for 
them. That is the system we are trying to design now.
    Senator Boozman. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Boozman.
    Senator Tillis.

       HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA

    Senator Tillis. Thank you, Mr. Chair. Mr. Chair, I am going 
to be married 30 years, 2 weeks from today. We have a slightly 
different approach to longevity. We do have a joint account; I 
just do not have access to it. [Laughter.]
    Chairman Isakson. That works also.
    Senator Tillis. I am not even allowed to go out of network 
to get an ATM withdrawal.
    Thank you all for being here. I am actually running between 
committees. We have an Acting Committee going on right now, and 
we are talking about supporting caregivers, the Hidden Heroes 
Project that Senator Dole is heading up, and it is critically 
important. I will not spend time talking about it here, but one 
thing that was striking in Senator Dole's opening testimony was 
the fact that there is about $14 billion a year in caregiving 
being donated by these husbands and wives and sons and 
daughters that we need to find a way to provide support over 
time.
    I understand that in order for us to do that, we have to 
talk about the resources and make sure that we are not shifting 
our attention away from so many other pressing things, but it 
is something I look forward to talking about in a future 
hearing.
    Dr. Shulkin, I want to know how we are doing. Some of the 
estimating, I have got to believe some of the uncertainty with 
respect to accounts, and how much we need in one or the other--
one thing----
    Secretary Shulkin. Yeah.
    Senator Tillis [continuing]. It is a fluid situation based 
on factors that are different across the country. Another one 
may have to do with having the right resources in place so that 
you can actually get to that information pretty quickly. How 
are we doing on getting your--I understand the CIO nominee, I 
think, has withdrawn their name from consideration. How are we 
doing on trying to get that administration stacked up so that 
you have got a good organization, permanent organization under 
you?
    Secretary Shulkin. Well, not only the CIO, but the CFO 
candidate. If we are attracting a good viewing audience, we 
need help. We need people to want to come and help serve.
    Senator Tillis. A permanent CFO is going to be pretty 
important to get in some of your financial----
    Secretary Shulkin. It really will.
    Senator Tillis [continuing]. Financial planning in order 
and getting your financial processes and planning processes in 
order, so----
    Secretary Shulkin. Yes.
    Senator Tillis. I think you have touched on something 
important. Hopefully, somebody can step forward.
    Secretary Shulkin. Yes.
    Senator Tillis. I know it is a sacrifice and you need 
somebody that is highly skilled, but we have got to get those 
positions filled. I, for one, think it will be one of the ways 
we can get back on track for the transformation effort.
    I am not going to spend much more time because I am going 
to get back to the other Committee, but I am going to echo 
again what I said in the last Committee. I am sure that there 
are various factors that led to the shortfall in one account 
versus another.
    Secretary Shulkin. Yes.
    Senator Tillis. There are probably other things that we 
need to do to make sure that we are facilitating the process 
and not giving you additional distractions or uncertainty as 
you go through the financial planning. Please speak candidly to 
the Committee Members----
    Secretary Shulkin. Thank you.
    Senator Tillis [continuing]. And make sure when there are 
things that we can do or should not do that are getting in the 
way of you giving us definitive answers, so we can count on it 
also.
    Secretary Shulkin. Yeah.
    Senator Tillis. I also want to reiterate what--Senator 
Murray made several very good points. I agree with all of them. 
I think that she is absolutely right. The sooner you articulate 
what your funding levels are, the better, so that we can go and 
be advocates for it.
    Secretary Shulkin. Yeah. Thank you.
    Senator Tillis. Thank you, Mr. Chair.
    Chairman Isakson. Thank you, Senator Tillis.
    Senator Boozman--Senator Blumenthal. I am sorry.

                   HON. RICHARD BLUMENTHAL, 
                 U.S. SENATOR FROM CONNECTICUT

    Senator Blumenthal. Thank you, Chairman.
    First of all, I want to express my appreciation on the 
Richard Staab v. McDonald case.
    Secretary Shulkin. Thank you.
    Senator Blumenthal. I join my colleague, Senator Rounds, 
in----
    Secretary Shulkin. Yes.
    Senator Blumenthal [continuing]. Expressing my appreciation 
for your decision to withdraw the appeal and also join with him 
in asking for a quick rulemaking, which I know you will do.
    On the VA's Vocational Rehabilitation and Employment 
Program, as you know, it provides career counseling and 
rehabilitative services to veterans with service-connected 
disabilities to overcome employment barriers. It also assists 
with postsecondary training at educational institutions.
    I have been told by Connecticut University that there are 
delays in vocational rehab housing and education payments for 
service-disabled veterans. The VA has previously attributed 
those delays to lack of vocational rehabilitation counselors at 
the Hartford Regional Benefit Office and nationwide staffing 
shortages. The VA's purported goal ratio of vocational rehab 
counselor to client is one counselor per 125 veterans, but the 
average ratio in July 2015, I am told was one counselor to 
every 139 veterans, despite the payment delays and the VA's 
inability to meet the ratio.
    The fiscal year 2018 budget makes cuts to this program; 
Vocational Rehabilitation is $13.8 million. You are probably 
more familiar with these numbers than I am, so I apologize for 
telling you something you already know. This decrease in 
requested funding seems unacceptable, particularly for those of 
us in Connecticut who see the results already of underfunding. 
I would like to know whether you plan to address the delays and 
your view of the apparent underfunding of this very valuable 
program.
    Secretary Shulkin. Senator, first of all, thank you for 
your outspoken leadership on the Staab case.
    On terms of Vocational Rehab and Education, we may have 
different numbers, so I would like to go over it with you. We 
see a $1.5 million increase in the President's budget for these 
programs, but there are some staffing issues and delays in the 
Hartford region that we do want to get improved and we do want 
to fix. We think this is an important program. We believe in 
it, and we believe the President's budget adequately funds it.
    But if you have different numbers and we are wrong, we will 
want to address that.
    Senator Blumenthal. Well, I would like my staff perhaps----
    Secretary Shulkin. Yes.
    Senator Blumenthal [continuing]. To get together with you 
all, but I think the overriding issue here is not necessarily 
even the numbers, because even if there is a slight increase, 
this is----
    Secretary Shulkin. Small.
    Senator Blumenthal. This program is so valuable, it ought 
to be a major increase and certainly not a reduction.
    Secretary Shulkin. Right.
    Senator Blumenthal. Again, this is not a criticism of the 
VA. In fact, on the contrary, it is saying you are doing great 
work. We do not want to see it diminished. We see these delays 
in Hartford and we would like your help in solving them.
    Secretary Shulkin. Yes. OK. We will follow up with you.
    Senator Blumenthal. I thank you.
    Secretary Shulkin. Yes.
    Senator Blumenthal. I do not know whether it has been 
asked, but I wonder if I could ask you again about the Veterans 
Benefit Administration, whether you see real progress in 
reducing the claims backlog. I am guessing someone has asked 
about it already, and I apologize for bringing it----
    Secretary Shulkin. No. No, that is not a problem.
    Senator Blumenthal. What is your prognosis?
    Secretary Shulkin. Well, I will briefly just tell you we 
are at 94,000 now. We hope by the end of the year to be at 
approximately 70,000, and then a year following that or 2 years 
from now below about half the level, so 45,000.
    We just announced that we have done 12 claims so far in 3 
days, called ``decision-ready claims.'' We are going to roll 
that process out nationally September 1. That will impact 
around 10 to 15 percent of our claims because they have to have 
all the information ready, they are presented, and we give a 
decision in 3 days. So, I think that we are making some 
progress.
    We are trying to actually look at some breakthrough ways to 
do better, but as of today, I have given you the most accurate 
information we have.
    Senator Blumenthal. The progress that you are making is the 
result of a different--reforms in the process----
    Secretary Shulkin. Yeah.
    Senator Blumenthal [continuing]. Or is it more resources or 
a combination?
    Secretary Shulkin. The budget--the budget stays flat for 
next year, so it is not in VBA. It is not necessarily more 
resources, although they have added in the past couple of 
years.
    I would say the major changes are process improvements. 
There is something called the National Work Queue, which is 
really allowing productivity adjustments. Therefore, you can 
distribute the workload across the country evenly. They have 
just enhanced and increased their productivity standards for 
the people who work in VBA, and they are doing a terrific job. 
We have a great staff who work in VBA, who are up to the 
challenge, and we are seeing improvements. It is mostly process 
improvement, but over the past couple of years, they had added 
to their staff.
    Senator Blumenthal. Well, I want to thank you for your 
focus. As you know, this is a problem that has continued to----
    Secretary Shulkin. Mm-hmm.
    Senator Blumenthal [continuing]. Bedevil us over many 
years, so I am glad that you are making those process changes. 
And there may be some breakthrough----
    Secretary Shulkin. Yes.
    Senator Blumenthal [continuing]. Changes in the foreseeable 
future?
    Secretary Shulkin. Yes, yes.
    Senator Blumenthal. Thank you.
    Secretary Shulkin. Thank you.
    Senator Blumenthal. Thank you, Mr. Chair.
    Chairman Isakson. Thank you, Mr. Blumenthal.
    I have been asked by Senator Sanders and Senator Tester to 
be able to make brief statements, so I am going to waive any 
time I might have and recognize Senator Tester and then Senator 
Sanders for their statement and/or question.
    Senator Tester. Thank you, Mr. Chairman.
    I have beaten this horse in the past. We have to beat it 
one more time. OK?
    Secretary Shulkin. Sure.
    Senator Tester. The VSOs we are going to hear from next 
want to have the VA as a primary care provider. I have heard it 
over and over again. Senator Sanders talked about it. Others 
have talked about it in this Committee.
    I have been in public life long enough to know that if you 
want to know where things are headed, you follow the money.
    Secretary Shulkin. Mm-hmm.
    Senator Tester. The fact that we have 1.2 percent increase 
for in-house medical care and 33 percent for outside medical 
care is disturbing.
    Moving forward, because you have said over and over again 
to me, ``Do not worry about this, Jon. It is going to be fine. 
We are going to make the VA the best it can be, and the VA is 
going to fill in the gaps,'' we just need to drive that point 
home because we are going to hear from a panel of VSO 
representatives. I have got a notion that they are going to 
talk about VA care, and they are going to be reasonably 
complimentary and talk about other ways we can fix it.
    Number 2, this is an authorization committee. Concerning 
electronical-IT funding, you have got $200 million in this 
budget. You should be asking this Committee to plus that budget 
up. You need to do it so it represents the money that you are 
going to be dumping out to Cerner for the DOD electronic 
platform that we all support you doing, by the way.
    Secretary Shulkin. Mm-hmm.
    Senator Tester. I think it is really important that we are 
honest with ourselves, and I will tell you why. I happen to be 
on both Committees, and I do not want to get nailed and say, 
``You know what? The Authorization Committee did not do that, 
and these spendthrift appropriators are just dumping money 
in.'' I would just say we need to have a budget that accurately 
reflects what we need to do. In this case, we know this IT 
thing is going to cost some dough.
    Secretary Shulkin. Mm-hmm.
    Senator Tester. So, we need to act accordingly.
    The last thing is we are going to have Carl Blake from 
Paralyzed Veterans of American (PVA), LeRoy Acosta from 
Disabled American Veterans (DAV), Carlos Fuentes from Veterans 
of Foreign Wars (VFW), and John Rowen from Vietnam Veterans of 
America (VVA), up here in a second. I just want to thank those 
guys for their service. We had said earlier that we need to 
take our direction from the VSOs. I am not going to be able to 
be here, although I am going to try to get back before the end, 
and we do need to take the direction from the veterans. I think 
it is critically important, so thank you all.
    Secretary Shulkin. Senator Tester, thank you, and, you 
know, the one thing is we are always clear on where you stand 
and appreciate that.
    I do want to try to work with you and your staff because we 
have different numbers than you have in terms of the Community 
Care and internal care. You know, we have an interest in making 
sure the VA is the best system.
    The ability to transfer more--right now, we are limited at 
1 percent--would help us a great deal, and that is something we 
will continue to work with you on.
    Senator Tester. I would just say, we are going to work with 
you on that, too. Johnny and I both agreed to that.
    I think that, as I said to you at the breakfast yesterday, 
you can outsource care, but you cannot outsource 
responsibility.
    Secretary Shulkin. No, that is right.
    Chairman Isakson. Senator Sanders.
    Senator Sanders. Thanks very much.
    I want to touch on briefly what is a terrible, terrible 
national crisis, and that is the opioid epidemic. I think in 
the past, the DOD and the VA were criticized for an 
overdependence on opioids.
    Secretary Shulkin. Sure.
    Senator Sanders. I know that there has been some 
significant changes. I have been pleased to go to VA hospitals 
around the country and see very robust programs regarding 
alternative complementary medicine--yoga, nutrition, and so 
forth and so on.
    Secretary Shulkin. Yes.
    Senator Sanders. Can you say a word about how the VA can 
lead this country away from opioids, although obviously 
sometimes they are necessary, into less type of dependent drug 
approaches?
    Secretary Shulkin. Yeah. I will try to do it briefly, but I 
will tell you I published an article on this 4 or 5 months ago 
in the Journal of the American Medical Association about the 
VA's approach, because I think it is a national example that 
others can learn from.
    We started this work in 2010, where we identified problems 
before the rest of America did, as the VA often does, and we 
did this through a multifactorial approach. We essentially now 
monitor the patterns of all of our providers, and we give them 
feedback on how they perform compared to their peers.
    Senator Sanders. If they are overprescribing.
    Secretary Shulkin. If they are overprescribing.
    We do academic detailing, where pharmacists go out and 
actually teach our providers the ways to use opioids 
appropriately.
    We have our patients sign informed consent, so that they 
are part of the process when they get an opioid.
    We participate in the State prescription data monitoring 
programs. It is mandatory that our providers do that.
    We are providing alternatives such as you said, 
complementary care. In fact, the best practice for us in the 
country--I do not know if you know this--is actually White 
River Junction, where we have a 50 percent reduction in opioid 
use, using those exact techniques, complementary medicine.
    Senator Sanders. Acupuncture.
    Secretary Shulkin. Acupuncture, yoga, mindfulness, 
biofeedback. I mean, you know, mind-body type of techniques, 
and so we are trying to get others to be as good as we are 
doing in White River Junction.
    We are working in a number of these areas, and of course, 
we are trying to work on research with the FDA and NIH on non-
addictive narcotics as well, because we think that is 
important.
    Senator Sanders. Good. Thank you very much.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Sanders.
    Thanks to all of you. It has been very helpful and 
informative.
    I would ask you to be excused, and our second panel may 
come forward.
    Secretary Shulkin. Thank you.
    [Pause.]
    Chairman Isakson. Let me thank Secretary Shulkin and his 
staff for their testimony and their support and the continued 
response to Committee. We are very grateful for that.
    Let me welcome our second panel, and I will begin with the 
introductions: Mr. Carl Blake, Associate Executive Director, 
Government Relations, Paralyzed Veterans of America; Mr. LeRoy 
Acosta, Assistant National Service Director, Disabled American 
Veterans; Mr. Carlos Fuentes, Director, National Legislative 
Service, Vietnam--Veterans of Foreign Wars; Mr. John Rowan, 
National President, Vietnam Veterans of America.
    Mr. Blake.
    You are each recognized for 5 minutes.

    STATEMENT OF CARL BLAKE, ASSOCIATE EXECUTIVE DIRECTOR, 
      GOVERNMENT RELATIONS, PARALYZED VETERANS OF AMERICA

    Mr. Blake. Mr. Chairman, thank you for the opportunity to 
testify today. With your approval and the Committee's approval, 
we would like to submit our fiscal year 2018 Independent Budget 
Report into the official hearing record.
    Chairman Isakson. Without objection.

    [The report can be found online at: http://
www.independentbudget.org/2018/FY18_IB_BudgetBook_6.6.17.pdf]

    Mr. Blake. Thank you.
    I think I would like to spend my time talking a little bit 
about what we have heard today rather than just specifically 
the recommendations that are included in our budget report.
    Let us recap. I appreciate Senator Heller bringing up the 
question about IU. Although I would say it is not readily 
apparent, the VA has said for sure that it is going to drop 
that proposal altogether, it sounds like the Secretary is 
willing to discuss it further and see where this goes from 
here.
    I appreciate Senator Manchin and also Senator Tester for 
bringing up the question about the electronic health record 
(EHR) modernization and Cerner.
    Senator Rounds continues to beat the drum about the Staab 
ruling.
    Senator Moran really started to probe at the question about 
holes that seemed to be appearing in the VA's budget.
    I appreciate that the Secretary has made the commitment he 
has as it relates to the EHR modernization, doing the right 
thing on the Staab ruling, and trying to address issues like 
the caregiver expansion. It is not an easy job. I do not envy 
the position he is placed in.
    Let us forget for minute, let us just set aside the fact 
that it sounded like to me, we may be staring a budget 
shortfall right in the face just for this current fiscal year 
based on this transferability problem and moving money between 
Community Care and Choice. All those things historically have 
added up to a shortfall somewhere.
    Let us look at fiscal year 2018. I think that is a good way 
to sort of snapshot the bigger hole that VA has to deal with.
    Senator Heller mentioned IU. IU and its proposal was 
presumably going to fund a large majority of Choice going 
forward, in perpetuity as it were, at least $3.2 billion. If we 
assume that that is not going to happen, that is $3 billion in 
Community Care under Choice that has to be addressed somehow. 
It is not addressed in the discretionary part of the VA's 
budget.
    It is all well and good to say we have enough money; $3 
billion is a lot of money to say that we have enough.
    Senator Manchin and Senator Tester mentioned the Cerner 
decision. I think on policy, that is probably the right 
decision to make for VA and for DOD, but I read an article 
recently that said the Department of Defense's obligation under 
Cerner is something on the order of $9 billion, I think, in the 
life cycle of that program. It also said that VA's obligation 
will be at least three to four times that great. How does the 
VA's budget rationalize that point? I am sure it does not.
    Senator Rounds mentioned Staab. It is the right thing to 
do, what the Secretary said. I think he knows it, and he is 
acting upon that. I was actually sort of amused that he said 
they expedited the rulemaking process. I think he said it went 
to OMB. That is where the expedited process goes to die. He 
said last week it might take 9 months. OMB will be on the clock 
for the next 9 months, I am sure, knowing their track record.
    That aside, the Staab ruling has already left VA with an 
obligation in previous years of at least $2 billion. Where is 
that money which is going to pay for that issue?
    The average in subsequent years is a billion dollars, 1.1, 
1.08, something in that range. Where is that money? It is not 
in the VA budget either.
    Now we are keeping score. We have a $3.2 billion IU hole 
for Choice. We have an approximately $1 billion hole for Staab, 
and then we have the Cerner issue. We do not even know what 
that hole looks like.
    I could also make the argument that looking out into fiscal 
year 2019 that budget is certainly short because the Community 
Care account in that budget alone is less than the projection 
for 2018, and the Choice plan has it at exactly the same dollar 
figure, approximately $3.5 billion. Are we going to decrease 
Community Care usage in 2019? I think we all at this table know 
that is not going to happen.
    Right now, the VA could be staring at a huge hole in its 
budget for 2018, and we have expressed this to the 
appropriators. Unfortunately, because of the timing and 
everything, the appropriators have already moved forward on the 
House side. They are going to mark up their MILCON/VA bill 
tomorrow, and none of these questions are answered, yet the VA 
is left with billions of dollars in unanswered questions. It is 
not enough to simply say, ``We have enough money. We can move 
it around.'' That is not true. That is just simply not true.
    Mr. Chairman, I appreciate the opportunity to testify. I 
would be happy to answer any questions you may have.
    [The prepared statement of Mr. Blake follows:]
   Prepared Statement of Carl Blake, Associate Executive Director of 
          Government Relations, Paralyzed Veterans of America
    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee, As one of the co-authors of The Independent Budget (IB), 
along with DAV and Veterans of Foreign Wars, Paralyzed Veterans of 
America (PVA) is pleased to present our views regarding the funding 
requirements for the delivery of health care for the Department of 
Veterans Affairs (VA) for FY 2018 and advance appropriations for FY 
2019. On the following page, we have included a side-by-side comparison 
of funding recommendations previously appropriated for FY 2017 
recommended by the Administration by the IB for FY 2018, as well as the 
advance appropriations for FY 2019.

                           VA Accounts for FY 2018 and FY 2019 Advance Appropriations
----------------------------------------------------------------------------------------------------------------
                                                        FY 2018     FY 2018                 FY 2018   FY 2018 IB
                                          FY 2017       Advance      Admin    FY 2018 IB    Advance     Advance
                                       Appropriation    Approps     Revised                 Approps     Approps
----------------------------------------------------------------------------------------------------------------
Veterans Health Administration (VHA)
  Medical Services...................    45,505,812   44,886,554  45,918,362  64,493,555  49,161,165  69,450,838
  Medical Community Care.............     7,246,181    9,409,118   9,663,118               8,384,704
                                      --------------------------------------------------------------------------
    Subtotal Medical Services........    52,751,993   54,295,672  55,581,480  64,493,555  57,545,869  69,450,838
  Medical Support and Compliance.....     6,524,000    6,654,480   6,938,877   6,657,955   7,239,156   6,793,408
  Medical Facilities.................     5,321,668    5,434,880   6,514,675   5,796,343   5,914,288   6,562,579
                                      --------------------------------------------------------------------------
    Subtotal Medical Care,               64,597,661   66,385,032  69,035,032  76,947,853  70,699,313  82,806,825
     Discretionary...................
  Medical Care Collections...........     3,558,307    3,627,255   3,271,000               3,277,000
  Choice Program**...................     2,900,000                3,500,000               3,500,000
                                      --------------------------------------------------------------------------
    Total, Medical Care Budget           68,155,968   70,012,287  75,806,032  76,947,853  77,476,313  82,806,825
     Authority (including
     Collections)....................
                                      --------------------------------------------------------------------------
  Medical and Prosthetic Research....       675,366                  640,000     713,200
  Millions Veterans Program..........                                             65,000
                                      ----------------------------------------------------
    Total, Veterans Health               68,831,334   70,012,287  76,446,032  77,726,053
     Administration..................
 
General Operating Expenses (GOE)
  Veterans Benefits Administration...     2,856,160                2,844,000   3,134,540
  General Administration.............       345,391                  346,891     406,454
  Board of Veterans Appeals..........       156,096                  155,596     158,196
                                      ----------------------------------------------------
    Total, GOE.......................     3,357,647                3,346,487   3,699,190
 
Departmental Admin/Misc. Programs
  Information Technology.............     4,278,259                4,055,500   4,361,502
  National Cemetery Administration...       286,193                  306,193     291,085
  Office of Inspector General........       160,106                  159,606     162,545
                                      ----------------------------------------------------
    Total, Dept. Admin/Misc. Programs     4,724,558                4,521,299   4,815,132
 
Construction Programs
  Construction, Major................       528,110                  512,430   1,500,000
  Construction, Minor................       372,069                  342,570     700,000
  Grants for State Extended Care             90,000                   90,000     300,000
   Facilities........................
  Grants for State Vets Cemeteries...        45,000                   45,000      46,000
                                      ----------------------------------------------------
    Total, Construction Programs.....     1,035,179                  990,000   2,546,000
  Other Discretionary................       201,000                  180,214     203,000
                                      ----------------------------------------------------
    Total, Discretionary Budget          78,149,718               85,484,032  88,989,375
     Authority (including Medical
     Collections)....................
----------------------------------------------------------------------------------------------------------------
**Choice Program funding for FY 2018 includes the expected carryover of $600 million from the previous fiscal
  year as well as $2.9 billion in new funding for the program. All Choice program funding is currently scored as
  a mandatory cost for VA.


    The IB's recommendations include funding for all discretionary 
programs for FY 2018 as well as advance appropriations recommendations 
for medical care accounts for FY 2019. The full budget report, released 
by The Independent Budget in March, addressing all aspects of 
discretionary funding for the VA can be downloaded at 
www.independentbudget.org. The FY 2018 projections are particularly 
important because previous VA Secretary Robert McDonald admitted last 
year that the VA's FY 2018 advance appropriation request was not truly 
sufficient and would need significant additional resources provided 
this year. We hope that Congress will take this defined shortfall very 
seriously and appropriately address this need. Our own FY 2018 
estimates affirm this need.
    We appreciate the fact that the Administration's recently released 
budget request for FY 2018 includes some increases in discretionary 
dollars for the Medical Care accounts above what had been previously 
provided through advance appropriations. Before addressing our specific 
budget recommendations, it is important for us to address the notion 
that VA does not need any additional resources, based on the expansive 
growth of overall VA expenses in the last 10 years. These ideas are not 
grounded in thorough analysis of demand and utilization of VA health 
care. Perhaps Congress can explain how the VA can take on significantly 
more demand for services both inside VA and in the community, and yet 
meet that demand and utilization with less resources--an assertion 
peddled by some organizations. While VA has seen substantial growth in 
its funding needs over the last decade, much of that is reflected in 
mandatory benefits to include the implementation of the Post-9/11 GI 
Bill. The fact is demand for health care services and actual 
utilization continue to rise at a significant rate. It may be possible 
to wring some efficiency savings out of VA to free up additional 
resources to address growing demand, but history has proven that 
process will not be sufficient to provide all of the resources VA needs 
to deliver on its promise to the men and women seeking health care and 
benefits.
    We also believe it is necessary to consider the projected 
expenditures under the Choice program authority that the previous 
Administration planned in FY 2017 and how that impacts the baseline 
that will dictate the funding needs for FY 2018. The previous 
Administration assumed as much as $5.7 billion in spending through the 
Choice program in FY 2017, on top of the Medical Services discretionary 
funding and the newly created Medical Community Care account. That 
amount was revised to approximately $2.9 billion. This means that the 
VA projected to spend more than $59.0 billion in Medical Services and 
more than $71.0 billion in overall Medical Care funding in FY 2017. 
These considerations inform the decisions of The Independent Budget to 
establish our baseline for our funding recommendations for both FY 2018 
and FY 2019.
    Earlier this year, the Administration also indicated that it 
intends to request as much as $3.5 billion in additional funding for 
the Choice program to keep it operating at least through the end of FY 
2018. That amount has since been revised to $2.9 billion for FY 2018 
(actually $3.5 billion when considering the already available $600 
million left over from the original authorization), as well as $3.5 
billion for FY 2019 and beyond. However, this recommendation begs the 
question: does this recommendation suggest that the Choice program as 
currently designed should continue in perpetuity? Certainly no 
reasonable person supports that idea. We believe that Congress must 
reject continued funding of this program through a mandatory account 
and place it in line with all other community care funded through the 
discretionary Community Care account established previously. This will 
eliminate competing sources of funding for delivery of health care 
services in the community, while maintaining visibility on spending 
through the Choice program.
    Moreover, we strongly oppose the decision to curtail Individual 
Unemployability (IU) benefits for veterans with significant service-
connected disabilities simply as a means to fund the continuation of 
the Choice program. It is beyond comprehension that the Administration 
would propose such a benefit reduction in order to pay for a flawed 
funding mechanism for a program (Choice) that sometimes provides health 
care access to non-service-connected disabled veterans. Does this 
Committee really believe that veterans with disabilities rated between 
60 percent and 90 percent should be the source of funding for the 
Choice program? Eliminating IU benefits for veterans over the age of 62 
provokes numerous questions for us. Will veterans who have statutorily 
protected evaluations (the 20-year rule) also be subject to reduction? 
Will those dependents using Chapter 35 education benefits based on 
their sponsor's IU rating be forced to drop out of school? Will those 
veterans on IU who are covered by Service-Disabled Life Insurance at no 
premium be forced to now pay premiums in order to keep coverage? What 
about state benefits, such as property tax exemptions or state 
education benefits that are based on 100 percent VA disability ratings? 
How will this proposal affect efforts to combat veteran suicide and 
homelessness? We hope that you will reject this proposal in the 
strongest terms.
    For FY 2018, the IB recommends approximately $77.0 billion in total 
medical care funding. Congress previously approved only $70.0 billion 
in total medical care funding for FY 2018 (which includes an assumption 
of approximately $3.6 billion in medical care collections). The 
Administration's budget request includes a not-insignificant overall 
medical care funding recommendation of approximately $75.2 billion. 
However, we remain concerned that this level of funding will not keep 
pace with the continually increasing demand and utilization. The IB's 
recommendation also considers the approximately $1 billion VA is 
expected to have remaining in the Veterans Choice Fund and expected 
demand for care, including community care, that will not diminish or go 
away if the Choice Program expires. The Independent Budget recommends 
approximately $82.8 billion in advance appropriations for total Medical 
Care for FY 2019.
                            medical services
    For FY 2018, The Independent Budget recommends $64.5 billion for 
Medical Services. This recommendation includes:

 
------------------------------------------------------------------------
 
------------------------------------------------------------------------
Current Services Estimate.............................   $60,897,313,000
Increase in Patient Workload..........................     1,595,242,000
Additional Medical Care Program Cost..................     2,001,000,000
                                                       -----------------
    Total FY 2018 Medical Services....................   $64,493,555,000
------------------------------------------------------------------------


    The current services estimate reflects the impact of projected 
uncontrollable inflation on the cost to provide services to veterans 
currently using the system. This estimate also assumes a 1.5 percent 
increase for pay and benefits across the board for all VA employees in 
FY 2018. It was previously reported that the new Administration would 
like to consider a 1.9 percent Federal pay raise.
    Our estimate of growth in patient workload is based on a projected 
increase of approximately 90,000 new unique patients. These patients 
include priority group 1-8 veterans and covered non-veterans. We 
estimate the cost of these new unique patients to be approximately $1.4 
billion. The increase in patient workload also includes a projected 
increase of 58,000 new Operation Enduring Freedom and Operation Iraqi 
Freedom (OEF/OIF) enrollees, as well as Operation New Dawn (OND) 
veterans at a cost of approximately $242 million. The increase in 
utilization among OEF/OIF/OND veterans is supported by the average 
annual increase in new users through the third quarter of FY 2016.
    Additionally, The Independent Budget believes that there are 
medical program funding needs for VA that must be considered. Those 
costs total approximately $2.0 billion.
Long-Term Services and Supports
    The Independent Budget recommends $535 million for FY 2018. This 
recommendation reflects the fact that there was a significant increase 
in the number of veterans receiving Long Term Services and Supports 
(LTSS) in 2016. Unfortunately, due to loss of authorities--specifically 
fee-care no longer being authorized, provider agreement authority not 
yet enacted, and the inability to use Choice funds for all but skilled 
nursing care--to purchase appropriate LTSS care particularly for home 
and community-based care, we estimate an increase in the number of 
veterans using the more costly long-stay and short-stay nursing home 
care.
Prosthetics and Sensory Aids
    In order to meet the increase in demand for prosthetics, the IB 
recommends an additional $320 million. This increase in prosthetics 
funding reflects a similar increase in expenditures from FY 2016 to FY 
2017 and the expected continued growth in expenditures for FY 2018.
Women Veterans
    The Medical Services appropriation should be supplemented with $110 
million designated for women's health care programs in FY 2018. These 
funds will be used to help the VA deal with the continuing growth in 
women veterans coming to VA for care, including coverage for 
gynecological, prenatal, and obstetric care, other gender-specific 
services, and for expansion and repair of facilities hosting women's 
care to improve privacy and safety of these facilities. The new funds 
would also aid VHA in making its cultural transformation to ensure 
women veterans are made to feel welcome at VA, and provide means for VA 
to improve specialized services for preventing suicide and homelessness 
and improvements for mental health and readjustment services for women 
veterans.
Reproductive Services (to Include IVF)
    Last year, Congress authorized appropriations for the remainder of 
FY 2017 and FY 2018 to provide reproductive services, to include in 
vitro fertilization (IVF), to service-connected catastrophically 
disabled veterans whose injuries preclude their ability to conceive 
children. The VA projects that this service will impact less than 500 
veterans and their spouses in FY 2018. The VA also anticipates an 
expenditure of no more than $20 million during that period. However, 
these services are not directly funded; therefore, the IB recommends 
approximately $20 million to cover the cost of reproductive services in 
FY 2018. We are pleased to see that the Administration does retain the 
authority to provide reproductive services in its budget proposal.
Emergency Care
    Recently, the VA has received serious scrutiny for its 
interpretation of legislation dating back to 2009, which required it to 
pay for veterans who sought emergency care outside of the VA health 
care system. The Richard W. Staab v. Robert A. McDonald ruling handed 
down by the US Court of Appeals for Veterans Claims last year, places 
the financial responsibility of these emergency care claims squarely on 
the VA. Although VA continues to appeal this decision, it is not 
expected to prevail in this case leaving itself with a more than $10 
billion dollar obligation over the next 10 years. The Staab ruling is 
estimated to cost VA approximately $1.0 billion in FY 2018 and about 
$1.1 billion in FY 2019, which the IB has included in our 
recommendations. We are disappointed to see that the Administration's 
proposal continues to ignore its growing obligation to cover the cost 
of emergency care as dictated by the Staab decision.
            fy 2019 medical services advance appropriations
    The Independent Budget once again offers baseline projections for 
funding through advance appropriations for the Medical Care accounts 
for FY 2019. While the enactment of advance appropriations for VA 
medical care in 2009 helped to improve the predictability of funding 
requested by the Administration and approved by Congress, we have 
become increasingly concerned that sufficient corrections have not been 
made in recent years to adjust for new, unexpected demand for care. As 
indicated previously, we have serious concerns that the previous 
Administration significantly underestimated its FY 2018 advance 
appropriations request. This trend cannot be allowed to continue, 
particularly as Congress continues to look for ways to reduce 
discretionary spending, even when those reductions cannot be justified.
    For FY 2019, The Independent Budget recommends approximately $69.5 
billion for Medical Services. Our Medical Services advance 
appropriations recommendation includes:

 
------------------------------------------------------------------------
 
------------------------------------------------------------------------
Current Services Estimate.............................   $66,334,946,000
Increase in Patient Workload..........................    $1,589,892,000
Additional Medical Care Program Cost..................    $1,526,000,000
                                                       -----------------
    Total FY 2019 Medical Services....................   $69,450,838,000
------------------------------------------------------------------------


    Our estimate of growth in patient workload is based on a projected 
increase of approximately 78,000 new patients. These new unique 
patients include priority group 1-8 veterans and covered nonveterans. 
We estimate the cost of these new patients to be approximately $1.3 
billion. This recommendation also reflects an assumption that more 
veterans will be accessing the system as VA expands its capacity and 
services and we believe that reliance rates will increase as veterans 
examine their health care options as a part of the Choice program. The 
increase in patient workload also assumes a projected increase of 
62,500 new OEF/OIF and OND veterans, at a cost of approximately $272 
million.
    As previously discussed, the IBVSOs believe that there are 
additional medical program funding needs for VA. In order to meet the 
increase in demand for prosthetics, the IB recommends an additional 
$330 million. We believe that VA should invest a minimum of $120 
million as an advance appropriation in FY 2019 to expand and improve 
access to women veterans' health care programs. Our additional program 
cost recommendation includes continued investment of $20 million to 
support extension of the authority to provide reproductive services to 
the most catastrophically disabled veterans. Finally, VA's cost burden 
for paying emergency care claims dictated by the Staab ruling will 
require at least $1.1 billion in FY 2019 alone.
                     medical support and compliance
    For Medical Support and Compliance, The Independent Budget 
recommends $6.7 billion for FY 2018. Our projected increase reflects 
growth in current services based on the impact of inflation on the FY 
2017 appropriated level. Additionally, for FY 2019 The Independent 
Budget recommends $6.8 billion for Medical Support and Compliance. We 
have concerns about the significant growth in these administrative 
account functions recommended by the Administration (nearly $300 
million in FY 2018 and an additional $300 million in FY 2019) as these 
areas have been shown to be bloated on numerous occasions in the past. 
These dollars could certainly be better spent providing direct care 
services to veterans.
                           medical facilities
    For Medical Facilities, The Independent Budget recommends $5.8 
billion for FY 2018. Our Medical Facilities recommendation includes 
$1.35 billion for Non-Recurring Maintenance (NRM). Likewise, The 
Independent Budget recommends approximately $6.6 billion for Medical 
Facilities for FY 2019. Our FY 2019 advance appropriation 
recommendation also includes $1.35 billion for NRM. We are pleased to 
see the Administration recommending real funding for this account in FY 
2018 (approximately $6.5 billion), but we are concerned that the Budget 
Request reflects the continued trend of reducing the recommendation in 
the advance appropriation year ($5.9 billion in FY 2019) in order to 
seemingly hold down discretionary projections.
                    medical and prosthetic research
    We are very disappointed to see the major cut in funding for the 
Medical and Prosthetic Research program in the Administration's Budget 
Request--from $675 million in FY 2017 to $640 million in FY 2018. The 
VA Medical and Prosthetic Research program is widely acknowledged as a 
success on many levels, and contributes directly to improved care for 
veterans and an elevated standard of care for all Americans. We 
recommend that Congress appropriate $713 million for Medical and 
Prosthetic Research for FY 2018. Additionally, under the President's 
Precision Medicine Initiative, the IBVSOs recommend $65 million to 
enable VA to process one quarter of the MVP samples collected, for a 
total research appropriation of $778 million.
    Thank you for the opportunity to submit our views on the FY 2018 VA 
Budget Request. We would be happy to answer any questions the Committee 
may have.

    Chairman Isakson. Thank you very much for your testimony.
    Mr. Acosta.

STATEMENT OF LEROY ACOSTA, ASSISTANT NATIONAL SERVICE DIRECTOR, 
                   DISABLED AMERICAN VETERANS

    Mr. Acosta. Mr. Chairman, Members of the Committee, as co-
author of the Independent Budget (IB), along with VFW and PVA, 
DAV is pleased to present our views regarding fiscal year 2018 
funding requirements for veterans' benefits programs.
    Today, I will focus on critical funding needs for VBA's 
Compensation Service, Vocational Rehabilitation and Employment, 
and the Board of Veterans Appeals. I will also cover our strong 
opposition to a couple of ill-conceived and unacceptable 
administration proposals to scale back veterans' disability 
compensation.
    Mr. Chairman, the IB recognizes that VBA has made 
significant progress in reducing the disability claims backlog. 
VBA is processing more claims than ever before, yet workload 
continues to rise. To manage current and future workload, the 
IB recommends an additional 1,750 FTEE for VBA's Compensation 
Service, which would require an increase of approximately $183 
million.
    VA's Voc Rehab Service also needs additional funding. Over 
the past few years, program participation has increased by 15 
percent overall, and based on historical trends, it would 
increase by another 5 percent in fiscal year 2018. To meet 
rising demand and to achieve and sustain the 1-to-125 
counselor-to-client ratio established for Voc Rehab by law, the 
IB recommends an additional 266 FTEE, which would require a $32 
million increase.
    Overall, the IB recommends total funding for VBA be 
increased by $278 million, a 10 percent increase in order to 
fund these two staffing increases and maintain current service 
levels for the rest of VBA.
    Unfortunately, the administration has recommended an 
outright cut in funding for VBA of $12 million. For overall 
funding, that is $300 million less than that recommended by the 
IB.
    We urge the Committee to support our recommended funding 
levels to continue VBA's progress in delivering earned benefits 
to veterans, their families, and survivors.
    Mr. Chairman, VBA has made significant progress on its 
claims backlog. One consequence has been an alarming increase 
in a backlog of appeals for denied claims. Today, there are 
over 450,000 appeals pending either at VBA or the board, and it 
takes almost 6 years on average for a decision by the board.
    Fortunately, the IBVSOs have been part of a stakeholder 
work group with VA to develop and enact comprehensive reform of 
the appeals process. S. 1024, the Veterans Appeals Improvement 
and Modernization Act of 2017, is built upon the stakeholder 
framework and has received broad bipartisan support.
    We urge you to move forward expeditiously and pass this 
legislation. The House has passed similar legislation earlier 
this year. Enactment of this legislation would lead to a more 
modern, responsive, and flexible appeals system, one that will 
provide veterans with quicker decisions on appeals while fully 
protecting veteran's due process rights. Even with passage of 
appeals reform, however, the board will continue to require 
resources commensurate with workload.
    Last year, Congress authorized the board to increase this 
FTEE by 242 to an authorized staffing level of 922 FTEE. The 
board has not yet filled all those positions. For fiscal year 
2018, the IB expects the board to continue hiring, to fill all 
authorized positions, and we do not recommend further staffing 
increases while this new legislation is being approved and 
implemented.
    Moving forward, the board and Congress must carefully 
monitor implementation of a new appeal system to ensure that 
staffing remains adequate to meet future workload demands.
    Finally, Mr. Chairman, DAV and the IB enthusiastically 
oppose two legislative proposals in the administration's 
budget. First, we strongly oppose the proposal to round-down 
COLAs for 10 years, which would hurt our Nation's injured and 
ill veterans, their families and survivors. The cumulative 
effect of this proposed tax would cost beneficiaries nearly 
$2.7 billion over 10 years. We urge this Committee and the 
entire Congress to soundly reject it.
    Furthermore, we adamantly object to the proposal that will 
cut off eligibility for VA's individual unemployability, or IU, 
simply because disabled veterans reach an age in which they 
might qualify for Social Security retirement benefits.
    Mr. Chairman, total compensation for IU is not a retirement 
benefit. It is provided for as compensation for veterans who 
suffer lifelong service-connected disabilities and are 
determined unable to work. Furthermore, this would also lead to 
veterans losing ancillary benefits that result from a total 
disability rating, such as dependents educational assistance, 
CHAMPVA, commissary and exchange privileges, and in many cases, 
State benefits such as property tax exemptions.
    We call on Members of this Committee and the entire 
Congress to soundly reject these dangerous proposals that would 
be harmful to disabled veterans.
    That concludes my testimony. I would be happy to respond to 
any questions that you or Members of the Committee may have.
    [The prepared statement of Mr. Acosta follows:]
  Prepared Statement of Leroy Acosta, Assistant National Legislative 
                  Director, Disabled American Veterans
    Mr. Chairman and Members of the Committee: As one of the co-authors 
of The Independent Budget (IB), along with Veterans of Foreign Wars 
(VFW) and Paralyzed Veterans of America (PVA), DAV is pleased to 
present our views regarding fiscal year (FY) 2018 funding requirements 
to support the Department of Veterans Affairs (VA) ability to process 
and deliver timely, accurate benefits to veterans, their families and 
survivors.
                    general operating expenses (goe)
Veterans Benefits Administration                          $3.135 billion

    The Veterans Benefits Administration (VBA) account is comprised of 
six primary divisions. These include Compensation; Pension; Education; 
Vocational Rehabilitation and Employment (VR&E); Housing; and 
Insurance. The increases recommended for these accounts primarily 
reflect current services estimates with the impact of inflation 
accounting for most of the increase. However, the IB recommendations 
for Compensation and VR&E also reflect a significant increase in 
requested staffing to meet the rising demand for those benefits. The IB 
recommends approximately $3.135 billion overall for VBA for FY 2018, an 
increase of approximately $279 million over the enacted FY 2017 
appropriations level. The IB recommendation includes an increase of 
$183 million above current services in the Compensation account, and 
approximately $32 million above current services in the VR&E account to 
provide for approximately 2,000 new full-time equivalent employees 
(FTEE) to address rising workload.

Compensation Service Personnel        1750 New FTEEs          $183 
                    million

    VBA continues to produce record numbers of claims while maintaining 
an emphasis on quality. Over the past few years, VBA has made 
significant progress in reducing the disability compensation backlog, 
which at its peak, stood at over 600,000 claims in March 2013. Today, 
the claims backlog stands at just over 90,000 claims, a decrease of 
more than 85 percent from its peak. However, there has recently been a 
rise in the overall disability claims inventory and the amount of time 
it takes to process both claims and appeals. These increases can be 
attributed to multiple factors, including an increase in the number of 
claims and appeals being filed, the lack of adequate resources to keep 
pace with demand and the curtailing of mandatory overtime to reduce the 
claims backlog.
    In 2009, VBA issued claims decisions on 2.74 million medical 
issues; that number more than doubled to 5.76 million in FY 2016, but 
was less than FY 2015 when it issued 6.35 million decisions on medical 
issues. In March 2013, VBA required roughly 282 days to process a 
claim. At the close of FY 2016, VBA reported that on average, it took 
123 days to process a claim; however, in FY 2015, VBA reported that it 
took, on average, 92 days to complete a claim. In FY 2015, total 
inventory stood at about 352,000 claims; today VBA has a total 
inventory close to 400,000 claims. Furthermore, VBA has an inventory of 
nearly 584,000 non-disability rating claims, such as, claims for 
changes in dependent or marital status.
    It will require a combined focus on technology and staffing levels 
for VBA to provide veterans and their dependents with more timely and 
accurate claims decisions. For FY 2018, the Independent Budget veterans 
service organizations (IBVSOs) recommend an additional 1,750 FTEE to 
manage VBA's overall rising workload. Furthermore, since VBA stopped 
utilizing mandatory overtime for claims processing, the true need for 
additional personnel has become more evident. Of the overall increase 
in personnel, we recommend 1,000 FTEE be dedicated to processing 
appeals pending at VBA in an effort to eliminate the backlog of 380,000 
appeals in VBA over the next three years. Depending on progress this 
year, further personnel increases may be necessary to reduce the 
appeals backlog at VBA. In addition, we recommend 350 FTEE be dedicated 
to addressing the growing backlog of non-rating related work, such as 
dependency claims. An additional 300 FTEE should be dedicated for 
claims processing to address the incremental rise in the claims 
inventory and backlog and 100 FTEE dedicated to staffing the Fiduciary 
program to meet the growing needs of veterans participating in VA's 
Caregiver Support programs. This recommendation is based on a July 2015 
VA Inspector General report on the Fiduciary program that found, `` . . 
. Field Examiner staffing did not keep pace with the growth in the 
beneficiary population, [and] VBA did not staff the hubs according to 
their staffing plan . . . .''

VR&E Service Personnel                   266 New FTEEs                  
                     $32 million

    The Vocational Rehabilitation and Employment Service (VR&E), also 
known as the VetSuccess program, provides critical counseling and other 
adjunct services necessary to enable service-disabled veterans to 
overcome barriers as they prepare for, find, and maintain gainful 
employment. VetSuccess offers services on five tracks: re-employment; 
rapid access to employment; self-employment; employment through long-
term services; and independent living.
    VR&E also operates its VetSuccess on Campus (VSOC) program at 94 
college campuses.
    Over the past few years, program participation has increased by 15 
percent overall: increasing by 7.3 percent in FY 2015, 3.8 percent in 
FY 2016, and an estimated 4 percent in FY 2017. As VBA continues to 
expand VR&E eligibility to more veterans, due to increased claims 
processing and the award of new service-connected disabilities due to 
new presumptive disabilities, we project that total program 
participation for FY 2018 will grow by at least 5 percent for total 
caseload of close to 155,000.
    Last year, Congress enacted Public Law 114--223, which authorizes 
the Secretary to use appropriated funds to ensure the ratio of veterans 
to full-time employment equivalents does not exceed 125 veterans to one 
full-time employment equivalent, a goal that VA has not met for many 
years. In July 2015, VR&E reported that its average Vocational 
Rehabilitation Counselor (VRC)-to-client ratio had risen to 1:139. 
However, in both FY 2016 and FY 2017, the Administration flat-lined the 
VR&E request for direct personnel at 1,442. In order to achieve and 
sustain a 1:125 counselor-to-client ratio in FY 2018, we estimate that 
VR&E would need 266 new FTEE, for a total workforce of 1,550 FTEE, to 
manage an active caseload and provide support services to 155,000 VR&E 
participants. At a minimum, three-quarters, of the new hires should be 
VRCs dedicated to providing direct services to veterans. This increase 
in personnel would address expected growth in VR&E claim filings and 
program participation, as well as collateral duties performed by VRCs 
outside of general case management. It is also essential that these 
increases be properly distributed throughout all of the VR&E program to 
ensure that VRC caseloads are equitably balanced among VA Regional 
Offices.
                         general administration
Board of Veterans' Appeals                                  $158 million

    Faced with a rising appeals backlog that could no longer be 
ignored, last year Congress authorized the Board of Veterans' Appeals 
(Board) to increase its FTEE by 242 over FY 2016 levels, bringing their 
total authorized staffing to 922 FTEE for FY 2017; however, the Board 
has not yet hired to their full authorized level. For FY 2018, the 
IBVSOs recommend no additional increases in FTEE; but note, the Board 
must be permitted to hire its full complement of 922 FTEE. Further, as 
the number of claims processed annually continues to rise as a result 
of the increased capacity of VBA, the number of appeals filed annually 
will grow commensurately. In order for the Board to keep pace with this 
new incoming workload alone, not including those appeals already in the 
system, FTEE levels will have to be adjusted accordingly, though 
appeals reform legislation could alleviate some of that need in the 
future.
    The IBVSOs thank Chairman Isakson, Senators Blumenthal, Tester and 
the other cosponsors for introducing the Veterans Appeals Improvement 
and Modernization Act of 2017 (S. 1024), legislation that would 
fundamentally reform and streamline the overall appeals process. 
Similar legislation, H.R. 2288, was introduced and passed in the House. 
These measures include provisions that reflect significant efforts and 
the consensus of a working group formed in March 2016 that consisted of 
the IBVSOs, other VSO stakeholders, and leaders within VBA and the 
Board. Regardless of potential passage of this legislation the Board 
will continue to require resources commensurate with workload, 
especially to process legacy appeals remaining at the time of enactment 
of new appeals reform legislation. Further, the Board must be funded 
and empowered to continue pursuing information technology (IT) 
modernization solutions that best meet the specific workflow needs of 
the Board, while ensuring it also supports seamless integration with 
the Veterans Benefits Management System and other IT systems used by 
VBA and the Court of Appeals for Veterans Claims. Given the potential 
for significant and positive impact this would have on veterans' 
ability to receive more timely decisions, we look forward to the 
Committee passing appeals modernization, followed swiftly by enactment.
                       cost of living round down
    The Administration's budget proposal released on May 23, 2017, 
contains a provision that would round down cost-of-living adjustments 
(COLAs) for our Nation's injured and ill veterans and their families 
and survivors for a period of 10 years. DAV and our IB partners are 
strongly opposed to this rounding down provision. Veterans and their 
survivors rely on their compensation for essential purchases such as 
food, transportation, rent, and utilities. It also enables them to 
maintain a marginally higher quality of life.
    Rounding down veterans' COLAs unfairly targets disabled veterans, 
their dependents and survivors to save the government money or offset 
the cost of other Federal programs. The cumulative effect of this 
provision of law would, in essence, levy a 10-year tax on disabled 
veterans and their survivors, reducing their income each year. When 
multiplied by the number of disabled veterans and recipients of 
Dependency and Indemnity Compensation or DIC, hundreds of millions of 
dollars would be siphoned from these deserving individuals annually. 
All totaled, VA estimates, this proposed COLA round down would cost 
beneficiaries close to $2.7 billion over 10 years. Congress must reject 
this ill-conceived proposal.
         individual unemployability and social security offset
    We also note there is, unfortunately, a new proposal included in 
the President's budget that would impact the VA's Individual 
Unemployability or IU program which allows VA to pay certain veterans 
disability compensation at the 100 percent rate, even though VA has not 
rated their service-connected disabilities at the total level. 
Specifically, the proposal would terminate existing IU ratings for 
veterans when they reach the minimum retirement age for Social Security 
purposes (62), or upon enactment of the proposal if the veteran is 
already in receipt of Social Security retirement benefits. The IBVSOs 
vehemently oppose this proposal.
    As the Members of this Committee know, Congress delegated to the 
Secretary of Veterans Affairs the authority to adopt and apply a 
schedule of rating disabilities pursuant to section 1155 of title 38, 
United States Code. In accordance with VA regulation promulgated by the 
Secretary, total disability exists when any veteran is determined by VA 
to be unable to secure and maintain substantially gainful employment by 
reason of service-connected disability, regardless of age. (See 38 CFR, 
section 4.16(b).) IU is based on the impact of the individual's own 
circumstances and it is an exception to the ``average person standard'' 
of the rating schedule. As a prerequisite for an IU rating, a veteran 
generally must have a disability rated 60 percent or higher under the 
rating schedule.
    Total compensation for IU is not a retirement benefit. Properly 
applied, the rules require a factual showing that the service-connected 
disability is such as to be incompatible with substantially gainful 
employment, regardless of age. Today, many people, including the 
President, members of the Cabinet and members of Congress, work well 
beyond the minimum or ``normal'' retirement age. Some continue to work 
because they love their job, while others may be forced by financial 
requirements to continue to work.
    This proposal is especially detrimental to the well-being of ill 
and injured veterans and their families because it forces a totally 
disabled veteran to take their social security benefits at the minimum 
age of 62, when the benefit is a small fraction of what he or she would 
receive at normal retirement age (65 to 67) or at age 70. Further, 
since the level of social security benefits is based on what an 
individual has paid into the fund, a veteran who was severely or 
totally disabled at a young age may not have paid sufficient funds to 
receive a level of benefits at the minimum age, or any age for that 
matter, to live a comfortable life because of reduced earnings due to 
service-related disabilities.
    We also remind the Committee that the loss of IU for many veterans 
would also have a negative impact on a veteran's family due to the 
concurrent loss of ancillary benefits. Once the total disability rating 
for IU is reduced at age 62, the veteran and his or her family will 
lose Chapter 35 benefits for Dependents Education Assistance program, 
essential health care benefits from the Civilian Health and Medical 
Program of the VA (CHAMPVA) for dependents, Commissary and Exchange 
privileges and, in many cases, state benefits such as property tax 
exemptions. This damaging proposal should be rejected by Congress as it 
lacks compassion for the men and women who served our country and were 
severely disabled as a result of that honorable service.
    In summary, a final point I would like to make is that benefits 
received from the VA, or based on military retirement pay and other 
Federal programs have differing eligibility criteria as compared with 
the earned payments of Social Security. Reducing a benefit provided to 
a disabled veteran in receipt of IU due to receipt of a different 
benefit offered through separate Federal benefit program is simply an 
unjust forfeit of an earned, necessary benefit.

    Mr. Chairman, thank you for the opportunity to submit testimony and 
to present the views of the IBVSOs regarding FY 2018 funding 
requirements to support the VA's ability to process and deliver 
benefits to veterans, their families and survivors. I would be happy to 
respond to any questions that you or Members of the Committee may have 
regarding this statement or our recommendations.

    Chairman Isakson. Thank you very much, Mr. Acosta.
    Mr. Fuentes.

     STATEMENT OF CARLOS FUENTES, DIRECTOR OF THE NATIONAL 
  LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED 
                             STATES

    Mr. Fuentes. Chairman Isakson and Members of the Committee, 
on behalf of the men and women of the VFW and its Auxiliary, I 
would like to thank you for the opportunity to present our 
views on VA's budget.
    The VFW is glad the administration has proposed a 6 percent 
increase in VA's discretionary budget. We certainly support the 
continued focus on expanding access to health care; expediting 
decisions on benefits, claims, and appeals, increased focus on 
combating veteran suicide and addressing the stigma associated 
with mental health; ensuring VA is ready and able to care for 
women veterans who are the fastest-growing cohort of the 
veteran population. However, I would like to make it clear the 
VFW strongly opposes efforts to claw back benefits from our 
most severely disabled veterans to pay for such improvements.
    In the past week, nearly 40,000 letters and e-mails from 
VFW members and supporters have been sent to Members of 
Congress opposing the administration's proposal to revoke 
individual unemployability benefits for veterans who are unable 
to work because of their service-connected disabilities. The 
VFW opposes the IU proposal and the COLA round-down proposal 
and other measures to balance the budget on the backs of our 
Nation's veterans.
    We are also concerned with the administration's request to 
make the Veterans Choice Program a permanent mandatory program, 
which could possibly lead to the gradual erosion of the VA 
health care system.
    The continued failure by Congress to eliminate 
sequestration has forced the administration's proposed cuts to 
veterans programs in order to expand the Choice Program under 
mandatory spending instead of including it in discretionary 
Community Care accounts.
    Sequestration and draconian spending caps limit our 
Nation's ability to provide servicemembers, veterans, and their 
families the care and benefits they have earned. The VFW calls 
on this Committee to join our campaign and finally end 
sequestration and do away with Federal budget processes based 
on arbitrary budget caps.
    In partnership with our Independent Budget co-authors, DAV 
and PVA, I would like to focus some of my remarks on VA's 
construction and National Cemetery administration budget 
request. For more than a decade, the IBVSOs have warned 
Congress and VA that perpetual underfunding has allowed VA's 
infrastructure to erode while its capacity has swelled from 81 
percent in 2004 to as high as 121 percent in 2012. We continue 
to believe that this need for space and chronic underfunding of 
major construction projects could force VA to ration care.
    VA's budget request says that improving the condition of 
VA's facilities through major construction projects accounts 
for the largest resource need to keep pace with the growing 
demand for VA outpatient care, yet the administration's major 
construction request only funds one VHA major construction 
project.
    The IBVSOs believe that VA has requested an adequate amount 
for its fiscal year 2018 major medical leases needs; however, 
Congress must find a way to quickly authorize leasing projects. 
There are now 27 major medical facility leases awaiting 
congressional authorization, 18 of which have been waiting 
since 2015. Delays in authorization of these leases has a 
direct impact on VA's ability to provide timely care to 
veterans.
    The National Cemetery Administration has a sacred duty to 
provide our Nation's veterans a final resting place that honors 
their service. In 2016, NCA entered more than 130,000 veterans 
and eligible family members. The number of interments is 
expected to increase until 2022. Other factors have placed 
additional demands on NCA, and the IBVSOs are glad to see the 
administration's request for NCA as higher than our 
recommendation, which I believe may be one of the only ones. We 
commend VA for continued commitment to NCA's mission.
    Mr. Chairman, this concludes my testimony. I am happy to 
answer any questions that you and the Members of the Committee 
may have.
    [The prepared statement of Mr. Fuentes follows:]
 Prepared Statement of Carlos Fuentes, Director, National Legislative 
         Service, Veterans of Foreign Wars of The United States
    Chairman Isakson, Ranking Member Tester and Members of the 
Committee, On behalf of the men and women of the Veterans of Foreign 
Wars of the United States (VFW) and its Auxiliary, thank you for the 
opportunity to present the VFW's views on the Department of Veterans 
Affairs' (VA) Fiscal Year (FY) 2018 appropriations and FY 2019 advance 
appropriations.
    The VFW is glad to see President Trump has proposed a six percent 
increase in VA's FY 2018 discretionary budget compared to FY 2017. 
However, we feel his proposal falls short of what VA needs to keep pace 
with demand for health care and benefits. The VFW thanks the 
Administration for its commitment to community care, long-term care, 
mental health care, woman veterans and efforts to prevent and eliminate 
veteran homelessness.
    However, we are very concerned that the Administration's request to 
make the Veterans Choice Program a permanent mandatory program could 
lead to a gradual erosion of the VA health care system. What is more 
concerning is that the Administration has chosen to make permanent a 
flawed program by ending Individual Unemployability benefits for 
certain severely disabled veterans who are unable to work due to their 
service-connected disabilities and round down cost of living disability 
pay increases, a proposal which the VFW has opposed in the past and 
continues to strongly oppose.
    The Administration has also proposed a cap on the amount of tuition 
and fees that may be paid under the Post-9/11 GI Bill for programs of 
education in which a public institution of higher learning enters into 
an agreement with another entity to provide such education. Currently, 
third party training programs that contract with public schools are 
able to charge unlimited fees since public schools have no set dollar 
amount cap.
    A couple of years ago, it came to light that some contracted flight 
training programs were charging exorbitant fees, which far exceeded the 
cost of an average in-state education. The VFW supports the 
Administration's proposal to place a reasonable cap on these sorts of 
training programs.
    The continued failure of Congress to eliminate sequestration has 
forced the Administration to propose cuts to veteran benefits and cap 
GI Bill expenditures in order to expand the Choice Program under 
mandatory spending instead of including the program in its 
discretionary community care account. In testimony before the Senate 
and House Committees on Appropriations, Secretary of Veterans Affairs 
David J. Shulkin has indicated that VA would like all its community 
care money to come from one account, instead of having two separate 
accounts for the same purpose and not having the flexibility to use 
both accounts in accordance with veterans' demand for community care. 
The VFW agrees with Secretary Shulkin and urges Congress to consolidate 
VA's community care programs and to fund such programs through VA's 
discretionary appropriations account.
    Sequestration and its draconian spending caps limit our Nation's 
ability to provide servicemembers, veterans, and their families the 
care and benefits they have earned and deserve. The VFW calls on the 
Committee to join our campaign to finally end sequestration and do away 
with a Federal budget process based on the arbitrary budget caps, which 
significantly limit the government's ability to carry out programs that 
experience spikes in demand, such as VA health care. To the VFW, 
sequestration is the most significant readiness and national security 
threat of the 21st century, and despite almost universal congressional 
opposition to such haphazard budgeting, Congress has failed to end it.
    The VFW, in partnership with our Independent Budget (IB) co-
authors--Disabled American Veterans (DAV) and Paralyzed Veterans of 
America (PVA)--produces annual budget recommendations for each of VA's 
discretionary appropriation accounts and compares them to the 
Administration's request. PVA has submitted testimony covering Veterans 
Health Administration (VHA) appropriation accounts and DAV has covered 
the IB's recommendations for the Veterans Benefits Administration 
accounts. I will focus my remarks on VA's construction and National 
Cemetery Administration (NCA) appropriations.
Major Construction:

        FY 2018 IB Recommendation--$1.50 billion
        FY 2018 Administration Request--$512 million
        FY 2017 Appropriations--$528 million

    For more than a decade, the IB Veterans Service Organizations 
(IBVSOs) have warned Congress and VA that perpetual underfunding has 
allowed VA's infrastructure to erode while its capacity has swelled 
from 81 percent in 2004 to as high as 120 percent in 2010. We continue 
to believe that this need for space and chronic underfunding of medical 
services could lead VA to ration care.
    The IBVSOs are working with VA to reform its construction process 
so facilities can be delivered on time and on budget. Previous errors 
must be corrected to ensure the issues in Aurora, Colorado, never occur 
again. However, Congress and the Administration must not ignore the 
growing capital infrastructure needs of the Department's health care 
system.
    When VA asked its Veteran Integrated Service Networks (VISN) to 
evaluate what they need to improve its facilities to meet the increased 
outpatient demand, VA determined that ``improving the condition of VA's 
facilities through major construction projects (96) accounted for the 
largest resource need.'' \1\ Yet the Administration's major 
construction request for VHA is 36 percent less than FY 2017 and 85 
percent less than actual expenditures in FY 2016.
---------------------------------------------------------------------------
    \1\ Department of Veterans Affairs 2018 Budget and 2019 Advance 
Appropriations Requests, Volume IV: Construction, Long Range Capital 
Plan and Appendix. Long Range Capital Plan, page 8.3-8.
---------------------------------------------------------------------------
    When asked why VA is taking a strategic pause on major construction 
for VHA when its capital infrastructure continues to age and demand 
continues to increase, VA informed the IBVSOs that it simply did not 
receive the request that it needed for major construction because of 
sequestration budget caps. Congress must not allow VA's inability to 
invest in its VHA's major construction to limit veterans' access to the 
health care they have earned and deserve by forcing veterans onto VA's 
community care programs and eliminating the choice to receive care at 
VA medical facilities.
    Currently, VA has 24 major construction projects that are partially 
funded--some of which were originally funded in FY 2004--that need a 
clear path to completion. An additional three projects are in the 
design phase. Outside of the partially funded major projects list are 
major construction projects at the top of the FY 2017 priority list 
that are seismic in nature. These projects cannot take a strategic 
pause while Congress and VA decide how to manage capital infrastructure 
long-term. VA will need to invest more than $3.5 billion to complete 
all 24 partially funded projects. Of the top five projects on the 
priority list, two are seismic deficiencies, two support the core 
mission of VA--a mental health clinic and a spinal cord injury center--
and one is an addition to an existing facility. The total cost of these 
five projects is $1.2 billion.
    The IBVSOs recommend that Congress appropriate at least $1.5 
billion for major construction in FY 2018. This amount will fund either 
the ``next phase'' or fund ``through completion'' all existing 
projects, and begin advance planning and design development on six 
major construction projects that are the highest ranked on VA's 
priority list.
Minor Construction:

        FY 2018 IB Recommendation--$700 million
        FY 2018 Administration Request--$343 million
        FY 2017 Appropriations--$372 million

    In FY 2017, Congress appropriated $372.1 million for minor 
construction projects. Currently, approximately 600 minor construction 
projects need funding to close all current and future year gaps within 
ten years. To complete all of these current and projected projects, VA 
will need to invest between $6.7 and $8.2 billion in minor construction 
over the next decade.
    In August 2014, the President signed the Veterans Access, Choice, 
and Accountability Act of 2014 (Public Law 133-146). In this law, 
Congress provided $5 billion to increase health care access by 
increasing medical staffing levels and investing in infrastructure. VA 
has developed a spending plan that obligated $511 million for 64 minor 
construction projects over a two-year period.
    While this infusion of funds has helped, there are still hundreds 
of minor construction projects that need funding for completion. It is 
important to remember that these funds are a supplement to, not a 
replacement of, annual appropriations for minor construction projects. 
The IBVSOs recommend that Congress fund VA's minor construction account 
at $700 million in an effort to close all identified gaps within ten 
years.
                                leasing
    Historically, VA has submitted capital leasing requests that meet 
the growing and changing needs of veterans. VA has again requested an 
adequate amount--$270.1 million for its FY 2018 major medical leasing 
needs. While VA has requested adequate resources, Congress must find a 
way to authorize and appropriate leasing projects in a way that 
precludes the full cost of the lease being accounted for in the first 
year. There are now 27 major medical leases awaiting congressional 
authorization, 18 of which have been waiting since FY 2016 and six from 
FY 2017 that Congress must still authorize. Delays in authorization of 
these leases have a direct impact on VA's ability to provide timely 
care to veterans in their communities. Congress must authorize these 
leases.
National Cemetery Administration:

        FY 2018 IB Recommendation--$291 million
        FY 2018 Administration Request--$306.2 million
        FY 2017 Appropriations--$286 million

    The NCA, which receives funding from eight appropriation accounts, 
has the sacred duty to provide the brave men and women who have worn 
our Nation's uniform a final resting place that honors their service.
    In a strategic effort to meet the burial and access needs of our 
veterans and eligible family members, the NCA continues to expand and 
improve the national cemetery system, by adding new and/or expanded 
national cemeteries. Not surprising, due to the opening of additional 
national cemeteries, the NCA is expecting an increase in the number of 
annual veteran interments through 2016 to more than 136,000, up from 
125,180 in 2014; this number is expected to slowly decrease after an 
expected peak of 138,000 in 2022. This much needed expansion of the 
national cemetery system will help to facilitate the projected increase 
in annual veteran interments and will simultaneously increase the 
overall number of graves being maintained by the NCA to 3.7 million in 
2018 and 4 million by 2021.
    Even as the NCA continues to add veteran burial space to its 
expanding system, many existing cemeteries are exhausting their 
capacity and will no longer be able to inter casketed or cremated 
remains. That is why the VFW is glad the see the Administration's FY 
2018 budget request for the National Cemetery Administration is higher 
than what the IBVSOs have recommended and includes a seven percent 
increase from FY 2017 appropriations.
    Factors that have placed additional demand on the NCA include an 
increase in the issuance of Presidential Memorial Certificates, which 
is expected to increase from approximately 654,000 in 2013 to more than 
870,000 in 2017; the expected increase in the burial of Native 
American, Alaska Native, and Pacific Islander veterans; and the 
possible increase, thanks to local historians and other interested 
stakeholders, in requests for headstones or markers for previously 
unidentified veterans. That is why the IBVSOs are glad to see the 
Administration has requested $256 million in FY 2018 to fund six 
national cemetery expansion projects which would provide more than 
161,000 new burial spaces for veterans.
    With the above considerations in mind, The Independent Budget 
recommends $291 million for FY 2018 for the Operations & Maintenance of 
the NCA. The IBVSOs believe that this should include a minimum of $20 
million for the National Shrine Initiative. The IBVSOs laud the 
Administration for providing NCA the first increase in this important 
initiative since FY 2013.
    Mr. Chairman, this concludes my testimony. I will be happy to 
answer any questions you or the Committee members may have.

    Chairman Isakson. Thank you, Mr. Fuentes. We appreciate it.
    Mr. Rowan.

 STATEMENT OF JOHN ROWAN, NATIONAL PRESIDENT, VIETNAM VETERANS 
                           OF AMERICA

    Mr. Rowan. Thank you, Mr. Chairman. Senator Sanders, nice 
to see you. Nice to see you, Senator. It is good to see you 
back. I missed you when I had my annual testimony this year.
    Chairman Isakson. I missed you more than you might think. 
[Laughter.]
    I am glad to be vertical again.
    Mr. Rowan. Yeah. Well, me too. I was coming out of the 
hospital when you were going in, I think.
    Anyway, I would like to, first of all, thank you for the 
Accountability Act. It is an issue we have been dealing with 
since we started VVA, frankly, 35 years ago, calling upon 
Congress to take full accountability of all the VA operations, 
and hopefully, this will work. We support that bill.
    IU, as was noticed, has got to be rescinded. That whole 
proposal is a classic budget-tier proposal that has no idea how 
it impacts on people. It is just a dollar amount to somebody in 
OMB, with effects beyond even what everybody understood the 
first time with this whole nonsense that Social Security was 
going to pick up the amount of money lost on IU, not even 
talking about the effects on the family members--the loss of 
dental care, the loss of CHAMPVA, loss of local benefits. As 
was mentioned earlier, tax abatements in New York City--we just 
got the expansion of our tax abatement for real estate, which 
would be cut significantly by that. So, that this has just got 
to be--one of the things we are calling upon, we would like--
since the Secretary has alluded to the fact that they may agree 
with the idea that this should be shelved, we would love to see 
a joint effort between the VA and the leadership in both the 
Senate and the House Veterans' Affairs Committee publicly 
denouncing this idea and saying we are not going to pass it, so 
that we can tell all those scared people out there, who have 
been sending me e-mails and letters about all of the horrors 
that they are concerned about. Let them know they have nothing 
to worry about. We have got to bring these people down about 
ten notches because they are climbing the walls right now. I 
mean, that is something I hope that the Committees, both in the 
Senate and the House, and the VA would take into consideration 
so they could publicly acknowledge that this was one bad idea.
    The Choice Program is not a choice. It is a false choice, 
and I think we need to understand how it is done. I just came 
back from Idaho, where I met with my State council up in 
Sandpoint in northern Idaho. Almost everybody there utilizes 
the Choice Program because they are hundreds of miles from any 
VA facility, but they also can tell me all the problems they 
have with Choice in finding doctors who will take Choice, who 
will take the VA's money, who will even sign on because of 
problems. Now, we know they are trying to resolve those 
problems, but it is going to be a big issue for that.
    The other thing is doctors. Where are they coming from? I 
can tell you, I live in New York City. My dermatologist that I 
had in my private medical program for 25 years just retired on 
me. I managed to outlive him and that was great. He is retired. 
I am still sick, and I have to go see the doctor. I called up 
my EmblemHealth, which is one of the largest health care 
providers in the country, and they could not find me a 
dermatologist that I could talk to--at the earliest in August, 
and really they were talking about October. That is a false 
choice. That is dermatology, which I think I could throw a 
stick out of my window and hit a dermatologist in New York 
City, but they are not there because they do not sign up with 
the VA. They will not take the VA's payments, just like we have 
seen in Medicare and Medicaid with problems with doctors not 
signing on. We are concerned about that. It really needs to be 
rethought significantly because the private sector is not ready 
whatsoever to take on the VA patients, no way.
    The last thing--a couple of things I would--my other point 
also, the R&D budget has been cut. It should not be cut. It 
should be increased. We need more R&D for all of the programs 
that we have. We need to get more evidence-based programs 
testing on PTSD and how do we really handle it.
    I cannot tell you all the different programs where folks 
tell me what a great panacea they have for PTSD; it sounds 
great. You know, I love my dogs, and yeah, they are helpful. 
Yes, they help some veterans, but without counseling, that does 
not end their problem. We need to get more evidence-based 
actions, research into these programs.
    I am also concerned--we passed a bill last year that would 
look into the effects of toxic exposure on the children of 
Vietnam veterans and veterans that came after us. Where is that 
money going to come from if the R&D budget is cut? We got a 
nice bill passed after we fought for years. Where is the money? 
We need the money, and if the VA's budget is not there, how are 
we going to get that done?
    Last, let me just say one quick thing about the Board of 
Veterans Appeals and the whole appeals process. It would go a 
lot quicker if the VA took outside doctors' opinions and did 
not have to redo everything that somebody came in with, with an 
outside doctor's opinion. That would be nice.
    The other thing is we need to blow up the Board of Veterans 
Appeals. It just does not function. Nobody should lose 70 
percent of the time, which the VA does every year. I have been 
in this position 12 years, and in 12 years, every year, our 
VSOs, 70 percent of the time, either get a remand or a direct 
payment from the Board of Veterans Appeals on cases we bring 
in--70 percent. We win; VA loses. Year after year after year, 
and I guarantee you, that is the same percentage with the rest 
of the gentlemen at this table. I will bet all of their VBA 
cases are around the same percentage. That is ridiculous.
    The other problem is no precedence. Carl can put in a 
claim. I can put in a claim for the exact same thing. He gets 
Judge A. I get Judge B. We get two different opinions. They 
both go down. He wins; I lose. Too bad. His opinion does not 
account for anybody that follows after them if they have been 
approved, and neither does mine, for that matter. The denial 
does not either. It just keeps regurgitating the same programs 
over and over and over again, the same problems over and over 
and over again. We need to get the issue of precedence, like in 
any other court. Frankly, now that we understand the Court of 
Veterans Appeals, we are going to be very happy to look at 
them, the idea of doing class-action lawsuits at the Court of 
Veterans Appeals.
    I would be happy to answer any and all questions that 
anybody may have. Thank you.
    [The prepared statement of Mr. Rowan follows:]
         Prepared Statement of John Rowan, National President, 
                      Vietnam Veterans of America
    Good afternoon, Chairman Isakson, Ranking Member Tester, and other 
exemplary members of the Senate Veterans' Affairs Committee. Vietnam 
Veterans of America is pleased to have the opportunity to present our 
views on the President's Fiscal Year 2018 Budget and 2019 Advanced 
Appropriations Request for the Department of Veterans Affairs.
    First off, VVA is pleased that the VA warrants increased funding to 
help meet the needs of the department and the veterans it assists in an 
array of areas designed to restore, as much as possible, those who have 
given of themselves--often at great cost to their health, to their 
sense of well-being, to their families. We know that you, the members 
and staff of this most important and hard-working committee, recognize 
this, and that you will be true to the sacrifices these men and women 
have made so that we all may live in a free society.
    We do, however, want to commence our remarks with the one issue in 
the budget proposal that has been the source of great consternation not 
only to VVA but to the multitude of VSOs and MSOs. This is a proposal 
that has unleashed a firestorm of protest, of questions, concerns, and 
fears, by veterans and their spouses who have come to depend on this 
income.
      individual unemployability termination and elderly veterans
    First and foremost, the Administration's proposal that would cap IU 
benefits for veterans rated 60-100 percent disabled at age 62 and 
terminate this benefit for those veterans currently receiving Social 
Security must be a non-starter. It is unfair and simply wrong to 
characterize IU and Social Security as duplicative. Veterans have 
earned both benefits, IU by virtue of their service in uniform and 
Social Security through working and contributing into the system.
    The logic behind this proposition, which seems to arise from the 
depths of the Office of Management & Budget (OMB) every eight years or 
so, often at the beginning of a new administration, is that, at age 62, 
veterans can avail themselves of their Social Security benefits. This 
does not take into account, however, that if a veteran has been 
receiving IU for several years, there's a pretty good chance, if indeed 
not a likelihood, that s/he does not qualify for any serious Social 
Security income because s/he has not had a significant work history.
    This piece of the Administration's budget proposal, if approved, 
would impact nearly every Vietnam-era veteran and their family whose 
survival depends on the income received from this earned benefit. This 
proposed change would cut the compensation of a married disabled 
veteran receiving 100% by dint of IU compensation to about $1,300 a 
month from just over $3,000 per month. Should any Member of Congress 
exhibit political naivete and vote to eliminate IU at age 62, tens of 
thousands of Vietnam veterans in their late sixties and seventies would 
be in jeopardy of not being able to meet their basic needs, which would 
lead, for many, to impoverishment, homelessness, even suicide.
    According to the budget proposal, this provision would ``save'' the 
Compensation and Pensions account in the Veterans Benefits 
Administration an estimated $3.2 billion in 2018; $17.9 billion over 
five years; and $40.8 billion over ten. The savings would go toward 
funding the Veterans Choice program, which at present is confusing 
endeavor in many areas, which many veterans neither understand nor 
embrace.
    Furthermore, there are 238,000 veterans 62 and older currently 
receiving 100% by dint of IU, and of those 178,000 are 67 and older. 
The plain fact is that the VA disability rating schedule for mental 
health, and particularly for Post Traumatic Stress Disorder (PTSD) has 
for many years been grossly unfair. In order to be rated at 100% for 
PTSD a veteran would need to be exhibiting symptomology of full blown 
dementia (which has nothing to do with PTSD!). Since these veterans 
should have been rated at 100% for PTSD, but were not because the 
rating schedule was faulty, they have continued to draw service-
connected compensation at the 100% level. They have been unable to 
work, so have not paid much, if any,into Social Security. Social 
Security is NOT akin to service-connected compensation, but rather it 
is analogous to an annuity. The more you pay in to Social Security, the 
more you get out of it in monthly increments. The less you pay into the 
Social Security Trust fund, the less your monthly payments. VVA has 
talked to numerous Vietnam veterans who have not been able to work 
since they were blown up in the Vietnam War, but paid into Social 
Security before Vietnam, so that their monthly payments are as little 
as $25 per month.
    The so-called ``savings'' achieved by means of this ruse would be 
illusory, because nearly every veteran in this situation would 
immediately re-apply seeking 100% service-connected disability without 
IU. This would result in a flood of claims at VA, and would once again 
create backlogs in processing of claims.
    We strongly urge the Committees on Veterans Affairs to issue a bi-
partisan declaration that his ill-advised move will not happen on your 
watch.
                             va health care
    The President's budget request for medical care is $4.6 billion 
greater than the FY'17 budget, representing a 7% increase in 
discretionary spending; also, $2.9 billion in new mandatory budget 
authority to continue, and to enhance, the so-called Choice Program. 
Undergirding this increase is the need to continue to improve access to 
care for the 6.8 million of the 9.2 million veterans enrolled in the VA 
healthcare system.
    Now, we understand that Secretary Shulkin embraces funding for 
Choice which, if you'll recall, was never meant to be a solution to the 
long-standing problem of access to quality care for veterans who seek 
services from the VA. His goal is to integrate Choice into a local/
regional program of Community Care, with significantly greater funding 
for the FY'19 budget.
    We want to focus attention on two issues: collections from third 
party payers, and privatization.
    In the recent past, the VA put forth overly optimistic assessments 
of the number of dollars it could recoup via third party collections 
(along with all the million$ that would be saved through ``management 
efficiencies''). We hope this is not the case again.
    The persistent call by some for privatization of VA health care 
should be quelled by a successful initiation and operation of the 
Community Care program. We know there is an unfortunate number of 
vacancies for clinicians--not only in the VA healthcare system but in 
private and public venues as well. It makes eminent good sense to bring 
in qualified, credentialed professionals to fill voids caused by, in no 
particular order: retirement and/or resignation of VA clinicians; 
increased demand in certain VA medical centers; delayed delivery of 
care, and other problems.
                               choice 2.0
    VVA is concerned that the proposed budget does not provide enough 
funding for the new Choice currently in development. The Secretary is 
redesigning the program, altering it from an administrative system to a 
clinical one. We have some concerns, too, over the impact of proposed 
organizational changes in care delivery to veterans; how the high 
performing networks will function; and how this will then ease health 
care access. We understand that under the new proposal, providers will 
bring their networks with them, modeled after the Defense Department's 
Tri Care system.
    Additionally, VVA has concerns about the consolidation of care 
authorities, a legislative ask that has been a priority for the agency. 
This authorization is needed, according to the VA, to move Choice 
forward, and yet this step has yet to be accomplished. The gist behind 
consolidating the care authorities was to make it simpler for veterans, 
employees, and providers to determine eligibility, and pay to providers 
more promptly, with less paperwork. The establishment of a mandatory 
pot of money for the Choice Program, with more than $2 billion in 
funding, seems to defeat the purpose of the care consolidation 
legislation.
                          caregivers expansion
    The budget for FY'18 shows the Caregivers program cost estimate 
decreased by $235.9 million due to a revision in the projected number 
of caregivers receiving stipend payments. VA dis-enrolled 7,000 
caregivers earlier this year. VVA was stunned to hear that these dis-
enrollments were seemingly haphazard and conducted in an effort to 
bring down the cost of the program. While the Secretary committed to do 
a look-back on some 300 cases to evaluate the accuracy of the actions 
of those in the field, the review has been extended for six weeks as he 
juggles priorities. There still has been no commitment to do a ``look 
back'' on all 7,000 cases, which VVA believes is demanded by simple 
justice. We, and you, must continue to monitor the progress of review 
and its outcome.
    As we testified on March 9, 2017, we will work with legislators to 
enact a bill that encompasses qualified caregivers of veterans who 
served before 9/11. We are aware that this is a relatively expensive 
program. However, it is a bargain when compared to the cost of caring 
for many of these same veterans in an institutional setting.
                        national center for ptsd
    VVA strongly supports the Center (NCPTSD), which leads the Nation 
(and indeed the world!) in research focused on war-induced PTSD and 
related mental health illnesses, and serves as the Nation's front-line 
resource center for information and education about PTSD research, not 
only for the VA and other mental health professionals, but for affected 
families and the general public. A strong and independent NCPTSD is 
essential.
                             mental health
    VVA also supports additional funding for the development and 
implementation of scientific, evidence-based, integrated psychosocial 
mental health programs, substance abuse recovery treatment programs, 
and suicide-risk assessment programs for all veterans, especially since 
Secretary Shulkin has publicly stated that veteran suicide is the VA's 
top clinical priority.
                    medical and prosthetic research
    VVA notes that the funding for Medical and Prosthetic Research for 
the 2018 budget request suffered a decrease of over $30 million. VVA 
has strong reservations concerning this decrease and recommends instead 
a significant increase instead. VA's research program is distinct from 
that of the National Institutes of Health in that it was created to 
respond to the unique medical needs of veterans. In this regard, it 
should seek to fund veterans' pressing needs for breakthroughs in 
addressing hazardous environmental exposures, post-deployment mental 
health issues, TBI, long-term care service delivery, and prosthetics to 
meet the multiple needs of the latest generation of combat-wounded 
veterans.
    We respectfully thank you for the opportunity to present our views, 
and will be pleased to respond to any questions you might want to put 
to us.

    Chairman Isakson. Thank you for your testimony.
    I do not have a question. I have a proposition for you, 
though. I would like to find a time--and I would like my staff 
to listen to this--find time you and I could have lunch 1 day 
in the next 3 weeks or month because you piqued an interest in 
my mind. Your comments about the IU earlier, unemployment 
compensation recommendation, which is a nonstarter with you, 
and I think anybody else would tell you that is pretty much a 
nonstarter too. It is not hard to pass benefits. It is hell to 
take them back, and once you pace past them, you are not going 
to take them back, or if you do, you lose a lot more than what 
you get.
    I also heard the comment, I think Mr. Acosta may have 
referred to his organization. Somebody did. Mr. Fuentes may 
have, about the COLA round-down. There are lots of things out 
there that over the period of years of the Veterans 
Administration and its existence and benefit existence and 
health care, where times have changed, things have changed. We 
probably ought to look at everything that we have out there, 
because there may be some pearls of wisdom. There may be some 
benefits in the scheme of things that are going to help us a 
lot more, applied a different way today than they were when 
they were passed. We need some folks who do not have any agenda 
except to help our veterans and solve our problems rather than 
going to court, to sit down and talk.
    I will call you, and we will have that lunch.
    Mr. Rowan. I would love to.
    Chairman Isakson. I am not avoiding you, Mr. Acosta or Mr. 
Fuentes. Bigger than everybody, I am not going to avoid him or 
Mr. Blake either. You made the comment that piqued the 
interest, so we will do that, because I think if we open a 
little one-on-one dialog, there may be in some of these things 
that we bring up, because staff brings them to us or the OMB 
brings it up or your organization. You are looking out for the 
best interest to your organization and its members, and I 
appreciate that. I serve them as a master, but I also serve the 
taxpayers as a master and other people. We ought to start 
having some meetings and talk some of this stuff through. We 
may end up finding no common ground anywhere; yet, we might 
find some pearls of wisdom. If we do, I would love to work with 
you and anybody else on doing that. We will try to set that up, 
Mr. Rowan.
    Senator Sanders.
    Senator Sanders. Thanks, Mr. Chairman.
    I should have known, but I had thought that we got rid of 
this round-down thing finally. I have been hearing about it 
probably from my first day in Congress. I was Chairman. We got 
rid of it. The idea of nickel-and-diming veterans did not seem 
a lot--so what you are telling me, Mr. Acosta or Mr. Fuentes, 
it is back again?
    Mr. Fuentes. Yes, sir. Thank you very much for your 
leadership while you were Chairman of this Committee by really 
eliminating that COLA round-down or that practice.
    Now the President's proposal, as Carl laid out, proposed to 
reinstate the COLA round-down as a way to pay for expansion of 
the Choice Program as a mandatory program.
    Senator Sanders. So, this is actually taking money away 
from VA benefits and using it in another purpose. How much 
would this--if this were implemented, how much would it cost 
veterans? Anyone know?
    I think, Mr. Acosta, you mentioned.
    Mr. Acosta. Yes. The cumulative effect of this proposed tax 
would cost beneficiaries close to $2.7 billion.
    Senator Sanders. Over what? A 10-year period?
    Mr. Acosta. Over 10 years.
    Senator Sanders. Wow. All right.
    Mr. Chairman, I do not think we should be nickel-and-diming 
veterans. I mean, we have been through this for years. I 
thought we got rid of it, and it is sad to see that it is 
coming back.
    Let me ask what I think is the elephant in the room, and 
that is the concern--and I know the numbers seem to be disputed 
and not quite the clarity we would like; but, the increase in 
appropriations for the Choice Program and the very, very modest 
increase for traditional VA care. Who wants to comment? Is that 
a concern of you guys? Mr. Blake, is that a concern? We will 
start with you.
    Mr. Blake. Well, I think one of the concerns is--and the 
Secretary sort of addressed this in his comments. There were a 
lot of talks about our marriages and checkbooks. I think the 
bottom line is we believe that all of the Community Care should 
be streamlined under one authority, one account, and manage it 
that way.
    I think I understand why they put Choice over here on the 
mandatory side. There are a number of reasons, things like 
discretionary caps that are holding down discretionary spending 
that place that at risk, but from the Independent Budget 
perspective, we believe they are still shorting even the larger 
discretionary pot. The differences for construction, in 
particular, which are tremendous, and when you take into 
account that outside of the health care accounts, virtually 
every other line item in the VA's budget takes a reduction of 
some type----
    Senator Sanders. Right, right. Let me get other comments, 
if I could.
    Anybody else want to comment?
    Mr. Acosta. Well, I concur with Mr. Blake.
    Senator Sanders. OK.
    Mr. Fuentes. I would also just like to add, this whole 
notion of having a mandatory program and discretionary issues 
and not being able to transfer, I think it is more about, as 
Carl said, having one checkbook instead of requiring VA to have 
to balance both.
    Ultimately, you are absolutely right, Senator. We cannot 
forget the need to invest in VA's ability to provide direct 
care, hire more physicians, expand facilities, because, 
ultimately, that is the preferred choice of veterans, and we 
need to continue that.
    Senator Sanders. John?
    Mr. Rowan. Yeah, I would just like to add, look, I have 
studied privatization. I worked for the city of New York as a 
manager for 26 years and the last 2 in the City Council in the 
Controller's office looking at all of those kinds of programs. 
I watched them privatize all kinds of things that never worked, 
because once you go outside and privatize, you are adding 
layers of bureaucracy and cost. You are not going to give it--
you are not going to a doctor. You are going to a plan. The 
plan is going to be administrated by somebody who is making $2 
million a year, and thank God our VA people are not paid that 
much. They maybe should be, as I will tell you in my hospital 
care that I got at the VA Manhattan Hospital. But, that is not 
what we should be doing.
    Senator Sanders. OK. Let me ask you for your very brief 
thoughts on a crisis that is impacting Vermont, NH, and the 
whole bloody country, which is this opioid epidemic. My 
impression is that the VA is trying to do the right thing. What 
are your thoughts on that? Who wants to jump in there? Mr. 
Fuentes?
    Mr. Fuentes. It is certainly an epidemic that must be 
addressed. We hear about anecdotes where veterans are being 
overmedicated.
    One of our concerns, though, I think would be the reverse 
as well because what we have heard is cutting off veterans 
without proper alternatives, and we certainly do not want that 
either. We do not want an overcorrection, but we do want to 
eliminate overmedication.
    Senator Sanders. Other thoughts?
    Mr. Acosta. I agree.
    Senator Sanders. OK. Mr. Chairman, thanks very much.
    Chairman Isakson. Thank you, Senator Sanders. I want to 
again thank all our VSO members for coming. I know when you go 
after the big guy and he testifies and we take 2 hours grilling 
him and then everybody is gone and you are stuck with me and 
the Secretary, which I want to commend the Secretary for 
staying through both panels. We really appreciate it. Your 
words are heard. We appreciate your input. We look forward to 
working with you toward providing the benefits that are earned 
and deserved for our veterans and doing it in the most 
efficient way possible for the taxpayer. That is our ultimate 
goal as a Committee.
    We thank you very much for your attendance today. The 
record will stay open for 7 days for any additional information 
you may want us to have. Now this Committee meeting stands 
adjourned.
    [Whereupon, at 4:39 p.m., the Committee was adjourned.]
 Response to Posthearing Questions Submitted by Hon. Johnny Isakson to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
                         information technology
    Question 1.  One of the Department of Veterans Affairs' (VA) 
motivations in moving to Cerner for the VA Electronic Health Record was 
the speed with which VA will be able to implement this solution. Please 
provide the Committee a broad timeline of VA's expectations in 
implementing the new system.
    a. How is VA planning to utilize the Department of Defense to learn 
from their experience implementing a large information technology (IT) 
acquisition?
    Response. VA is judiciously balancing the speed of implementation 
with risks to cost, schedule and performance objectives, and of course 
the care of our Veterans and other beneficiaries. VA has been working 
closely with DOD and ensuring alignment with commercial implementation 
best practices to optimize our prospective schedule. VA will be looking 
to go faster as our learning increases, and change management, 
training, and governance strategies take hold in support of greater 
deployment/implementation efficiencies. As an additional barometer of 
how aggressive VA is in their plan, DOD is deploying over a 7-year 
period under its 10-year contract with less than one-third of the size 
and substantially less complex than VA. VA will assess our full 
deployment (FD) strategy upon completion of Initial Operating 
Capabilities (IOC) roll-out over the first 18 months, and incorporate 
schedule efficiencies as warranted.

    b. How much additional funding does VA anticipate requesting for 
the transition of Electronic Health Records?
    Response. The VA requested to transfer $782 million in FY 2018 to 
implement the EHRM contract, PMO efforts and support infrastructure.

    c. Given the large number of ongoing IT contracts that VA has, how 
does VA plan to evaluate the current projects to determine if they are 
necessary after the transition to Cerner?
    Response. As part of the overarching EHRM effort, the Veterans 
Health Administration (VHA) and the Office of Information and 
Technology (OI&T) are evaluating health IT and related area projects 
and contracts currently underway to determine which efforts should 
continue, be paused, modified or canceled.

    d. From an acquisition standpoint, does VA have the ability to 
modify contracts post-award, based on internal preferences, to change 
out solution components or team members that were selected under 
specific Request for Proposal criteria?
    Response. Yes. This is a firm-fixed price contract with clearly 
delineated and discrete deployment schedules, timelines, and 
milestones. Though there are no ``built-in'' penalties, the VA 
Contracting Officer and Program Management Office (PMO) are authorized 
to withhold payments for failure to perform contracted services or 
deliver contracted capabilities in accordance with the terms and 
conditions of the contract. The issuance of task orders will be 
judiciously managed to ensure excessive risk to the achievement of 
cost, schedule and performance objectives is not injected into the EHR 
modernization portfolio.

    e. If so, how does that affect liability and the burden of risk in 
the underlying contract? Do changes post-award shift the burden of risk 
from the prime contractor and team that was selected over to VA since 
the modification was made after the contract and terms were already 
awarded?
    Response. Post-award contractual changes may shift the burden of 
risk; however, since task orders are intended to stay within the 
general scope of the basic contract, VA should be protected against 
liability claims. Moreover, and as detailed above, since VA does not 
intend to mandate the use of a specific product, partner or methodology 
in order to meet contractual requirements, it will be further protected 
against liability claims. If the use or incorporation of a particular 
product or methodology is required, then the parties will work toward a 
bilateral agreement whereby the prime contractor will maintain the 
burden of risk and the adherence to the requisite performance 
parameters.

    f. How does VA plan to address elements such as time or cost 
overruns and increased protests due to requirements changes post-award, 
thus impacting the ability to provide timely solutions to our veterans 
for improving healthcare services?
    Response. VA is already operating on the Veterans Health 
Information Systems and Technology Architecture (VistA) platform 
delivering the requisite capabilities. In the event of a protest, VA 
will continue to utilize the VistA platform to support Veterans until a 
protest is formally adjudicated. The indefinite delivery and indefinite 
quantity (IDIQ) type contract and site surveys in advance of deployment 
will support the identification of issues that could cause scope creep 
or negatively impact schedule in advance of committing resources.
                              construction
    Question 2.  VA's testimony submitted for the hearing highlights 
VA's participation in the White House Infrastructure Initiative to 
explore ways to modernize and obtain upgrades to VA's real property 
portfolio. Please provide additional details on VA's participation in 
this initiative and the process VA is using to examine its real 
property portfolio.
    Response. VA is participating in the White House Infrastructure 
initiative, and is working with the Office of Management and Budget 
(OMB) to explore methods to enhance the delivery of high quality care 
and services for Veterans in VA facilities. The Department will 
continue to keep Congress informed as the Infrastructure Initiative 
evolves.

    Question 3.  The fiscal year 2018 budget request includes $255 
million for construction of six cemetery projects.
    a. In terms of locations across the country and types of 
interments, please describe some the most immediate priorities for 
increasing veterans' access to National and State veterans cemetery 
options.
    b. What would those needs be over the next decade if this funding 
request for expansion in fiscal year 2018 is provided?
    Response. The National Cemetery Administration (NCA) administers 
burial and memorial benefits to Veterans and eligible family members 
worldwide. Currently, VA operates and maintains 135 national cemeteries 
in 40 states, and Puerto Rico, and is in the process of establishing 
new cemeteries. VA has also funded the establishment, expansion, or 
improvement of 105 state and tribal Veterans cemeteries in 47 states, 
Guam, and the Northern Mariana Islands (Saipan), through the Veterans 
Cemetery Grant Program (VCGP). Combined, these cemeteries provide 
burial options to approximately 91.7 percent of the total Veteran 
population in all 50 states, Puerto Rico, and the U.S. Island Areas.
    NCA's near term focus is establishing congressionally approved and 
planned cemeteries, increasing availability of state and tribal 
Veterans cemeteries, and keeping existing national cemeteries open 
through expansion.
    New burial policies approved by the Congress in 2011 and 2013 
support NCA's Long Range Plan for 18 new national cemeteries--including 
in urban and rural locations. Additionally, VA is establishing five new 
columbarium-only cemeteries to enhance burial access for approximately 
2.4 million Veterans residing in densely populated areas. Moreover, NCA 
is improving burial access for Veterans residing in sparsely populated 
rural areas not meeting the criteria for new national cemeteries, and 
which are unlikely to receive a grant for a state Veterans cemetery. 
Eight such identified locations will serve an additional 133,000 
Veterans.
    Four of the 18 new cemeteries have already opened at Yellowstone 
County, MT (2014); Cape Canaveral, FL (2015); Tallahassee, FL (2015); 
and Omaha, NE (2016). NCA plans to open the remaining 14 (listed below) 
by 2021 at which point over 3 million Veterans and their families will 
have new access to burial options.

 
----------------------------------------------------------------------------------------------------------------
                                                                        Uniquely
                                                                         Served
                  City                              State               Veterans           Type Interments
                                                                       within 75
                                                                         Miles*
----------------------------------------------------------------------------------------------------------------
                   Cities with at least 80,000 Unserved Veterans within a 75 Mile Service Area
----------------------------------------------------------------------------------------------------------------
Colorado Springs.......................  Colorado..................     278,137              All Burial Options
Western New York (Buffalo).............  New York..................      87,538              All Burial Options
----------------------------------------------------------------------------------------------------------------
                                      Cities Targeted for Rural Initiative
----------------------------------------------------------------------------------------------------------------
Twin Falls.............................  Idaho.....................      12,789              All Burial Options
Machias................................  Maine.....................       3,381              All Burial Options
Elko...................................  Nevada....................       4,964              All Burial Options
Fargo..................................  North Dakota..............      24,855              All Burial Options
Cedar City.............................  Utah......................      15,904              All Burial Options
Rhinelander............................  Wisconsin.................      19,109              All Burial Options
Cheyenne...............................  Wyoming...................      17,103              All Burial Options
----------------------------------------------------------------------------------------------------------------
                             Cities Targeted for Enhanced Service (Urban Initiative)
----------------------------------------------------------------------------------------------------------------
Los Angeles............................  California................     539,163                                Columbarium only
San Francisco..........................  California................     444,434                                Columbarium only
Chicago................................  Illinois..................     557,861                                Columbarium only
Indianapolis...........................  Indianapolis..............     250,245                                Columbarium only
New York...............................  New York..................     782,139                                Columbarium only
----------------------------------------------------------------------------------------------------------------
* The Veteran populations cited above are based on the Vet Pop 2016 model.

    VA also helps fund new or expanded state and tribal Veterans 
cemeteries through the VCGP. NCA currently has no plans to establish 
more national cemeteries beyond the planned 18, but is committed to 
providing reasonable access to burial options through VCGP grants for 
state and tribal Veterans cemeteries. In total, we anticipate that by 
the end of 2018, 92.3 percent of the total Veteran population (over 20 
million Veterans) will have access to burial options in national, state 
or tribal Veterans cemeteries, within 75 miles of their home. Shown 
below is a list of planned expansion and establishment VCGP projects 
funded through FY 2018.

        2017 Grants for Construction of State Veterans Cemeteries
------------------------------------------------------------------------
       Cemetery               State                 Type of Grant
------------------------------------------------------------------------
Rocky Gap............  Maryland...........  Expansion
Knoxville-2..........  Tennessee..........  Expansion
Higginsville.........  Missouri...........  Expansion
King.................  Wisconsin..........  Expansion
Springfield..........  Montana............  Expansion
Middletown...........  Connecticut........  Expansion
Hopkinsville.........  Kentucky...........  Expansion
Milledgeville........  Georgia............  Expansion
Radcliff.............  Kentucky...........  Expansion
Gallup...............  New Mexico.........  Establishment
Cass Lake............  Minnesota..........  Establishment
Fort Yates...........  North Dakota.......  Establishment
Middle town..........  Connecticut........  Operations and Maintenance
Maui.................  Hawaii.............  Improvement
Lanai................  Hawaii.............  Improvement
Killeen..............  Texas..............  Improvement
Mission..............  Texas..............  Improvement
Hilo II..............  Hawaii.............  Improvement
------------------------------------------------------------------------


        2018 Grants for Construction of State Veterans Cemeteries
------------------------------------------------------------------------
       Cemetery                    State                Type of Grant
------------------------------------------------------------------------
West Hawaii..........  Hawaii......................  Expansion
Spanish Fort.........  Alabama.....................  Expansion
Garrison Forest......  Maryland....................  Expansion
Spring Lake..........  North Carolina..............  Expansion
Black Mountain.......  North Carolina..............  Expansion
Killeen..............  Texas.......................  Expansion
Suffolk..............  Virginia....................  Expansion
North Little Rock....  Arkansas....................  Expansion
Boscawen.............  New Hampshire...............  Expansion
Saipan...............  Northern Mariana Islands....  Expansion
Jennings.............  Louisiana...................  Establishment
Angel Fire...........  New Mexico..................  Establishment
------------------------------------------------------------------------

Existing Cemeteries:
    In addition to increasing access through new national and grant-
funded cemeteries, NCA maintains access at existing cemeteries through 
major and minor construction projects to develop additional gravesites 
and columbaria, or by acquiring more land. Requested funding for these 
initiatives varies based on projected burial workload and gravesite 
depletion forecasts. The FY 2018 budget includes $255.9 million in 
Major Construction funding for gravesite expansion at six national 
cemeteries, and advance planning and design activities. Gravesite 
expansion projects at National Cemetery of the Alleghenies, PA; Florida 
National Cemetery, FL; Abraham Lincoln National Cemetery, IL; National 
Memorial Cemetery of Arizona, AZ; Sacramento Valley National Cemetery, 
CA; and Calverton National Cemetery, NY will enable these cemeteries to 
remain open. Together, these cemeteries provide over two million 
Veterans with access to burial options. FY 2018 funding will be used to 
complete master planning, design, and construction in time for 
necessary modifications prior to the anticipated depletion of burial 
options, and to avoid a temporary closure at one or more cemeteries.
    The FY 2018 request includes $98 million for minor construction 
projects to develop additional gravesites at existing cemeteries, 
support the urban and rural initiatives, acquire land, and make 
infrastructure improvements. NCA relies heavily on minor construction 
funding to develop additional gravesites for smaller scale projects to 
keep existing cemeteries open.
    The enclosure provides information related to depletion of 
gravesites for national cemeteries projected to deplete gravesites 
within the next 10 years. Projects in italics represent those with an 
immediate need to prevent a burial option from closing. This list does 
not include gravesite expansion projects that are funded, currently 
underway, or not projected to deplete within 10 years.





    c. What would those needs be over the next decade if this funding 
request for expansion in fiscal year 2018 is provided?
    Response. The enclosure provides information related to depletion 
of gravesites for those national cemeteries projected to deplete 
gravesites within the next 10 years. This information includes cemetery 
names, current operating status, and years in which specific burial 
options are projected to deplete. The projected depletion dates account 
for, and assume the completion of current, in-progress gravesite 
expansion construction projects on schedule. The depletion dates do not 
account for any potential future gravesite expansion construction 
projects. Bold highlights are the six cemetery expansion projects 
included in the 2018 Major Construction request of $255.9 million.
                              medical care

    Question 4.  VA's testimony submitted for the hearing indicates 
that, after becoming the Under Secretary for Health, Secretary Shulkin 
``discovered that years of ineffective systems and deficiencies in 
workplace culture led to [the access] problem.'' While VA has made 
strides in improving care to veterans, more work is needed.
    a. What were some of the ineffective systems and deficiencies that 
contributed to the access issue?
    Response. VA identified several factors that contributed to 
extended appointment wait times, including:

    1. Increased patient requirements for care coupled with inadequate 
staffing levels of providers, nurses, and schedulers led to inability 
to keep up with the demand for care;
    2. Inefficient clinic practices, lack of adequate training, and 
complicated legacy software led to high rates of scheduling errors; and
    3. Lack of national oversight and local monitoring systems meant 
access red flags were not responded to in time and proactive strategies 
were not set in place.

    b. What specific changes have been made to improve the system?
    Response. Since 2015, VA embarked on its largest access 
transformation, a major part of which was the MyVA Access improvement 
endeavor. Subject matter experts across VA were sequestered for 4 weeks 
to identify ineffective systems and deficiencies contributing to VA 
access shortfalls, standardize national guidance, and implement strong 
practices. Through MyVA Access, VA developed a comprehensive approach 
toward systemic access improvements. Specific changes related to the 
aforementioned reasons are as follows:

1. Increased patient requirement for care coupled with inadequate 
        staffing levels of providers, nurses, and schedulers led to 
        inability to keep up with the demand for care.
    Provider Recruitment and Productivity: VA prioritized active 
recruitment of healthcare providers and clinic staff--supported by the 
Veterans Access, Choice and Accountability Act of 2014. This resulted 
in increasing provider and nursing staff by approximately 12 percent 
over the past 2 FYs. Additionally, on January 13, 2017, VA full 
practice authority went into effect for all Advance Practice Registered 
Nurses (APRNs). This rule is expected to continue to grow and fill gaps 
with access coverage. VA also focused on improving productivity for 
existing providers. By assessing clinical workload by the community 
standard of work RVUs (work relative value units), VA marked a 13 
percent increase in total clinical productivity (wRVUs) produced and an 
increase in physician productivity, wRVU per clinical full-time 
equivalents (FTE), of 9 percent from FY 2014 to April 15, 2017.
    Utilizing internal resources: VA focused on increasing the use of 
telehealth for Primary Care and Mental Health. As a result, 12 percent 
of Veterans (727,000) receiving VA care from obtained 2.18 million 
telehealth appointments. VA has also expanding telehealth ``hubs''--
medical centers that easily hire providers to deliver telehealth to 
another part of the country where a provider shortage exists. As of the 
end of 2017, VA has nine fully operational hubs in Primary Care and 11 
in Mental Health. Additionally, some Veterans Integrated Service 
Networks (VISNs) have been setting up their own hubs.
    VA is also working to implement VA Video Connect, a simplified 
mobile and web-based application connecting Veterans with providers 
using encrypted video. It allows Veterans to see and talk to their 
health care team from anywhere using their smart phone, iPad or desktop 
computer, making appointments more convenient and reducing travel and 
wait times. VA is in the process of implementing this across VA.
2. Inefficient clinic practices, lack of adequate training, and 
        complicated legacy software led to high rate of scheduling 
        errors.
    Clinic Practice Management: Beginning in early 2016, VA implemented 
a Clinic Practice Management program at each VA Health Care System 
based upon private sector and DOD best practices to optimize 
administrative activities. This program monitors data and oversees 
timeliness and accuracy of Veteran appointments. Each VA system has at 
least one Group Practice Manager as well as a Clinic Practice 
Management team. A user-friendly Clinic Practice Management dashboard 
allows the Group Practice Managers as well as facility leadership to 
monitor clinic activities. This dashboard includes scheduling 
performance data down to each individual scheduler.
    Scheduler Training: VA recognized its scheduler training in the 
past was ineffective. To reduce scheduling errors, VA enhanced its 
training and identification of scheduling error warning signs. In 
December 2016, VA commenced system-wide mandatory face-to-face 
scheduler training, including hands-on supervised practice scheduling 
sessions. All newly hired schedulers must successfully complete this 
training. Over 30,000 schedulers have completed the training.
    Scheduling Directive: Revisions and clarifications on national 
guidelines were included in VHA Directive 1230, Outpatient Scheduling 
Processes and Procedures, published on July 15, 2016. VA completed over 
70,000 episodes of directive-related training for over 50,000 staff who 
schedule appointments. Using Lean methodology, VA is also in the 
process of simplifying the scheduling process, which was initiated 
based upon input from front-line staff including schedulers. This is 
expected to result in a simplified update to scheduling and consult 
directives.
    VistA Scheduling Enhancement: Using 1980's technology, VA's current 
scheduling system is inefficient, results in scheduling errors, and 
creates barriers to optimize clinician productivity. Until the time a 
comprehensive resource-based scheduling system can be deployed VA is 
implementing VistA Scheduling Enhancement (VSE) as an interim solution. 
This improved user interface makes it easier to view available 
appointment times and reduces entry errors. The VistA Scheduling 
Enhancement has been implemented in 97% of facilities within VA.
3. Lack of national oversight and local monitoring systems meant that 
        red flags were not responded to in time.
    New National Establishments: The Office of Veteran Access to Care, 
a national level program office, was created in 2016. The office 
provides oversight and direction for policy and operations for 
optimization of Veteran access to health care. This office is led by an 
executive-level Assistant Deputy Under Secretary for Health for Access 
to Care who directly reports to the Deputy Under Secretary for Health 
for Operations and Management, and also has a platform for interaction 
and feedback with the Secretary, Deputy Secretary, Under Secretary for 
Health and Principal Deputy Under Secretary for Health.
    VA established a Health Improvement Center to track trends in 
quality, safety, access, and Veteran experience across multiple 
indicators. Sites that display anomalies or unfavorable trends are 
contacted and, where it is determined sub-par performance exists, the 
new Office of Reporting, Analytics, Performance Improvement, and 
Deployment, within the VHA Office of Organizational Excellence, 
mobilizes a team of experts to visit the site and provide on-site 
training and consultation, with follow-up to assure that progress is 
made.
    Scheduling Triggers and Audits: Using advanced statistical 
techniques, Scheduling Triggers were implemented as an early warning 
sign to alert leadership about inconsistencies with scheduling 
procedures and timeliness of care. Additionally, a mandatory 
standardized Supervisory Audit Tool was implemented June 1, 2017 to 
ensure every scheduler is audited at least twice annually. Audit 
results lead to direct feedback and coaching of individual schedulers, 
and is used by Facility, VISN and National leadership to ensure 
compliance, and assist with identifying opportunities for improvement.
4. Additional Improvements to improve access.
    Timely Care: VA has made it a priority to focus on ensuring that 
the urgent care needs of Veterans are met in a timely manner. VA held 
two stand downs in November 2015 and February 2016 to reduce backlogs 
and ensure Veterans with urgent needs received timely care. 
Additionally VA worked to deliver same-day services for Primary Care 
and Mental Health. As of December 31, 2016, same-day services were 
achieved at all VA medical centers and as of November 2017, same day 
services is now available at the more than 1000 outpatient clinics 
across VA.
    VA also standardized processes to ensure new referrals to 
specialists are screened for urgent needs. In FY 2014, the average time 
it took to complete the most urgent referrals to a specialist was 31.3 
days. As of December 2017, the average time was 2.6 days. In support of 
the focus on urgent consults, VA instituted a weekly national consult 
management call whereby scheduling experts provide technical assistance 
to the field to ensure the timeliness of scheduling. The calls 
commenced in 2015 and have become a driving force supporting timely 
scheduling and completion of urgent consults.
    To ensure the timely follow-up care for Veterans with urgent needs, 
in December 2016 VA implemented a process for providers to indicate 
priority level for follow-up appointments to ensure that Veterans' 
timely follow-up needs are met. Providers flag these time-sensitive 
appointments in the return to clinic order to signal the scheduler to 
arrange for the follow up appointment no later than the provider 
recommended date. Since implementation through the end of FY 2017, 
128,000 time-sensitive appointments were completed across VA and of 
those about 90 percent have been completed by the provider recommended 
date. Over the first 3.5 months of FY 2018, almost 80,000 such 
appointments have been completed and of those, 94.8% have been 
completed by the provider recommended date.
    Veteran Control: VA is working to empower Veterans to schedule the 
care they need. The Veterans Appointment Request App enables Veterans 
to schedule or cancel Primary Care appointments, and has been deployed 
to 1 14 sites since January 2017. VA also instituted Direct Scheduling 
allowing Veterans to request routine audiology, optometry, and 
nutrition appointments without having to obtain a referral from a 
Primary Care Provider. This not only decreased the wait time for 
services, it freed up primary care capacity. VA is working to expand 
Direct Scheduling options to podiatry, prosthetics, wheelchair, 
screening mammography, smoking cessation, and weight management 
appointments as well.
    Access and Quality in VA Healthcare website: In April, VA launched 
the ``Access and Quality in VA Healthcare'' website at 
www.accesstocare.va.gov to promote transparency. Through this tool, 
Veterans, their families, and caregivers can view data related to:

     Patient wait times at VA facilities in their area;
     Veterans experiences scheduling primary and specialty 
care;
     Available options for same day services; and,
     Quality of healthcare delivered at every medical center.

    Question 5.  The fiscal year 2018 budget request estimates a 
reduction in medical care collections for fiscal year 2017 and fiscal 
year 2018. Please explain in detail what factors contributed to this 
estimated decrease in collections.
    Response. There are several key factors that contribute to the 
stable/declining collections estimate for 2017 and 2018:

    1. Tiered Medication Copayments: Effective February 27, 2017, VA 
amended its regulations governing copayments for certain Veterans for 
medication required on an outpatient basis to treat non-service-
connected conditions. Prior to this change, the medication copayment 
was $8 per fill for Veterans in Priority Groups 2--6 with an annual out 
of pocket cost cap of $960. For Veterans in Priority Groups 7 & 8, the 
medication copayment was $9 per fill and there was no out of pocket 
cost cap. Under current policy, per fill copayments are $5 for Tier 1 
medications, $8 for Tier 2 medications, and $11 for Tier 3 medications; 
with an annual out of pocket cost cap of $700 applicable to Priority 
Groups 2--8. Under the revised regulations, the average copayment per 
prescription is less than in the past. Thus, VA estimates collections 
for these pharmacy copayments will be lower in 2017 and into the 
future.
    2. Third Party Collection or Recovery: Changes in the healthcare 
landscape have caused payers to adjust rates and/or reimbursement 
methodologies to minimize expenditures. 38 CFR 17.101 permits health 
plan contracts to pay billed charges or the amount they would pay for 
care or services furnished by providers in the same geographic area. 
Historically, many health plan contracts paid VA 100 percent of billed 
charges or above market rates. During the last six months of 2016, five 
large payers reduced reimbursement rates, or requested a decrease to 
align VA with what they are paying other providers in their respective 
markets. Additionally, VA has been tracking six payers identified as 
being at ``high risk'' for reducing payments based upon high 
reimbursement rates. These payers may request reductions in 
reimbursement rates with 30 to 120 days' notice.
    Additional factors: VA's Third Party reasonable charges are 
projected to decrease in CY 2017 by an average of 3 percent, which 
translates to a negative impact on collections; in particular for 
payers reimbursing on a percent of charge basis. Pursuant to 38 CFR 
17.101, outpatient charges are calculated at the 80th percentile of 
various data sources such as Fair Health, MarketScan and Medpar for the 
Centers for Medicare & Medicaid Services (CMS)/Medicare data. In 2017, 
VA experienced a decrease in outpatient charges as a result of 
decreased charges in the Fair Health data as well as decreased charges 
for Durable Medical Equipment (DME) in the CMS data.
                               education
    Question 6.  One of VA's priorities is to improve timeliness of 
service, and VA has made it a goal to fully automate claims for 
veterans' education benefits and consolidate outdated enrollment 
certification systems. This would produce faster decisions, reduce 
labor and administrative costs, and improve accuracy of claims. Is the 
decision to postpone this development due to a lack of IT resources or 
are there other practical considerations for waiting?
    Response. VA is prioritizing the retirement and replacement (when 
warranted) of its legacy information technology systems due to the 
increased cost, risks with maintaining these systems, and the need to 
modernize our business processes to improve service delivery. For 
example, the Benefits Delivery Network (BDN) is the claims processing, 
payment, tracking, and disposition system used for education programs 
but consists of antiquated mainframe systems and is in need of 
replacement. VA is currently working on a solution to address its 
enterprise IT challenges, and is prioritizing accordingly to ensure 
that replacement systems meet the needs of all users and Veterans. Once 
these systems are replaced VA can redirect its focus on newer systems. 
For example, enhancing the Long Term Solution to provide functionality 
such as automated certificates of eligibility for original claims; 
electronically generated letters; expanded automation of supplemental 
claims; issuance of advance payments; monthly certification of 
attendance; and improved business analytics for reporting purposes.
                                appeals

    Question 7.  At the hearing, Secretary Shulkin testified that VA 
would need an additional $800 million in order to address the 470,000 
legacy appeals.
    a. Please provide copies of the modeling data and assumptions used 
in reaching that conclusion.
    Response. VA is committed to addressing the pending inventory of 
legacy appeals. Since the Secretary's testimony, several enhancements 
to VA's appeals process have influenced the assumptions VA uses to 
inform resource decisions. Following enactment of the Veterans Appeals 
Improvement and Modernization Act on August 23, 2017 VA immediately 
began implementation. By February 2019, all requests for review of VA 
decisions will be processed under the new, multi-lane process. VA is 
also continuing work to address the pending inventory of legacy appeals 
through an approach that focuses resources on legacy appeals processing 
while also allowing Veterans to enter the new appeals system.
    VA established a new program on November 1, 2017, the Rapid Appeals 
Modernization Program (RAMP), to provide those Veterans who are waiting 
on the legacy appeals process, an opportunity for early participation 
in the new system. The administration of RAMP allows VA the opportunity 
to quickly resolve legacy appeals and to test certain facets of the new 
appeals system. VA will refine the new system based upon actual data 
prior to full implementation. VBA will direct appeals resources to 
maintain RAMP claims processing within prescribed timeliness goals as 
well as continue to process legacy appeals.
    VA will also utilize the legal authority for Veterans who receive 
Statements of the Case or Supplemental Statements of the Case after the 
effective date of the legislative change to elect to participate in the 
new system and transition from the old process.
    Once the new system is implemented, VA intends to allocate 
resources in an efficient manner that will establish timely processing, 
and utilize all remaining appeals resources to address legacy appeals. 
The Board will focus its resources on its core mission and will work to 
maximize efficiencies in appeals processing, to include technological 
and process improvements. This will enable the Board to also meet 
timeliness goals in the new system and devote all remaining resources 
to processing legacy appeals.
    The rate at which the legacy appeals inventory can be resolved is 
dependent on a number of factors, including the rate of election into 
the new framework process of claimants with appeals pending in the 
legacy system. As VA gathers data, and creates a forecasting model 
based upon actual Veteran behavior and employee productivity, this will 
inform resource needs and help establish achievable goals and 
milestones for reducing the number of pending legacy appeals, including 
the expected number of appeals, remands, and hearing requests at VBA 
and the Board.

    b. Please explain what steps VA has taken or will take to identify 
or secure any resources necessary to address the backlog of legacy 
appeals.
    Response. VA remains committed to reducing the pending inventory of 
legacy appeals as quickly and efficiently as possible. In January 2017, 
the Veterans Benefits Administration (VBA) realigned its appeals policy 
and oversight of its national appeals operations under a single office, 
the Appeals Management Office (AMO). This realignment allows VBA to 
focus on internal people, process and technology appeals initiatives, 
and implementation of the appeals reform legislation. Under this 
realignment, VBA's appeals productivity through May 31, 2017, has 
increased by 32 percent over FY 2016 production during the same period.

    Question 8.  According to the fiscal year 2018 budget request, the 
Board of Veterans' Appeals (Board) had 660 employees in fiscal year 
2016, expects 886 employees in fiscal year 2017, and requests 1,050 
employees for fiscal year 2018. The budget request also reflects that 
the Board issued 52,000 decisions in fiscal year 2016, expects to issue 
nearly 66,000 decisions in fiscal year 2017, and expects to issue over 
80,000 decisions in fiscal year 2018.
    a. As of March 2017 (half way through the fiscal year), the Board 
had issued about 19,000 decisions. Is the Board still expecting to 
issue over 66,000 decisions in fiscal year 2017? If not, please outline 
the factors that have contributed to not meeting that target and how 
many decisions the Board now expects to issue during fiscal year 2017.
    Response. The Board is committed to its mission to hold hearings 
and decide appeals for Veterans and their families. Unfortunately, due 
to a variety of reasons, the Board did not meet its FY 2017 goal. There 
were a number of contributing factors, to include, hiring falling short 
of goals; the impact of revised attorney performance standards; time 
spent training and mentoring new attorneys; time attorneys spend on 
FMLA/leave and on official time; outdated technology; complexity of 
cases; and Veterans Benefits Management System user difficulties. As of 
June 25, 2017, the Board issued 32,598 decisions. compared to the 
37,490 that it had issued during the same time period in the prior 
fiscal year. As more Board attorneys complete training and become fully 
productive, the Board projects increased productivity in the remaining 
weeks of FY 2017. We anticipate that the Board will decide at least 
50,000 appeals by the end of FY 2017.

    b. In a June 8, 2016, memorandum to stakeholders about appeals 
reform, VA noted as a risk factor that ``staffing ramp at the Board is 
steep and challenging.'' What challenges has the Board faced since 2016 
in hiring additional employees; what steps is the Board taking to 
address those challenges; and what impact has that hiring had on 
overall productivity at the Board?
    Response. In FY 2017, Congress provided an additional $45.7 million 
to the Board to facilitate hiring additional personnel. To support the 
Board's aggressive hiring in FY 2017, the Center of Excellence Pilot 
Program for hiring legal professionals was established with VA's Office 
of Human Resources and Administration (HRA). The Board made great 
progress in hiring early in FY 2017, consistent with the budget, but 
was slowed by the hiring freeze. On March 13, 2017, the Secretary 
approved exemptions for eight occupations directly involved in appeals 
processing. Since that time, the Board resumed its aggressive hiring 
plan and, as of June 29, 2017, the Board had 882 FTEs employees on 
board, compared to 667 FTEs at the start of FY 2017. Additionally, the 
Board is in the process of filling approximately 100 additional 
attorney positions, as well as other key vacancies. As more Board 
attorneys completed training and became fully productive, the Board 
projected an increased productivity in the remaining weeks of FY 2017. 
At the end of FY 2017, the Board issued 52,661 appeals decisions.

    c. Would the Board expect to encounter similar difficulties in 
hiring an additional 164 employees during fiscal year 2018? If so, 
please outline what steps would be taken to mitigate those risks.
    Response. The Board does not anticipate difficulties in hiring 
additional employees during FY 2018. The Board has worked successfully 
with the Center of Excellence to on board over 200 new attorneys in FY 
2017 to date. Based on this proven ability to hire and on board a large 
number of new employees, the Board does not anticipate difficulties in 
hiring additional employees in FY 2018. We plan to continue to work 
closely with HRA to accomplish our hiring objective.

    d. When would the Board expect to realize an overall increase in 
productivity as a result of employees hired during fiscal years 2017 
and 2018?
    Response. The Board has a 6-month period during which new attorneys 
receive training and develop the necessary skills to effectively 
produce quality decisions in a timely manner. Therefore, new Board 
attorneys are not fully productive until after they have completed 
their 6-month training period. The Board anticipates that we will see 
incremental increases in productivity as new employees complete this 
training period. We would project all employees to be fully productive 
6 months after we complete our FY 2018 hiring plan. Notably, while 
Board attorneys are on production after 6 months, most cannot handle 
and are not given the most challenging cases until their 2-year point.

    e. What steps--other than hiring new employees--is the Board taking 
to improve overall productivity; what is the cost of each such 
initiative; and what impact is each such initiative expected to have on 
productivity?
    Response. The Board is committed to improving productivity. The 
Board is modernizing appeals processing technology to optimize 
efficiency to best serve Veterans and their families, and to ensure the 
seamless transfer of appeals between jurisdictions by leveraging 
industry best practices and Human Centered Design principles. The Board 
is fortunate to have Digital Service at VA (DSVA) leading the technical 
approach to this effort. Specifically, DSVA is developing several 
attorney-specific tools, including a document review tool for claims 
file review; a Decision Builder; and eFolder Express, providing a one-
click download of the eFolder. These tools are intended to assist 
decision-writing attorneys in reviewing the record and drafting 
decisions more efficiently. The Board revised its attorney performance 
standards in October 2016. After using these standards for one quarter 
and evaluating their effectiveness in enabling the Board to meet its 
mission, the standards were revised again, effective January 15, 2017. 
The Board continually monitors performance, and during FY 2017 was in 
negotiations with the union about revising the attorney performance 
standards, to best position the Board to meet its goal of deciding 
appeals. As a result, new standards went into effect at the start of FY 
2018. There are no anticipated additional costs to the Board for the 
technological changes being developed by DSVA, because their 
development work is ongoing and all funding for these changes is 
covered by the existing Appeals Modernization budget.
                                 ______
                                 
   Response to Posthearing Questions Submitted by Hon. Jon Tester to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    Question 9.  Does this budget allow for VA to accommodate those 
Veterans who are currently not enrolled in VA care but who may lose 
their other health insurance if Obamacare is repealed?
    Response. Any impacts on Veterans or VA would depend on the 
specific changes to the Affordable Care Act enacted by Congress.

    Question 10.  I am concerned that the President has not accurately 
projected in-house demand for health care services. Can you explain the 
utilization and reliance projections for FYs 18 and 19? Please also 
provide data showing budget projections and actual utilization and 
reliance statistics for FY 2013, 14, 15, 16, and 17 (as available).
    Response. The following information on utilization and reliance is 
from the 2017 VA Enrollee Health Care Projection Model (EHCPM), which 
supported VA's 2018 Budget. The table below shows historical and 
projected annual change in utilization for ambulatory and inpatient 
services as modeled using the EHCPM. It separately shows data for 
Veterans eligible for the Choice Program based on the 40-mile distance 
criterion.
     Utilization in VA facilities and of community care 
increased significantly from FY 2013 to FY 2014, in part due to VA 
capacity issues that led to passage of the Veterans Access, Choice, and 
Accountability Act of 2014 (Choice Act).
     Choice Act funding helped VA sustain growth in community 
care from FY 2013 to FY 2014 and continue growth into 2015.
     From FY 2015 to FY 2016, utilization of community care 
increased significantly for Choice Program eligible Veterans based on 
residence. Utilization by eligible Veterans based on other criteria 
also increased but to a lesser extent.
     The historical and projected decline in total inpatient 
days is due to a number of factors, including transition of inpatient 
care to ambulatory facilities (a general trend in health care across 
the Nation), VA's efforts to reduce avoidable in VA's management of 
inpatient care, and changes in the enrollee demographic mix.

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

    The graph below shows historical and projected average reliance 
across all services (excluding LTSS). Reliance refers to the portion of 
an enrollee's total health care he/she is expected to receive through 
VA rather than other health care sources.

     The projected reliance reflects the impact of all known 
factors that affect enrollee reliance on VA health care, including 
economy, demographic changes in the enrolled Veteran population, and 
the anticipated impact of recent VA initiatives and changes in 
legislation and policy.
     The FY 2018 Budget request assumes that reliance by 
Veterans eligible for the Choice Program based on distance is assumed 
to increase by 10 percent per year until it reaches 50 percent by 
approximately 2021. (We assume all of these Veterans will elect to 
receive care in the community).
     Changes in the enrollee demographic mix results in 
slightly lower reliance in 2018 and 2019. New enrollees tend to be 
healthier and less reliant on VA than the enrollees who are dying.

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

    Question 11.  What projection methods are you using to anticipate 
costs of deciding not to appeal the court's decision in Staab?
    Response. To implement the Staab decision, VA published Interim 
Final Rule- AQ08 on January 9, 2018 to establish a payment methodology 
that will apply to claims where partial payment was made by the 
Veterans' health insurance plan. The regulation incorporates the 
statutory limitation that VA unable to provide reimbursement for any 
copayment, coinsurance, deductible, or other similar payment a Veteran 
is responsible for under a health plan contract. VA's current cost 
estimates for implementing the decision are based on this methodology 
and projected claim volume for outpatient and inpatient emergency 
treatment, including transportation.

    Question 12.  GAO continues to list VA health care on its high-risk 
list. Explain how this budget addresses concerns raised by GAO.
    Response. VA continues to work diligently to mitigate the 
Government Accountability Office (GAO) High Risk concerns. VA is also 
addressing GAO High Risk List issues through Modernization efforts. VA 
leveraged FY 2017 resources to exercise an option year of an existing 
federally Funded Research Development Center (FFRDC) to aid in 
designing and implementing a strategy to mitigate the risks outlined by 
GAO. Under consideration for VHA will be the possibility of funding 
further support effort with the FFRDC for GAO High Risk List work. In 
May 2017, a Root Cause Analysis (RCA) presented to GAO was met with 
positive response. VA also met with GAO on Jan 11, 2018 regarding the 
root causes for the five risk area; this also was met with a positive 
response. VA is currently updating action plans for the five high risk 
areas based on the enterprise RCA and anticipates FY 2018 resources 
will support these efforts. There are no existing discretionary line 
items in the FY 2018/FY 2019 budget to specifically address the five 
individual high risk areas. Requests for additional budgetary 
consideration will be driven by the corrective action plans. A VHA 
Office of Internal Audit and Risk Assessment, designed to conduct 
independent and objective risk-based audits to enhance oversight and 
accountability, has been funded and has achieved initial operating 
capability.

    Question 13.  The President's Budget Request includes $751 million 
for HEP C drugs. How many veterans have you treated? How many have you 
identified that still need treatment? What are you efforts to reach 
those who need treatment but may not be taking advantage of treatment 
at VA? What resources are you expending to provide education to 
veterans to avoid the spread of HEP C?
    Response. The President's Budget Request includes $751 million for 
hepatitis C virus (HVC drugs. Since January 2014 through December 31, 
2017, VA treated over 100,000 Veterans with new direct-acting 
antivirals, with cure rates between 90-95 percent. As of the end of 
December2017, there were approximately 40,000Veterans in VA care who 
needed hepatitis C treatment. Attempts have been made to contact most, 
if not all, of these patients by phone, letter, or direct provider 
contact, and many have refused treatment or were unable to be engaged 
in treatment. VA providers are continuing to reach out to these 
patients to ensure all who are interested and able receive treatment. 
VA estimates approximately 15,000-20,000 of patients who need HCV 
treatment may be difficult to engage in care and treat due to treatment 
refusal, inability contact and, treatment-limiting medical, mental 
health, or substance use co-morbidities
    VA's outreach efforts include:

    1. Field-based VISN Hepatitis Innovation Teams deploying system 
redesign/LEAN at the majority of facilities to address gaps in HCV 
testing and treatment, including outreach to at-risk populations
    2. National and local clinical informatics tools are in place 
across VA's health care system for tracking all patients diagnosed with 
HCV
    3. VA encourages all Veterans who think they may have hepatitis C 
to get tested, and if eligible for VA care, to come in to VA for 
treatment. VA has an ongoing HCV testing and treatment ad campaign in 
18 high prevalence cities in the US: www.hepatitis.va.gov/campaign-
test-treat-cure.asp VA encourages all Veterans who think they may have 
hepatitis C to get tested, and if eligible for VA care, to come in to 
VA for treatment. VA has an ongoing HCV testing and treatment ad 
campaign in 18 high prevalence cities in the US: www.hepatitis.va.gov/
campaign-test-treat-cure.asp

    Resources for HCV prevention education include:

    1. Prevention information, including transmission risk and what to 
do if you test negative or positive for HCV, are included in the 
resources on the Veteran Portal of VA's hepatitis website: 
www.hepatitis.va.gov
    2. More direct HCV prevention patient education materials are 
available at: https://www.hepatitis.va.gov/products/patient/hcv-
prevention-factsheet.asp.
    3. Treatment as Prevention (TasP) is a successful intervention for 
the prevention of HIV transmission, which has shown that people with 
HIV who have an undetectable viral load (e.g., are successfully on 
antiviral treatment) have an incredibly low, if any, possibility of 
transmitting the virus to another person. This is also true for HCV 
treatment as an intervention for HCV prevention, particularly given 
cure rates of over 90-95 percent among Veterans treated in VA in care.

    While not explicitly focused on prevention, VA's national hepatitis 
awareness campaign messaging on hepatitis C testing includes 
transmission risk information: www.hepatitis.va.gov/campaign-test-
treat-cure.asp.

    Question 14.  According to the OIG's 2016 report on staffing 
shortages, Physician Assistants are one of the top five occupations in 
greatest need. What are you doing to fill PA positions and others 
identified as having the greatest need?
    Response. Several strategies have been employed to address the PA 
occupation shortage and to enhance recruitment and retention. The 
policy governing PA practice is currently under review to identify and 
eliminate barriers to PA practice in order to promote greater patient 
access, as well as making VHA a more attractive practice environment. 
Critical access disciplines such as primary care and mental health have 
been targeted for increased training and PA utilization. For example, 
the PA Post-Graduate Patient Aligned Care Team (PACT) Primary Care 
Residency has been successful in providing advanced training in the 
PACT Patient Centered Medical Home model of care and incorporating 
graduates into VA's clinical workforce. The recent expansion of PA 
postgraduate residencies in Mental Health has been highly successful in 
attracting trainees, and has added to VA's mental health clinicians. 
Establishment of additional PA residency programs in other critical 
specialties is currently under consideration. Nationwide, the PA 
profession has experienced a robust growth in demand with a resultant 
increase in salaries. The American Academy of Physician Assistants 2016 
Salary Survey, confirmed by the Department of Labor, Bureau of Labor 
Statistics, reports the average annual starting pay for PAs is over 
$100,000. In contrast, current starting salary under the U.S. Locality 
Pay Schedule is $49,765.
    Local facilities prioritize hard to recruit and retain occupations 
based on local workforce needs. Medical Center Directors are authorized 
to approve special salary rates for PAs when recruitment or retention 
of occupations or individuals with specialized skills is difficult. VA 
is also considering using the Secretary's existing authority to include 
PAs as a covered occupation in the Locality Pay System to transition 
PAs to a market based pay system.
    Facility leadership also determines which occupations are eligible 
for consideration of other existing recruitment tools such as the 
Education Debt Reduction Program and the Employee Incentive Scholarship 
Program.

    Question 15.  Over the last few years, VA has taken action to 
create qualification standards to enable the recruitment of Licensed 
Professional Mental Health Counselors as well a Marriage and Family 
Therapists. The number of licensed professional mental health 
counselors employed by the VA declined from 72 in FY 2015 to 64 in FY 
2016 and the number of marriage and family therapists increased from 
only 15 in FY 2015 to 24 in FY 2016. This data suggest that VA's 
efforts to expand hiring of these occupations is not succeeding. What 
new initiatives is VA undertaking to hire more counselors and MFTs? 
What aspects of the President's Budget support this effort?
    Response. The addition of Licensed Professional Mental Health 
Counselors (LPMHCs) and Marriage and Family Therapists (MFTs) to the VA 
mental health workforce has expanded VA facilities' staffing options. 
The number of LPMHCs employed by VA increased from 189 at the end of FY 
2015 to 284 as of December 2017, similarly, the number of MFTs 
increased from 122 to131 over the same period. This data suggest VA's 
efforts to expand hiring of LPMHCs is working, however, is still 
experiencing challenges hiring MFTs.
    As VA's demand for mental health professionals grows, we expect 
that VA will continue to successfully recruit LPMHCs and MFTs i. 
Because LPMHCs and MFTs are relatively newer professions within VA, and 
decisions to hire into these occupations are made at a local level, the 
pace of hiring may vary from site to site.
    To promote the MFT and LPMHC professions throughout the country, 
VA's Mental Health Offices also created a marketing plan to target 
stakeholders including: Mental Health hiring officials, Human Resources 
staff and VISN and Medical Center leadership. The marketing plan 
focused on the benefits of hiring LPMHCs and MFTs, including their 
contribution to inter-professional mental health teams and their cost 
effectiveness.

    Question 16.  The VA requested separate occupational series from 
OPM for LPMHCs and MFTs in 2011. Considering VA's hiring challenges for 
other mental health providers and the Secretary's focus on veteran 
suicide, will VA reprioritize the creation of occupational series for 
LPMHCs and MFTs? If not, please explain how the lack of the series does 
not inhibit hiring efforts.
    Response. Beginning September 28, 2010, VA facilities were 
authorized to hire LPMHCs and MFTs as specialty mental health providers 
after Congress recognized these as occupational categories of mental 
health specialists in the Veterans Benefits, Health Care, and 
Information Technology Act of 2006. VA has an approved occupational 
series and title codes for this occupation under Hybrid Title 38.
    Although a standalone occupational series for this occupation does 
not exist, this has not complicated hiring within VA. VA has developed 
and established a specific qualification standard and would continue to 
use this standard even if OPM developed a standalone series; therefore, 
the creation by OPM would not have a bearing on VA's recruitment or 
retention. Qualified candidates have successfully searched, applied 
for, and been hired for VHA positions announced for this occupation as 
established under Hybrid Title 38 with the official title of Marriage 
Family Therapist or Licensed Professional Mental Health Counselor 
within the GS-0101 Series.

    Question 17.  Please provide information on the number of social 
workers and psychologists hired by the VA in FY 2015, FY 2016, and FY 
2017 to date, as well as the number of social workers and psychologists 
participating in Office of Academic Affiliation internships in FY 2015, 
FY 2016, and FY 2017 to date.
    Response. Please see table below for data through May 31, 2017. 
(Note: VHA's data pull for mental health occupations includes 
psychologists and social workers. However, social workers include all 
hires, even though they may not work in mental health specifically).

 
------------------------------------------------------------------------
                                                       FY 2017
          Occupation             FY 2015    FY 2016    thru May   Total
------------------------------------------------------------------------
Psychology....................      670        680        204      1,554
Psychiatrist..................      351        348        169        868
Licensed Prof Mental Health          72         64         43        179
 Counselor....................
Marriage Family Therapist.....       15         24          7         46
Peer Support..................      121         68         23        212
                               -----------------------------------------
    Total Mental Health Hires.    1,229      1,184        446      2,859
Registered Nurse..............    7,700      6,531      4,101     18,332
Social Work...................    1,887      1,173        783      3,843
------------------------------------------------------------------------
RN and Social Work hires are provided separately since all RNs and
  Social Workers are not assigned to a mental health area.


    Question 18.  One of the Department's goals is to change the 
culture of VA to be more welcoming to women. What in the President's 
Budget Request supports that goal?
    Response. Women Veterans currently comprise 9.6 percent of the 
Veteran population and that is expected to increase to 10.5 percent by 
2020. We are committed to providing increased access to gender-specific 
health care (genitourinary care; female cancer screening; osteoporosis; 
pregnancy and childbirth; care in a women's clinic) in a safe and 
welcoming environment. The 2018 President's Budget shows an increase of 
$33.5M for women's gender-specific care from $471.2M in 2017 to $504.7M 
in 2018.
    VA provides health care services to women Veterans, including 
primary care, gynecology care, maternity care, specialty care, and 
mental health services. VA has also focused on improving its facilities 
to meet the needs of women Veterans.
    In order to review facility accommodations for women Veterans VHA 
has adopted Environment of Care (EoC) standards. These are incorporated 
into a tablet-based survey that is conducted regularly. The facility 
Women Veterans Program Manager is a member of the EoC team. EoC data is 
shared with each facility and VISN monthly, and is the responsibility 
of the VISN Capital Asset Manager.
    When a need arises to enhance facilities, the VISN follows the 
Strategic Capital Improvement Process (SCIP). The VHA Office of Women's 
Health Services participates in this process and provides input on 
specific facility needs for women Veterans. Currently, there are 21 
projects in process (either in design, solicitation/bid, or 
construction) specific to women Veterans' health.
    VA has enhanced the provision of care to women Veterans through 
Designated Women's Health Primary Care Providers (WH-PCP). By the end 
of FY 2016, VA had trained over 3,000 WH-PCPs, and has at least one at 
all of VA's health care systems. In addition, 90 percent of community 
based outpatient clinics (CBOCs) had a WH-PCP in place. VA is training 
additional providers to ensure every woman Veteran has the opportunity 
to receive primary care from a WH-PCP.
    VA is proud of its high quality health care for women Veterans. VA 
is on the forefront of information technology for women's health and is 
redesigning its electronic medical record to track breast and 
reproductive health care. Quality measures show that women Veterans are 
more likely to receive breast cancer and cervical cancer screening than 
women receiving their care in the private sector. VA also tracks 
quality by gender and, unlike other health care systems, has been able 
to reduce and eliminate gender disparities in important aspects of 
health screening, prevention, and chronic disease management.

    Question 19.  Does this budget support the new initiative to cover 
Veterans with other-than-honorable discharges, and how much do you 
anticipate that it will cost? Considering that you are unable to 
provide these veterans with beneficiary travel compensation and access 
to non-VA care, how will you provide services under this initiative to 
veterans who do not live near a VA facility?
    Response. Effective July 5, 2017, VA began implementing an 
initiative to expand urgent mental health care to former Servicemembers 
with other than honorable (OTH) administrative discharges who believe 
their mental health condition is related to military service. This 
marks the first time VA has implemented an initiative specifically 
focused on expanding these services to former Servicemembers with OTH 
administrative discharges who are in mental health distress and may be 
at risk for suicide or other adverse behavior. Under this initiative, 
former Servicemembers with an OTH administrative discharge may receive 
care for their mental health emergency for an initial period of up to 
90 days, which can include inpatient, residential, or outpatient care. 
If after 90 days, the former Servicemember still requires emergency 
mental health services, he/she may receive another 90 day episode of 
care within the VA or be transitioned to services. Each VISN has 
developed their own protocol for requesting an additional 90-day 
episode of care, which must be approved by the VISN CMO.
    This initiative is focused on reducing suicide among those who 
served their Nation. VA will work to maximize existing capacity in 
support of this initiative. Because this initiative began after the 
budget request was submitted, VA did not include an estimate in the FY 
2018 Budget. However, VA currently estimates the cost of this 
initiative to be $200 million in FY 2018 and is funding it within 
existing resource levels.

    Question 20.  As the mental health-diagnosed veteran population 
continues to age and veterans develop age-related diseases such as 
dementia, please describe the Department's efforts to develop long-term 
care options for these veterans. How is the Department monitoring 
changes in state-operated facilities that house this population of 
veterans? Please provide the Department's projections for changes in 
state-operated bed numbers over the next 10 or 20 years and how it 
plans to make up any gaps.
    Response. The growth in the aging Veteran population with multiple 
medical, mental, and neurocognitive disorder comorbidities is expanding 
the need for additional services for these patients. The ``Complex 
Patient'' Care Implementation Task Force (``Task Force''), launched in 
August 2016, is focused on providing safe and effective care for this 
growing group of Veterans, and to follow up on recommendations made by 
the Inpatient Care for Veterans with Complex Cognitive, Mental Health 
and Medical Needs Task Force (``Care of Veterans with Complex Needs 
Report'').
    The Task Force was created in response to multiple, repeated 
requests from field leadership and also the Congressionally-mandated 
Federal Advisory Committee for Geriatrics and Gerontology. The Task 
Force has created a definition for Veterans with complex problems and 
conducted a national needs assessment of all 138 facilities with 
inpatient settings. Through the effort, several innovative inpatient 
promising practices for this patient population have been identified.
    Additional efforts include building Community Living Center (CLC) 
capacity to care for aging Veterans with serious mental illness (SMI), 
and/or neurocognitive disorders, including integration of mental health 
professionals on all CLC teams, a range of dementia training programs, 
including STAR-VA, and development of a SMI toolkit. Additional efforts 
include National Investment Center for Seniors Housing & Care programs 
that support long-term care in the home and integration of mental 
health professionals in Home Based Primary Care, and Community 
Residential Care (CRC) and Medical Foster Homes. Relatedly, there are 
ongoing efforts to support family caregivers to care for Veterans with 
SMI and/or neurocognitive disorders (e.g., REACH-VA and other caregiver 
support programs) to support long-term care in the home.
    State operated beds or nursing home care of any type is generally 
not preferred by Veterans. Appropriate use of home and community based 
services provided by VHA can reduce the need for such nursing home beds 
in the future. Available data suggest the projected need for additional 
nursing home care for Veterans over the next 15 years can be met in 
Medicare and Medicaid-certified community nursing homes; however, VA is 
having difficulty accessing many community nursing homes because of 
Federal Contract requirements. Community nursing homes frequently cite 
complexity of the Federal contracting process as an issue along with 
the requirement to comply with the Service Contract Act. VA is working 
on identifying best practices for managing these Veterans to honor 
their preferences for care whenever possible in home and community 
based settings.
    VHA Geriatrics and Extended Care is conducting a study of Long Term 
Services and Supports to understand Veteran needs for these services 
through 2030, and how they differ by rural and urban status. Moreover, 
the study is expected to provide policy options for addressing gaps in 
projected future needs.

    Question 21.  Data provided to the Committee in April 2017 
indicated that the Asheville, North Carolina and Salem, Virginia 
Medical Centers in VISN 6 were unable to hire psychiatrists, 
psychologists, social workers, and nurse practitioners due ``to budget 
constraints.'' Please provide an update on their hiring abilities, as 
well as a list of any other mental health positions at any VA facility 
that are under a similar hold.
    Response. There are no mental health vacancies on hold due to 
budgetary constraints. The budget supports hiring actions for clinical 
positions vacated over the course of the FY. All Mental Health Service 
clinical vacancies are in an auto-fill status to expedite the 
recruitment process.

    Question 22.  You have spoken about adding thousands of new mental 
health providers. Can you please update us on these efforts as well as 
the retention of existing employees?
    Response. VHA is making steady progress toward reaching the 
Secretary's goal of a net increase of 1,000 Mental Health Providers by 
December 31, 2018. We have increased our net onboard of psychiatrists, 
psychologists, and mental health counselors by 258 as of November 30, 
2017, and we are embarking upon a national recruitment and marketing 
campaign to attract the best mental health providers to meet our goal.
    VHA utilizes the Education Debt Reduction Program (EDRP) to repay 
education loans for healthcare professionals, including mental health, 
in critical positions where recruitment and retention is difficult. The 
EDRP, authorized by the Veterans Programs Enhancement Act of 1998, and 
implemented in 2002, as amended, allows participants to receive 
education debt reduction payments up to $120,000 for up to 5 years.
    EDRP is one of VHA's most effective tools for filling critical 
positions, however, it is a limited resource. Local medical centers are 
responsible for identifying and prioritizing positions that are the 
most critical for recruitment and retention based on local needs and 
funding. Since the implementation of the new maximum award amount 
authorized under Public Law 113-146, VHA has awarded nearly 2,500 new 
EDRP awards. Occupations identified in the FY 2015 Office of Inspector 
General Mission Critical Occupation Report (physicians, registered 
nurses, psychologists, physical therapists and physician assistants) 
account for nearly 79 percent of all new awards in FY 2015-2016. 
Physicians and registered nurses (including advance practice nurses) 
receive the most EDRP awards, at 37 percent and 23 percent, 
respectively.
    VA also utilizes other programs to recruit and retain highly 
qualified employees to mental health and other specialties. For 
example, the Student Loan Repayment Program (SLRP) improves recruitment 
and retention by offering assistance which enables VA to provide up to 
a lifetime total of $60,000 with a maximum of $10,000 per year in 
payments to the lending institution. Full-time VA employees may also be 
eligible for loan forgiveness through the Public Service Loan 
Forgiveness (PSLF) program. Only the entity that holds a loan may 
forgive outstanding loan balances, therefore the authority for the PSLF 
resides with the Department of Education.

    Question 23.  What lasting impacts did the hiring freeze have on 
your ability to recruit high quality staff?
    Response. Minimal impact. Four days after the Presidential 
Memorandum VA provided exemptions for its most critical positions; more 
specifically, patient care positions, safety positions in activation of 
leases and construction projects, and those supporting burial benefits. 
Since then, the Secretary has allowed the Administrations to fill 
positions they deem necessary to meet mission requirements. The 
prioritization of filling vacancies is determined by the requesting 
organization, in coordination with the servicing human resources 
office.

    Question 24.  VA has articulated on multiple occasions that the 
flip side of accountability is the importance of recruiting high 
quality staff. It's my understanding that much of that work with 
candidates is done through HR. So you can imagine that it seems 
somewhat counterintuitive that you have not ended the hiring freeze for 
H.R. professionals, and now you have flat funded them for 2018. How do 
these factors align?
    Response. VA is undertaking a comprehensive Department-wide 
analysis at how to provide all internal support services, to include 
Human Resources (HR), in the most efficient manner. We are determined 
to provide a single enterprise-wide efficient and effective approach to 
HR. In light of this process, we are being deliberative in hiring H.R. 
professionals. At this time, frontline (i.e., those supporting a 
medical center) H.R. offices are able to hire against vacant H.R. 
positions.
    Once we fully understand our H.R. approach for the future, we'll be 
in a better position to align budget requirements.

    Question 25.  Can you explain the differences between the services 
provided by VA human resources and VHA human resources, and tell us why 
we need to fund both? They seem duplicative in many ways. Would there 
be cost savings for the Department if the two were consolidated?
    Response. In accordance with OMB Memorandum M-17-22, VA is 
undertaking a comprehensive Department-wide review of its support 
services, including HR.
    The mission of VA's HRA is to develop and implement enterprise 
human capital management strategies, policies, and practices. Program 
offices comprising HRA focus on policy and programs such as Human 
Resources Management, Diversity and Inclusion, Labor-Management 
Relations, Equal Employment Opportunity complaints, and Senior 
Executive Management. HRA is closely reviewing where potential 
efficiencies may exist.
    In addition, each Administration, to include VHA, operates on-the-
ground H.R. offices that provide daily operational and advisory 
functions for managers, supervisors, and employees. These include, but 
are not limited to, classification, recruitment, on-boarding, personnel 
actions processing, employee development, benefits, separation 
management, employee relations, performance management, etc.

    Question 26.  Can you explain why the H.R. office is flat funded 
from last year, but the FTE level is effectively cut in half? Where is 
the funding going, and where will the staff go?
    Response. HRA's FY 2018 budget request reflects no increase in the 
level of Budget Authority from 2017. Most of HRA funding is generated 
by reimbursable authority funding from other VA entities. Among the 
largest reimbursable services is the handling of EEO complaints by the 
Office of Resolution Management (ORM). The reduction in staff reflected 
in FY 2018 is based on the plan that 296 ORM staff positions will be 
re-aligned to the Office of Accountability and Whistleblower 
Protection. After further review by the Department, it was determined 
that ORM FTEs should remain in the organizational structure of HRA.

    Question 27.  I note that FTE for Acquisitions and Construction 
management is increasing by over 60 people in your budget request for 
this year. I expected to see a cut, frankly. Major construction is 
taking a ``strategic pause,'' and the construction that is happening is 
being managed by the Army Corps of Engineers. What cuts have been made 
to reflect the Corps' role, and why do you need additional staff in 
that office?
    Response. For the major construction staff request, the current 
estimated FTE number for FY 2017 is 139 and for FY 2018 the estimate is 
197. The original estimate for FY 2017 was 177. The combination of 
project slippages and the hiring freeze have reduced the number needed 
and VA's ability to hire staff still required for its major 
construction projects.
    VA will have 26 ongoing projects valued at $4.15B in FY 2017/FY 
2018 and six new projects (primarily national cemeteries) totaling 
$0.24B. It will also be overseeing the execution by the Army Corps of 
Engineers (USACE) of 13 projects valued at $6.474B. There are four 
other projects in planning valued at over $2B that requires contracting 
officer support.
    It should be noted that the partnership between VA and USACE 
includes VA responsibilities to coordinate with USACE during 
construction and provide the interface with the medical center, as well 
as the on-site knowledge of VA technical requirements. VA believes 
Resident Engineer and Contracting Officer positions were not 
sufficiently staffed in the past. VA's 2018 Budget reflects staffing to 
appropriate levels by following the model established by the Defense 
Health Agency in providing support and guidance to the USACE 
construction management team, and ensuring that the project meets the 
VA programmatic requirements.
    It should be noted that the appropriation language was changed in 
FY 2017 to allow major construction staff funding to include support 
for contracting officers working directly on major construction 
projects to ensure alignment with the program they are supporting. The 
inclusion of contracting officers accounts for 35 of the 197 FTEs in FY 
2018 with 162 resident engineers comprising the remainder of the FTEs.
    Since FY 2016, significant cuts have been made to the General 
Administration funding that provides support to Major Construction via 
project/program managers, planners, architect/engineers and other 
support personnel.

    Question 28.  Your Budget rescoped and resized several major 
medical lease projects as well as eliminated two leases that had 
previously been proposed for authorization. Please provide specific 
information regarding any services that have been eliminated or reduced 
from these clinics. Please provide specific information that explains 
the underlying analysis VA used to determine these services or spaces 
were no longer needed. If the Department determined that the community 
would be able to take on this extra demand, please provide information 
that explains how the Department determined that capacity exists in the 
community.
    Response. Prior to the finalization of the FY 2018 Budget, VHA 
reviewed 28 Major Lease initiatives. Out of these, 9 included reduction 
of Specialty Care services and associated square feet because it was 
determined such services were more readily available through community 
providers and/or at the parent VA Medical Center. VHA utilizes the VA 
Health Systems Planning Application, Veterans Choice Locator and other 
available databases, to project demand and match that to capacity, both 
in house and through community providers. This process helps ensure 
appropriate and sufficient services are available. In no cases were 
services removed because they were no longer required, and in all cases 
services will be available to Veterans.

    Question 29.  Does this request take into account the partnerships 
you have with other agencies, such as HUD? Did you know, for example, 
that the HUD budget for supporting HUD-VASH vouchers decreased by 8%? 
Will the Administration be able to serve the same number of Veterans?
    Response. VHA has been in communication with the Department of 
Housing and Urban Development (HUD). If HUD does not receive additional 
funding for HUD-VASH in FY 2018, it would not impact the availability 
of existing FY 2008-FY 2017 awards, which mean VHA must continue to 
provide case management for recipients of nearly 90,000 existing 
vouchers, as required by statute. If HUD does not receive new funding 
in FY 2018, VHA will not need to add staff to support new vouchers, but 
will need continued funding to support existing vouchers.

    Question 30.  Does VA have the resources in this budget to provide 
the wrap-around services that are so critically important to doing more 
than just addressing a crisis situation? (VHA)
    Response. The FY 2018 budget request supports an additional 5,500 
HUD-VASH vouchers from the FY 2017 HUD budget. HUD-VASH staff provides 
clinical case management and supportive services primarily in the 
community or the home, and which vary based on the needs of the 
Veteran. There are five basic levels of case management--intensive, 
stabilization, maintenance, preparation for discharge, and graduation/
discharge. Each level has varied levels of engagement with Veterans in 
HUD-VASH.

    Question 31.  Granted great progress has been made in the last five 
years on ending homelessness among veterans, but given that there are 
still 40,000 homeless Veteran nationwide, why has VA decided to put 
less emphasis on this core VA mission?
    Response. VA remains steadfast in its commitment to ensuring 
Veterans are able to obtain permanent, sustainable housing and have 
access to high quality health care and other supportive services.

    Question 32.  Do you agree that consistent resources need to be 
dedicated to VA counter-homelessness programs in order to get as close 
to zero homeless veterans nationwide as we can?
    Response. Yes.

    Question 33.  I was concerned by a recent military times article 
indicating VA has shifted its goals on veteran homelessness from zero 
to what you referred to as functional zero, and I quote here ``12,000 
to 15,000 that despite being offered options for housing and getting 
them off the street, there are a number of reasons why people may not 
choose to do that.'' The 2016 PIT count included just over 13,000 
unsheltered veterans, and your homeless programs are operating at the 
same pace, as I believe they should. Can you explain how you arrived at 
this specific range as your goal for unsheltered veteran homelessness, 
and can I get your commitment to reducing veteran homelessness, 
especially unsheltered homelessness, as much as possible and to 
ensuring that all of the administration's programs are collaborating 
effectively with each other, and community partners, to make veteran 
homelessness rare, brief, and nonrecurring?
    Response. VA remains fully committed to ending and preventing 
Veteran homelessness, and continues to operate with the urgency to 
ensure it is rare, brief and non-recurring, especially for unsheltered 
Veterans.

    Question 34.  Your own studies demonstrate the importance of 
research opportunities to recruiting and retaining clinical staff. In 
addition to VA's own research cuts, other agencies are cutting their 
contributions to VA research also. Do you have an estimate of the 
impact that this overall Trump budget will have on your hiring efforts?
    Response. At this time, VA does not have the ability to predict a 
detrimental impact on hiring, although, many clinicians view the 
ability to conduct research as advantageous to a well-rounded clinical 
experience.

    Question 35.  What percentage of the work on appeals currently sits 
with the VBA in the appeals management center? Is there a reason that 
addressing the existing appeals with additional staff was not a 
priority?
    Response. As stated above, in January 2017, VBA realigned its 
appeals policy and oversight of its national appeals operations under 
AMO. The realignment promotes increased accountability of appeals 
performance and establishes a clear division of labor between claims 
and appeals work, with dedicated appeals FTE. This realignment allows 
VBA to prioritize appeals by focusing on internal people, process and 
technology, and implementation of appeals reform legislation if 
enacted. Under this realignment, specific guidance has been 
disseminated instructing field offices that appeals staff must maintain 
authorized staffing levels.
    In 2015 and 2016, Congress provided funding for additional staff 
that included a total of 300 FTE employees for appeals processing at 
VBA. VBA's appeals productivity through May 31, 2017, has increased by 
32 percent over FY 2016 production during the same period. As of 
June 30, 2017, the Appeals Resource Center, the centralized processing 
resource for appeals remanded from the Board of Veterans' Appeals, had 
35.8 percent of the remand workload in VBA and 3.3 percent of the total 
appeals workload.
    VA continues to assess the current and future allocation of FTE 
employees to work appeals to ensure that the pending legacy appeals 
inventory is addressed in a timely and efficient manner. Whether VA 
will need additional resources for appeals since the August 23, 2017, 
enactment of appeals reform legislation is contingent upon resource 
allocation decisions made by the Department and the Administration 
during the annual budget process and cannot be predicted at this time.

    Question 36.  Fiduciaries are some of the most vulnerable of the 
Veteran population and it is currently taking more than TRIPLE the time 
it should in order for a field examination to happen so that a 
fiduciary can be appointed. How is your budget, which flat funds this 
program, helpful in addressing this problem?
    Response. In 2017, VBA allocated an additional 51 FTEs to meet the 
program's oversight responsibilities in order to avoid delays in the 
initial appointment of fiduciaries, and the FY 2018 President's Budget 
codifies those additional FTEs. As of May 2017, VBA has reduced the 
average days to complete initial appointments to 151.1 days--down from 
287 days in FY 2016--and we are making progress toward the goal of 82 
average days to complete initial appointments by FY 2018 and 76 days by 
FY 2022.

    Question 37.  If VA does not plan to hire additional FTE for the 
VR&E program how does VA intend to assist veterans in critically 
understaffed regions?
    Response. Staffing requirements for the Vocational Rehabilitation 
and Employment (VR&E) program are influenced by many factors. 
Currently, we are supplementing our Vocational Rehabilitation 
Counselors (VRCs) workload with the expanded use of and augmentation of 
tasks through National service contracts for the execution of certain 
VRC tasks, such as vocational assessments. We recently developed and 
deployed targets for these contracts by Region/District based on 
workload density to better serve Veterans and VRCs. Additionally, VBA 
is continually looking at VR&E system and process improvements to 
reduce administrative burden on VRCs. Current efforts include working 
to deploy a new case management system (in development), and examining 
ways to centralize VR&E administrative tasks like invoice processing.

    Question 38.  In the past two years, ITT and Corinthian College 
both closed and left tens of thousands of veterans in an unacceptable 
and precarious position. We've also seen other predatory behavior by 
for-profit schools looking to take advantage of Veterans and their 
beneficiaries. Are you confident that the levels of staffing supported 
by this budget, and the amount of oversight that staff is able to do, 
will prevent these practices in the future? We want to identify these 
schools before we have a situation where a school is shut down, rather 
than after. Moreover, we want to ensure that VA has the resources to 
communicate with veterans far ahead of any school closure in order to 
facilitate the transfer of the GI Bill beneficiary to an alternate 
school for the completion of their degree.
    Response. Based on the staffing levels requested for FY 2018, VA 
will facilitate proper oversight of GI Bill benefits. Since the closure 
of these schools, the Department has focused on improving the quality 
of the oversight process, increased communication and information 
sharing activities with other Federal agencies with oversight of post-
secondary educational institutions, and has increased outreach 
activities and assistance to beneficiaries enrolled in ``at risk'' 
schools.

    Question 39.  Will the staffing levels for these Education programs 
support continued rates of original and supplemental claim completion 
within a reasonable amount of time?
    Response. VBA has approximately 800 FTEs processing claims with a 
current Fiscal Year-to-Date timeliness for original claims at 22.8 days 
and supplemental claims at 8.0 days. At the beginning of FY 2017, VBA 
redirected 75 Atlanta Regional Processing Office employees from 
processing education claims to processing compensation claims. This 
increased the workload at the three remaining Regional Processing 
Offices. Also, during the fall peak enrollment period from August 2017 
to October 2017, VBA received an increase in education claims. This 
year, VBA received a 24 percent increase in claims for FY 2017 compared 
to FY 2016. Last, other factors (i.e., legislative changes and system 
changes) may impact future processing times. VBA did not meet its 
Fiscal Year To Date goal for original claims with an average days to 
complete (ADC) of 24.66 days; however, VBA did achieve the goal for 
supplemental claims with an ADC of 8.6 days. In addition, VBA continues 
to utilize overtime and a national brokering strategy to balance the 
workload and reduce the time it takes to process a claim.

    Question 40.  Can you give us a timeline for the plan to modernize 
VA's infrastructure you're developing and hoping to pilot?
    Response. VA is committed to developing high performing healthcare 
networks that consider current and future Veteran demand for medical 
care, and responsive services by integrating VA-provided healthcare, 
community care, and telehealth services. VA is partnering with private 
sector healthcare experts to conduct objective assessments, based on a 
piloted methodology, to develop local health system optimization plans. 
A contract was awarded in September that will enable VA to recommend 
health system optimization plans in all 96 VA healthcare markets. Our 
current target is to complete this by the 3rd quarter of FY 2019.

    Question 41.  Your budget includes a proposal that would allow VA 
to more easily transfer funding for infrastructure between agencies. 
How does that authority play into the modernization plan you're 
developing?
    Response. The proposed legislation would allow VA to pursue joint 
projects with other Federal agencies, including DOD. Joint facility 
projects between VA and other Federal agencies (i.e., medical 
facilities not specifically under the jurisdiction of the Secretary) 
currently require specific statutory authorization. The proposed 
legislation would: (1) enhance VA's ability to coordinate with DOD and 
other Federal agencies; (2) improve access, quality, and cost 
effectiveness of direct health care provided to Veterans, 
Servicemembers, and their beneficiaries; (3) permit joint capital asset 
planning and capital investments to design, construct, and utilize 
shared medical facilities; (4) provide VA authority to procure the use 
of joint medical facilities for itself and other Federal agencies like 
DOD, and transfer funds between agencies for such initiatives.

    Question 42.  Please explain what legislative barriers exist that 
prevent the Department from disposing of the roughly 1,100 facilities 
that are described as underutilized and vacant buildings.
    Response. To clarify, at this time VA is only pursuing disposal or 
reuse of 430 vacant buildings. The underutilized buildings will be 
reviewed, as VA works to determine where additional efficiencies can be 
identified and reinvested in Veterans' services, and will be considered 
when VA completes the market area optimization assessments and plans.
    Occasionally, there are impediments that delay disposal or reuse 
stemming from environmental factors and/or the historic nature of a 
building. Impediments do not specifically prevent disposal/reuse, but 
can significantly slow the process. The National Historic Preservation 
Act (specifically, Section 106 consultation requirements) as well as 
the National Environmental Policy Act provide statutory requirements 
which VA must adhere to when pursuing this process.
    Additionally, other authorities would provide greater reuse 
flexibility of unneeded assets, and help improve services for Veterans. 
For example, VA's FY 2018 Budget request proposed to expand VA's 
enhanced use lease authority beyond the scope of supportive housing. 
This authority would provide more opportunities for VA to successfully 
repurpose underutilized and vacant properties nationwide, for uses that 
are consistent with VA's mission and operations.

    Question 43.  We understand that VHA is conducting a series of 
market-based analyses examining VA capacity and private sector capacity 
nationally. What role is OALC playing in these analyses?
    Response. VA's Office of Construction & Facilities Management (CFM) 
is working closely with VHA to conduct market-based assessments 
nationwide. Previous VA Integrated Planning efforts did not 
comprehensively assess the optimal balance of services for VA to 
provide in its facilities, versus those that can be provided in the 
community. The market-based Service Delivery Planning will focus on 
community care providing additional services other than foundational 
and essential services (e.g. Primary Care, Mental Health and associated 
Rehabilitation). CFM will manage the planning process in partnership 
with VHA, once a contract has been awarded.

    Question 44.  Please explain what factors go into determine SCIP 
ratings. What weights does each category and subcategory receive? How 
often does the Department update those needs?
    Response. The Strategic Capital Investment Planning (SCIP) process 
is reviewed each year to consider changes in medical delivery, 
technology, Departmental and Congressional mandates, and local or 
regional projections. Changes, related to VA's Construction and Lease 
program, inform updates to the criteria and weights. The SCIP Board is 
comprised of nine senior management members from the three 
Administrations and the offices of six Assistant Secretaries. The Board 
works on a Departmental level with each member applying their 
specialized knowledge to discussions. The SCIP Panel, which is 
comprised of one staff member representing each Board member, supports 
the Board.
    Decision criteria and sub-criteria priority weights are developed 
using a multi-attribute decision methodology--the analytic hierarchy 
process (AHP). This methodology facilitates the development of criteria 
and sub-criteria weights, by allowing multiple evaluators to consider a 
number of diverse criteria when setting weights. Within the AHP, 
priority weights are set using the Pairwise Comparison method, which 
asks each Board member to rate the importance of criteria, one pair at 
a time, reducing the likelihood of inconsistent ratings. The results of 
the Pairwise Comparison exercise are the criteria weights. Priority 
weights for each group of sub-criteria are developed that same way.
    The Board presents a recommendation to the SCIP process, including 
criteria and priority weights, through a formal executive review 
process. That process is developed through senior management, with 
approval of the Secretary to ensure consistency with the Department's 
strategic goals.
    Below is the SCIP 2018 Decision model and criteria and sub-criteria 
weighting.

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

    Question 45.  The Department projects a large drop in the resources 
needed to support facility activations, dropping from an estimated $862 
million in FY 2018 to $744 million in FY 2019. Please provide a list of 
facilities that are projected for activation in FY 2018 and FY 2019. 
Additionally, the request explains that VA has taken steps to better 
synchronize resources. Please provide further details of these steps.
    Response. Attached is the activations report that has been 
submitted to Congress. VA's Office of Construction & Facilities 
Management and VHA are working to improve communication of updated 
project schedules for Major Construction and Major Lease projects, to 
help ensure improved activation project scheduling. Additionally, VA 
Facility Activation Project Management teams have been established to 
coordinate and synchronize resources.

    Question 46.  We understand that VA has never before utilized a 
public interest exception to a full and open procurement. In fact, the 
exception has only been used in national security situations. The last 
time Congress was assured by VA that a contract was guaranteed and 
solid, VA lost badly in court and we were forced to provide an 
emergency appropriation to complete construction of the Denver VA 
Medical Center. What guarantee can you give the Committee that this 
procurement method will be the best value for taxpayers and veterans?
    Response. VA is taking the necessary precautions to ensure that the 
scope of this effort is well-defined, feasible, and will further the 
public interest of providing seamless care for our Veterans.

    Question 47.  Your budget requests funding for a further review of 
the EHR decision through an IPT. Is this request still valid? Can you 
explain what new information this team will be looking at that wasn't 
previously available? Or are these resources that can be shifted?
    Response. The June 5, 2017, announcement of the Determinations and 
Findings (D&F) by Secretary Shulkin supporting direct negotiations by 
the VA with Cerner Corporation alleviated the requirement for such an 
IPT. These costs and efforts are being supported by the present PMO 
budget requirements. In addition, VA has extensive testing, change 
management and data migration strategies to be fielded during the 
Initial Operating Capability phase and will leverage lessons learned 
from DOD.

    Question 48.  Your budget projects essentially flat staffing for 
OIT in FY 2018. It is our understanding that part of the MyVA project 
was looking at the OIT staffing levels present at VHA, VBA, and NCA 
facilities in order to provide proper IT support at those facilities. 
Can you update the Committee on the development of these staffing 
models?
    Response. OI&T is working on the draft for a Comprehensive Staffing 
Model that will perform an analysis of existing workforce, project 
needs and examine how to address identified gaps. As part of the 
Secretary's initiative to increase efficiency, OI&T is currently 
reviewing existing workforce structuring and identifying positions that 
can be realigned to direct customer facing support. Starting in FY 
2018, OI&T will work with VA customers to balance between service level 
requirements and industry best practices for IT staffing.

    Question 49.  What resources are allocated in the Budget Request 
for the development of the Digital Health Platform?
    Response. The Digital Health Platform concept has transformed to be 
more inclusive, creating a gateway and interfaces for benefit, 
memorial, and corporate systems as well. The systems requiring 
interfaces and the resources of this Digital Veteran Platform will fund 
its development.

    Question 50.  What VistA enhancement projects will this Budget 
Request support in FY 2018? In what ways has this roster of projects 
changed as a result of the decision to procure Cerner's EHR?
    Response. The FY 2018 budget includes a request for development 
funding for the following VistA related activities as summarized below.
Dollars in Thousands:
            NMOC (Medical MyHeV) $15,000
                 MHV Infrastructure and Interface Enhancements 
                Phase 2 $10,000
                 MHV Veteran-Facing Enhancements Phase 2 $5,000
            VistA Module Enhancement $9,000
                 Fileman 24 DME $5,000
                 VistA Data Access (VDA) Phase 2 $4,000
            Access to Care (Medical Core) $2,495
                  Veteran Self-Scheduling Appointment System 
                Faster Care for Veterans Act $2,495
            Health Provider Systems $2,400
                 CPRS Enhancements Phase 2 $2,400
                 Registries $1,410
                 Veterans Integrated Registries Platform (VIRP) 
                $1,410

    Based on the Secretary's June 5, 2017, announcement regarding VA's 
path forward for VA's EHRM, proposed health development and sustainment 
investments are being reviewed to ensure they are in full alignment 
with the Secretary's decision. Many projects will continue until VA 
systems can be transitioned to the new EHR system. To minimize the 
impact to Veterans and the providers who use VistA to document care, 
the decommissioning of VistA and other legacy systems will be done 
along a structured timeline that ensures there are no compromises to 
Veteran patient privacy and continuity of care.
    The EHRM decision that the Secretary announced on June 5, 2017, 
comprises a large and complex replacement of VA's EHR which would take 
place over a multi-year period. While VA is conducting an ongoing 
review to ensure all current projects included in VistA Evolution and 
beyond are aligned to the Secretary's June 5 decision, it is clear that 
many projects will continue for a period of time because VA will need 
to continue to maintain its existing system until VA systems can be 
transitioned in an organized way to the new EHR system. Again, VA will 
be reviewing all relevant ongoing or planned projects to ensure they 
are aligned with the Secretary's June 5 decision.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Bill Cassidy to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    Question 51. The VA's several affiliations with academic medical 
institutions provide a significant opportunity to incorporate the input 
of the person who is actually treating the veteran. This process would 
eliminate many of the mistakes being made when it comes to more complex 
and advanced technology in the med-surg items and device space. 
Processes and procedures driven from the top down cannot overcome a 
lack of informed decisionmaking from the beginning.
    What is the VA doing to better incorporate physician and clinical 
practitioner feedback into their procurement process, especially with 
regards to the Next Generation--Med- Surg Prime Vendor (NG-MSPV) 
program?
    Response. VA has embraced Clinically Driven Sourcing (CDS) to 
better incorporate physician and clinical feedback. Under the CDS 
concept clinicians identify, review and select products to be made 
available for their use under national, regional, or local contracts. 
Next-Generation Medical/Surgical Prime Vendor (NG-MSPV) provides a good 
example of this concept. Before products are made available through the 
NG-MSPV they are reviewed by a multi-disciplinary integrated team that 
includes clinicians familiar with the products that are candidates for 
inclusion in the NG-MSPV formulary. The clinician's role on the team is 
to select the products that meet their needs.

    Question 52. a. Last year, the VA established a new pre-
authorization requirement for the procurement of certain medical 
products, with the stated goal of getting a contracting officer 
involved prior to a surgical case to ensure the government pays fair 
pricing for the products used.
    Response. In April 2016, VA started the pre-authorization process 
by establishing a not-to-exceed order, and then a post-procedure 
consult with VA contracting to finalize the purchase order (PO). In 
that process, pre-authorization consults are performed by VA 
clinicians/staff to identify implant components and pricing, which are 
then used by contracting staff to establish a price and product ceiling 
on the order (the ``not-to-exceed'' level). Following a procedure, 
vendors and VA staff confirm what products were implanted in the 
patient (units, cost, quantities, serial numbers, contract number, 
etc.), which is then submitted to VA contracting (the post-procedure 
consult).
    As understood, if a post-procedure consult is not submitted to 
contracting within 24 hours of the procedure, it is considered an 
``unauthorized commitment,'' and is subject to a ratification process 
that can significantly delay vendor receipt of a PO. Overall, I have 
heard numerous reports that this new process has indeed resulted in a 
significant backlog of payments to manufacturers for devices already 
implanted in Veterans.

    b. What is being done to establish an improved process that 
includes appropriate procurement safeguards but also ensures 
appropriate efficiencies in payments to manufacturers providing 
critical medical technologies to our veterans?
    Response. For clarification, a delay in a post-procedure consult 
does not result in an ``unauthorized commitment'' and is not subject to 
ratification; however, it does delay payment. VA is continuing to 
refine the implant contracting process to include changes to improve 
submittal timeliness for post-procedure consults, and the requirements 
for ratification to include expediting the process through completion 
of payment to the vendor. We are also monitoring payment timeliness, 
numbers of ``unauthorized commitments'' and ratification speed to 
determine if our improvements are effective.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Patty Murray to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
                    medical and prosthetic research
    Question 53.  VA's medical and prosthetic research has contributed 
many vitally important advances in medicine. Yet, medical and 
prosthetic research is cut five percent in the President's Budget 
Request. With cuts being made across President Trump's budget to other 
Federal sources of research funding, such as the draconian cuts to the 
National Institutes of Health, critical Federal investments in 
lifesaving medical research will be eliminated. What specific research 
would be eliminated or curtailed under the Department's request?
    Response. At this time we are unable to determine which projects 
may be impacted. VA's Office of Research and Development will continue 
to perform robust research in priority areas and those of unique 
healthcare needs for Veterans such as:

     Suicide prevention
     PTSD
     TBI/Neurotrauma and Neurotechnology
     Chronic Pain and Opiate Abuse
     Spinal Cord Injury
     Precision Medicine and Patient-Centered Care
     Access, Choice and Coordination of Care
     Implementation and Spread of Innovation
     Limb Loss
     Million Veteran Program

    Research program areas that would be curtailed includes:

     Disorders of Aging
     Musculoskeletal Disorders
     Neurodegenerative Diseases

    Question 54.  For years VA has been citing problems with 
recruitment and retention as a problem within the VHA system. VA 
studies have shown that 80 percent of VA clinicians cited research 
programs as a factor in coming to VA, and over 90 percent cited it as a 
reason for staying at VA. How will these cuts impact VA's ability to 
remain competitive in recruiting and retaining quality researchers and 
physicians?
    Response. The All Employee Survey data indicates that job 
satisfaction for physicians is closely linked to academic activities 
including involvement in research and teaching; however, VA is unable 
to predict any potential outcomes recruiting and/or retention that may 
result from any decreases.
                           homeless veterans
    Question 55.  Since 2009 it has been the goal of VA to end veteran 
homelessness. Since that time, great progress has been made in 
addressing veteran homelessness. But this progress has only come from 
complete VA dedication to that goal and the utilization of an array of 
Federal resources. Earlier this month, you announced that zero homeless 
veterans is no longer an agency priority, and President Trump's budget 
would cut the HUD budget for supporting HUD-VASH vouchers decreased by 
88 percent.

     What impact will these decisions have on homeless veterans 
trying to access VA services?
     What impact will these decisions have on veterans 
currently utilizing the HUD-VASH program?
     What services will VA offer to veterans that are adversely 
impacted by any change in homeless veteran services?

    Response. If HUD does not receive additional funding for HUD-VASH 
in FY 2018, it will not impact the availability of existing FY 2008-FY 
2017 awards, which means that VHA must continue to provide case 
management for recipients of nearly 90,000 existing vouchers, as 
required by statute.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Joe Manchin III to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    Question 56. Originally, our understanding was that the VA 
anticipates that funds for the Choice Program will exhaust in November/
December of this year. However, that is not the case. What is the 
actual date that Choice will run out of money?
    Response. In August 2017, the President signed the VA Choice and 
Quality Employment Act of 2017, which authorized an additional $2.1 
billion for the Veterans Choice Program (VCP). These funds represent a 
short-term, temporary funding solution that will enable Veterans to 
continue receiving care through VCP while a replacement program is 
developed.
    A number of fluctuating variables influencing program utilization 
will dictate actual obligation rate. VA will continue to analyze 
program utilization trends and will refine funding projections as 
future utilization patterns become better defined and will stay in 
close communication with our Committees to apprise all members of 
current status.

    Question 57. Your budget asserts that ``the number of VR&E 
participants has steadily increased and is expected to continue to 
increase over time.'' In fact, program participation has increased by 
15% since 2015. However, in your budget you propose a cut to the 
program of $13.8 million or 4.2%. If the VA does not plan to hire 
additional full-time employees for the VR&E program, how does the VA 
intend to support veterans in critically understaffed regions, like 
West Virginia?
    Response. VA utilizes several mechanisms to allocate resources to 
support VR&E programs, including the expanded use of and augmentation 
of tasks through National service contracts, which help to balance the 
caseloads for Vocational Rehabilitation Counselors (VRCs). We recently 
developed and deployed targets for the use of these contracts by 
Region/District based on workload density, in order to better serve 
Veterans and VRCs. Additionally, VBA is continually looking at VR&E 
system and process improvements in order to reduce administrative 
burden on counselors. Current efforts include working to deploy a new 
case management system now in development, and examining ways to 
centralize VR&E administrative tasks like invoice processing.

    Question 58.  It is my understanding that even though the hiring 
freeze has been lifted, VA has done a self-imposed hiring freeze.

    a. How are you reviewing which positions are exempted?
    b. What is your process?
    Response. Consistent with OMB Memorandum M-17-22, VA removed hiring 
restrictions for field positions at VHA's medical facilities (for 
medical and non-medical positions), and for VBA regional and field 
offices. NCA had no restrictions and this remains unchanged. Hiring 
restrictions were also removed for the following Executive level 
positions: Medical Center Directors; Network Directors; Cemetery 
Directors; and VBA Regional Office Directors. This allowed the 
Administrations to fill positions they deemed necessary to meet mission 
requirements.
    For all other positions, VA is following a process that requires 
thorough review before hiring, and which also requires an approval at 
the appropriate Under Secretary level. VA Central Office and all other 
Executive level hiring must be approved by the VA Chief of Staff.

    Question 59.  In March, you announced that veterans with other-
than-honorable or ``bad paper'' discharges will be allowed to be 
receive mental health treatment.

    a. How do you ensure that access for an honorably discharged 
veteran is not diminished with this policy?
    b. If a veteran shows up at an emergency room today and says he is 
suicidal how will you treat him differently today than when your plan 
is in effect?
    c. We were told that we would have a comprehensive plan for 
implementation by June. Where is that plan?

    VA Response A-C: Effective July 5, 2017, VA began implementing an 
initiative to expand the provision of urgent mental health care to 
former Servicemembers with other than honorable (OTH) administrative 
discharges who believe their mental health condition is related to 
military service. This marks the first time VA has implemented an 
initiative specifically focused on expanding these services to former 
Servicemembers with OTH administrative discharges who are in mental 
health distress, or may be at risk for suicide or other adverse 
behavior.
    This initiative is focused on reducing suicide among those who 
served the Nation.
    Under the initiative, which utilizes existing legal authorities, if 
a former Servicemember with an OTH administrative discharge presents to 
a VHA Emergency Department and self-identifies as being in mental 
health distress, a provider will conduct a clinical assessment and 
determine the appropriate course of action in conjunction with the 
former Servicemember. Under this initiative, former Servicemembers with 
an OTH administrative discharge may receive care for a mental health 
emergency for an initial period of up to 90 days, which can include 
inpatient, residential, or outpatient care. In addition to presenting 
at an Emergency Department, individuals make seek help by calling the 
Veterans Crisis Line or visiting a VA Urgent Care Center or Vet Center.
    Regarding the implementation plan, VHA and VBA developed a joint 
action plan addressing required policy updates, internal and external 
communications, IT modifications to CPRS, field education and support. 
The field was notified of the OTH Initiative via memos dated 3/20/17 
(Access for Mental Health Services for Other Than Honorable Discharged 
Servicemembers), 4/19/17 (Validating VA Mental Health Plan to Meet the 
Needs of Other Than Honorable (OTH) Discharged Servicemembers), and 6/
26/17 (Eliminating Veteran Suicide: Emergency Services for Other Than 
Honorable Discharges). A training PowerPoint presentation was developed 
in May, 2017 for field staff who register OTH Servicemembers in the 
electronic health record (EHR). VHA Directive 1601.02A was updated on 
June 7, 2017 to include information about providing care to this 
population. A Communications Plan was completed in June, 2017, which 
included internal and external PowerPoint presentations and Fact Sheet. 
In addition to external presentations to VSO groups and congressional 
partners, a series of national webinar calls was completed for VA field 
education.VA began implementing this initiative on July 5, 2017. In 
September, 2017, the IT contract was awarded to develop and implement 
necessary computer upgrades for the EHR, which will allow the field to 
track the 90-day episode of care.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
                        va health care outcomes
    Introduction: Despite the bipartisan investments made in the VA 
each year, there continues to be basic failings that impact the 
experience of Veterans: issues in accessing benefits, communications 
with the VA, problems with VA medical care, and others.

    Question 60.  What will be different next year in how you address 
just one of those issues--for example, health care access? Under this 
budget how will access to care be different for veterans next year in 
how they get it through the VA or outside it? How will the average 
veteran feel these proposals in their everyday interaction with VA?
    Response. VA continues to work to ensure all eligible Veterans have 
their urgent care needs met in a timely fashion. A year ago, VA 
implemented same day services at all medical centers and some of its 
community based outpatient clinics. On January 12, VA announced that 
100 percent of its more than 1,000 medical facilities across the 
country now offer same-day services for urgent primary and mental 
health-care needs. . VA is also working to ensure new referrals to 
specialists are screened for urgent needs, and that these Veterans are 
referred for timely care. Since FY 2014, the average wait time to 
complete the most urgent consults decreased from 31 days to 2.8 days 
during December2017. VA is also working to ensure follow-up 
appointments for time-sensitive issues are managed in a timely fashion. 
In late 2016, VA also implemented a process to ensure timely follow-up 
appointments for time-sensitive medical needs. Since then, over 200,000 
such appointments have been completed. A year ago 90% of such 
appointments being no later than the provider recommended appointment 
date. Over the past 3 months, this number increased to 95%.
    Patient Self-referral Direct Scheduling, the ability for Veterans 
to schedule a routine appointment without a consult from a primary care 
provider, was implemented in Optometry and Audiology in 2016. In 2017, 
it was implemented in all nutrition clinics and is nearing full 
implementation in podiatry, amputee and wheelchair clinics. In 2018, VA 
will be adding direct scheduling in cancer Care (Veterans new to VA or 
transferring their care to VA with a known cancer diagnosis), smoking 
cessation, mammography (when provided at VA), weight management, social 
work and pharmacy clinics.
    Expansion of telehealth services continues to be a priority for 
improving access to care particularly to parts of the country where 
there is a shortage of providers. The use of a national hub and spoke 
model in VA for Telehealth allows virtual medical appointments to occur 
in sites that may be rural or have difficulty recruiting providers, 
where otherwise Veterans would not be able to access care as quickly. 
As of the beginning of this CY, VA has 11 fully operational Mental 
Health Hubs and 9 fully operational Primary Care Hubs. Additionally, 
some of our VISNs are setting up their own hubs. Additionally VA is in 
the process of implementing a tele-urgent care initiative in five VISNs 
this year. The initiative is designed to enhance first call resolution, 
properly addressing the Veteran's need the first time they call to 
prevent the need for a second or follow up call.
    VA is also working to implement VA Video Connect, a simplified 
mobile and web-based application connecting Veterans with providers via 
encrypted video, is also being implemented. It allows Veterans to see 
and talk to their health care team from anywhere, making appointments 
more convenient and reducing travel and wait times. VA is in the 
process of implementing this across the Department.
    VA has also been implementing Veterans Scheduling Enhancement in 
all of its healthcare facilities. This system eliminates many of the 
previously occurring scheduling errors and improves the scheduling 
experience for the Veteran.
    In April, VA launched the ``Access and Quality in VA Healthcare'' 
website at www.accesstocare.va.gov. The website promotes transparency 
and enables Veterans, their families, and caregivers to view data 
related to:

     Patient wait times at VA facilities in their area;
     Veteran experiences scheduling primary and specialty care;
     Available options for same day services; and,
     Quality of healthcare delivered at every medical center.

    The contracts through which we purchase care in the community are 
undergoing significant changes based on lessons learned. New contracts 
will be significantly different based on experiences with current 
contractors and their performance (e.g. access, coverage, etc.). VA 
followed a methodical approach to receive, categorize, analyze and 
incorporate feedback from all stakeholders.
    The new Community Care Network will increase the number of service 
areas from two to four, divided by state boundaries, thus allowing each 
new contractor to provide more local flexibility, improved customer 
service and increased access to care. Responsibilities for care 
coordination and scheduling of appointments, which were once assigned 
to the contractor, will return to VA field sites, unless there is the 
exercise of an optional task. Interactions with Veterans will be 
maintained by VA staff on a more face-to-face and timely basis.

    Question 61.  Do the investments outlined in this budget provide 
any particular support for veterans in rural communities--like Hawaii--
where geography and generational differences in the veteran community 
require different outreach and communications strategies?
    Response. The FY 2018 budget supports Veterans residing in rural 
communities. VHA's Office of Rural Health (ORH), in concert with VHA 
national program offices, diligently works to create enterprise wide 
initiatives and create new and innovative programs that are increasing 
access to care for rural Veterans. Examples include: Tele-Primary Care 
and Tele-Mental Health Hubs, Clinical Pharmacy Staffing, and Rural 
Veteran Transportation Services.
    Ensuring access to timely and high-quality care is one of VA's 
highest priorities. VA Research works to identify and evaluate 
innovative strategies to improve access and quality, especially for 
rural Veterans.

    Question 62.  Will the fact that you are not using the exact 
platform used by DOD lead to interoperability issues at implementation? 
What conversations have you had with Secretary Mattis about ensuring 
interoperability with community providers or CHOICE providers?
    Response. With the decision to acquire and implement the same 
Cerner system that DOD is currently implementing will address the 
interoperability challenges between the VA and DOD. VA is working with 
the Department of Defense (DOD) and other subject matter experts, both 
in government and in the private sector, to ensure our new system will 
be interoperable with that of community partners. The exact mechanics 
of the interoperability will be addressed to provide seamless care 
across a common system is critical to providing the best care for 
Veterans. VA also realizes the importance of interoperability with our 
community care partners and educational institutions, and is 
determining how best to meet this need and will update the Committee 
soon.

    Question 63.  Secretary Shulkin you have said that ``we're still 
looking at a multi-year process'' and reducing the number of homeless 
veterans nationwide from roughly 40,000 to 10,000 or 15,000 is an 
``achievable goal.'' What is this Administration's specific goal to 
reduce homelessness and how will this budget help achieve that?
    Response. VA is committed to ending Veteran homelessness. While 
significant progress has been made to reduce Veteran homelessness, 
there are sub-populations of homeless Veterans who are hard to reach 
and engage (e.g., chronically homeless Veterans, those with serious 
mental illness, justice involved Veterans, and those ineligible for VHA 
health care services).
    The 2018 President's Budget includes $1.7 billion for VA's Veteran 
homelessness programs, including case management support for 
approximately 93,000 existing HUD-VASH vouchers, grant funding for 
community-based prevention and rapid rehousing services provided 
through the Supportive Services for Veteran Families program, clinical 
outreach and treatment services through Health Care for Homeless 
Veterans, service intensive transitional housing through the Grant and 
Per Diem Program and prevention services to justice involved Veterans 
in the Veteran Justice Program; and employment supports in Homeless 
Veterans Community Employment Services.
     status of maui community based outpatient clinic replacement 
                              construction
    Question 64.  Secretary Shulkin, it is my understanding that the VA 
has received a land donation offer for the Maui CBOC replacement from 
the State of Hawaii and is currently going through review and 
concurrence in VA's Central office. What is the current status of this 
review and concurrence process and when can we expect the concurrence 
process to be completed? The project is very important to veterans on 
Maui. Can you ensure that this process is completed as quickly as 
possible?
    Response. The donation of a ground lease from the State of Hawaii 
was approved by the Office of Construction & Facilities Management on 
June 23, 2017. VA's local contracting office is now able to proceed 
with the project.

                            A P P E N D I X

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Prepared Statement of Joseph R. Chenelly, National Executive Director, 
                       AMVETS (American Veterans)
    Mr. Chairman Isakson, Ranking Member Tester and Members of the 
Committee: As the largest veterans service organization open to all 
veterans who served honorably, regardless of when or where they 
served, it is a pleasure to present our views on the fiscal year 2018 
budget for the U.S. Department of Veterans Affairs (VA).
    On behalf of AMVETS National Commander Harold Chapman, we are proud 
to fully support the requests for funding as outlined in The 
Independent Budget (IB). It is crucial that the VA Secretary has all 
the resources needed to successfully, efficiently and responsibly run 
the many facets of the Department.
    One area of great concern that AMVETS wants addressed immediately 
is the White House's proposed cut to Individual Unemployability (IU) 
compensation for veterans eligible for Social Security.
    AMVETS National Headquarters has received thousands of emails, 
calls and messages over the past two weeks from veterans decrying the 
proposal to steal 225,000 Social Security eligible aged veterans the 
U.S. Department of Veterans Affairs' IU compensation program if they 
have paid into Social Security at any point during their life.
    Individual Unemployability is a VA program for veterans who cannot 
work because of their service-connected disabilities. These veterans 
are rated below 100 percent per the VA rating schedule. But each 
recipient of IU has been through an exhaustive verification process to 
ensure they are unable to earn wages above Federal poverty guidelines 
because of their wounds, injuries or illness.
    Cutting this earned and needed benefit would ``save'' $3.2 billion 
in 2018 and $41 billion over the next decade, which is slated to go 
toward an expanded VA Choice program, which has yet to be fully 
developed. We feel if President Trump knew of the serious 
repercussions, he would have not included this in his budget request.
    These veterans earned a lifetime disability benefit for their 
service to this Nation. They did not ask to become disabled or to 
become unemployable as a result of their injuries or wounds. Our nation 
owes it to them to keep its promise, so they may continue to make ends 
meet.
    If veterans lose their IU, it would trigger the loss of:

        - Civilian Health & Medical Program of the VA (CHAMPVA)
        - Dependency and Indemnity Compensation (DIC)
        - Chapter 35 Educational Benefits for the family
        - Commissary privileges
        - Property tax relief
        - VA Dental & Vision Care
        - Vehicle exemption fees

    We firmly believe that if this measure of the budget passes, that 
it would put the lives of these veterans at serious risk. VA's most 
recent report on suicide notes that about 65% of all veterans who died 
from suicide were aged 50 years or older.
    We urge your committee to reject this dangerous part of the 
President's budget and not include any cuts to IU in your budget. Every 
day those who would be affected are growing more distressed. They 
deserve to keep this earned benefit and live their senior years with 
some peace of mind knowing that the country they served is not 
deserting them in the time of their greatest need.
    AMVETS is grateful for the Committee's hard work to provide 
oversight and the resources necessary for our Federal Government to 
keep its promises to veterans, their families and survivors. Any 
questions or need for additional information may be addressed to AMVETS 
National Legislative Adviser Ms. Amy Webb.

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