[Senate Hearing 115-320]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 115-320

                     HEARING ON PENDING LEGISLATION

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 11, 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

                      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

                              ----------                              

                             July 11, 2017
                                
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........  1,10
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......    11
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    14
Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    14
Sanders, Hon. Bernard, U.S. Senator from Vermont.................    14
Boozman, Hon. John, U.S. Senator from Arkansas...................    43
Rounds, Hon. Mike, U.S. Senator from South Dakota................    46
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    49
Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    53
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........   106

                               WITNESSES

Baldwin, Hon. Tammy, U.S. Senator from Wisconsin.................     1
    Prepared statement...........................................     3
Flake, Hon. Jeff, U.S. Senator from Arizona......................     4
    Prepared statement...........................................     5
Inhofe, Hon. James M., U.S. Senator from Oklahoma................     6
    Prepared statement...........................................     7
Strange, Hon. Luther, U.S. Senator from Alabama..................     8
    Prepared statement...........................................     9
Yehia, Baligh R., M.D., Deputy Under Secretary for Health for 
  Community Care, Veterans Health Administration, U.S. Department 
  of Veterans Affairs; accompanied by Tom Lynch, M.D., Assistant 
  Deputy Under Secretary for Health Clinical Operations, VHA; 
  Brad Flohr, Senior Advisor for Compensation Services, Veterans 
  Benefits Administration; and Carin Otero, Associate Deputy 
  Assistant Secretary for Human Resources Policy and Planning, 
  Human Resources and Administration.............................    16
    Prepared statement...........................................    17
    Response to posthearing questions submitted by Hon. 
      Richard Blumenthal.........................................    55
Celli, Louis, Director, National Veterans Affairs and 
  Rehabilitation Division, The American Legion...................    57
    Prepared statement...........................................    59
Webb, Amy, National Legislative Policy Advisor, AMVETS...........    70
    Prepared statement...........................................    72
Atizado, Adrian, Deputy National Legislative Director, Disabled 
  American Veterans..............................................    79
    Prepared statement...........................................    80
Stultz, Gabriel, Legislative Counsel, Paralyzed Veterans of 
  America........................................................    91
    Prepared statement...........................................    93

                                APPENDIX

Crapo, Hon. Mike, U.S. Senator from Idaho; prepared statement....   111
Flake, Hon. Jeff, U.S. Senator from Arizona; letters from 
  constituents and organizations.................................   113
Association of American Medical Colleges (AAMC); prepared 
  statement......................................................   130
American Academy of PAs (AAP); prepared statement................   136
American Federation of Government Employees, AFL-CIO (AFGE); 
  prepared statement.............................................   137
Currie, Col. James T., USA (Ret.) Ph.D., Executive Director, 
  Commissioned Officers Association of the U.S. Public Health 
  Service (USPHS); letter........................................   141
Fighting for Veterans Healthcare, Association of VA Psychologist 
  Leaders, Association of VA Social Workers, and Nurses 
  Organization of Veterans Affairs; prepared statement...........   143
Augustine, Lauren, Director of Government Relations, Got Your 6 
  (GY6); prepared statement......................................   149
Porter, Tom, Legislative Director, Iraq and Afghanistan Veterans 
  of America (IAVA); prepared statement..........................   154
Military Officers Association of America (MOAA); prepared 
  statement......................................................   158
Stier, Max, President and CEO, Partnership for Public Service 
  (PPS); prepared statement......................................   163
Urgent Care Association of America (UCAO); prepared statement....   166
DaSilva, Rubina, MBA, PA-C, President, Veterans Affairs Physician 
  Assistant Association (VAPAA); prepared statement..............   166
Fuentes, Carlos, Director, National Legislative Service, Veterans 
  of Foreign Wars of the United States (VFW); prepared statement.   169
Wounded Warrior Project (WWP); prepared statement................   182

 
                     HEARING ON PENDING LEGISLATION

                              ----------                              


                         TUESDAY, JULY 11, 2017

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:32 p.m., in 
room 418, Russell Senate Office Building, Hon. Johnny Isakson, 
Chairman of the Committee, presiding.
    Committee Members Present: Senators Isakson, Boozman, 
Heller, Cassidy, Rounds, Tillis, Tester, Sanders, Brown, 
Blumenthal, Hirono, and Manchin.

                HON. JOHNNY ISAKSON, CHAIRMAN, 
                   U.S. SENATOR FROM GEORGIA

    Chairman Isakson. I call this meeting of the Senate 
Veterans' Affairs Committee to order. Welcome to our Members 
and our guests today as well as all others that will testify.
    As is always the tradition of the Committee, we will 
recognize visiting Senators who are here to testify first. They 
will be recognized for up to 5 minutes. There will be no Q&A, 
and you are welcome to leave afterwards, or if you want to 
stay, you can move to the back of the room--that is fine--or 
come up here and sit with me. It does not matter. [Laughter.]
    You can do anything you want to. We are all United States 
Senators.
    We are delighted to have you here at the Veterans' Affairs 
Committee, look forward to your input, and just--I will 
reserve--we will reserve opening statements until after these 
Senators speak.
    We will, first of all, ask unanimous consent that the 
statement submitted for the record by Senator Crapo, who was 
going to testify and then could not come, be put in the record. 
Without objection.
    [The prepared statement of Senator Crapo appears in the 
Appendix.]
    Chairman Isakson. So, starting with Sen. Baldwin, we will 
recognize her up to 5 minutes. Welcome.

               STATEMENT OF HON. TAMMY BALDWIN, 
                  U.S. SENATOR FROM WISCONSIN

    Senator Baldwin. Thank you so much. Thank you, Mr. 
Chairman. Thank you, Ranking Member Tester. I really want to 
thank you for the opportunity to testify today on bipartisan 
legislation that I have introduced, the Veterans ACCESS Act, 
and I was pleased to work across the aisle with Senator Moran 
on this bipartisan reform.
    Together with the Disabled American Veterans, The American 
Legion, AMVETS, the Paralyzed Veterans of America, we are 
working to help ensure that no matter where they receive 
treatment, our veterans will find the quality health care that 
they need, deserve, and have earned.
    The simple premise of this legislation is that a health 
care provider who is suspended or fired from the VA should not 
be able to then serve veterans seeking care through the Choice 
Program or other care-in-community programs.
    This is a common-sense reform. If a doctor cannot treat our 
veterans at a VA facility, that doctor should not be able to 
treat our veterans under their own shingle in the community.
    Currently, a loose patchwork of VA regulations intend to 
stop fired or suspended VA providers from participating in VA-
administered community care programs; however, VA's lack of 
consistent implementation of national standards at the local 
level, including in Wisconsin, demonstrates that Congress must 
act and not leave veterans' health and safety to chance.
    The Veterans ACCESS Act would require the VA Secretary to 
deny or revoke the eligibility of a health care provider to 
participate in community programs if that provider is fired 
from the VA, violates his or her medical license, has a 
Department certification revoked, or breaks the law.
    In Wisconsin, a doctor was suspended from treating patients 
at the VA while under investigation for deadly prescribing 
practices for which he was later fired. However, in the 
intervening time between his suspension and firing at the VA, 
he opened a private practice and was alleged to have been 
trying to see former VA patients.
    I wrote to the VA to ensure that he could not see patients 
through the Choice Program, and the VA responded that since his 
Wisconsin medical license was suspended, he could not see any 
patients. However, that temporary suspension was later 
overturned by a State administrative law judge, and from April 
2016 until January 2017, this doctor had a valid Wisconsin 
medical license.
    At last year's appropriations legislation--or in last 
year's appropriations legislation, at my request, Congress 
directed the VA to report back on existing VA policies to 
ensure that no health care providers removed for misconduct 
subsequently become providers through community care programs.
    The VA sent back a laundry list of regulations without ever 
answering the very simple, central question of whether or not a 
health care provider removed from the VA could see a patient 
through the Choice Program.
    Our legislation will ensure that the answer to this 
question is no, and it will provide Congress the needed 
oversight to ensure that the VA successfully implements 
congressional intent.
    I look forward to working with the Committee to address any 
concerns that arise from today's hearing, and I want to thank 
the veterans service organizations testifying later for their 
support of this bipartisan legislation, including Disabled 
American Veterans, The American Legion, AMVETS, and the 
Paralyzed Veterans of America.
    Thank you, Mr. Chair, Ranking Member, and all Members of 
the Committee.
    [The prepared statement of Senator Baldwin follows:]
 Prepared Statement of Hon. Tammy Baldwin, U.S. Senator from Wisconsin
    Chairman Isakson and Ranking Member Tester, I want to thank you for 
the opportunity to testify before the Senate Veterans' Affairs 
Committee on bipartisan legislation that I have introduced, the 
Veterans ACCESS Act.
    I am proud to be working across party lines with Senator Moran on 
this bipartisan reform.
    Together, with the Disabled American Veterans, the American Legion, 
AMVETS and Paralyzed Veterans of America, we are working to help ensure 
that no matter where they receive treatment, our veterans will find the 
quality health care they need, deserve and have earned.
    The simple premise of this legislation is that a health care 
provider who is suspended or fired from the VA should not be able to 
serve veterans seeking care through the Choice Program and other care 
in the community programs.
    This is a commonsense reform. If a doctor can't treat our veterans 
in a VA facility, that doctor shouldn't be able to treat our veterans 
in their own communities as well.
    Currently, a loose patchwork of VA regulations intend to stop fired 
or suspended VA providers from participating in VA-administered 
community care programs.
    However, VA's lack of consistent implementation of national 
standards at the local level, including in Wisconsin, demonstrates that 
Congress must act and not leave veterans' health and safety to chance.
    The Veterans ACCESS Act would require the VA Secretary to deny or 
revoke the eligibility of a healthcare provider to participate in 
community programs if that provider is fired from the VA, violates his 
or her medical license, has a Department certification revoked, or 
breaks the law.
    In Wisconsin, a doctor was suspended from treating patients at the 
VA while under investigation for deadly prescribing practices for which 
he was later fired.
    However, in the intervening time between his suspension and firing 
at the VA, he opened a private practice and was alleged to have been 
trying to see former VA patients.
    I wrote to the VA to ensure that he could not see patients through 
the Choice Program and the VA responded that since his Wisconsin 
medical license was suspended, he could not see any patients. However, 
that temporary suspension was later overturned by a state 
administrative law judge and from April 2016 until January 2017, this 
doctor had a valid Wisconsin medical license.
    In last year's appropriations legislation, at my request, Congress 
directed the VA to report back on existing VA policies that ensure no 
healthcare providers removed for misconduct subsequently become 
providers through community care programs.
    The VA sent back a laundry list of regulations without ever 
answering the very simple question of whether or not a healthcare 
provider removed from the VA could see a patient through the Choice 
Program.
    Our legislation will ensure that the answer to this question is 
unquestionably ``no,'' and it will provide Congress the needed 
oversight to ensure that the VA successfully implements Congressional 
intent.
    I look forward to working with the Committee to addressing any 
concerns that arise from today's hearing and I want to thank the 
Veteran Service Organizations testifying later today for their support 
of this bipartisan legislation--including Disabled American Veterans, 
the American Legion, AMVETS and Paralyzed Veterans of America.
    Thank you.

    Chairman Isakson. Thank you, Senator Baldwin. We appreciate 
your work with the Committee and your interest in our veterans 
and their affairs and the hard work you did on opioids in the 
last legislation that we passed through the Committee. Thank 
you very much.
    Senator Flake.

                 STATEMENT OF HON. JEFF FLAKE, 
                   U.S. SENATOR FROM ARIZONA

    Senator Flake. Thank you, Mr. Chairman, Ranking Member 
Tester, and other Members of the Committee. I am pleased to 
speak today in support of the Veterans Treatment Court 
Improvement Act. I am pleased to have joined the Ranking Member 
to introduce this sensible piece of legislation.
    Let me take the opportunity to introduce the bill now and 
to thank the veterans service organizations that support the 
bill, including The American Legion, AMVETS, Disabled American 
Veterans, Paralyzed Veterans of America, each of whom will 
testify here later.
    Mr. Chairman, with your consent, I will submit for the 
record, letters from these four organizations----
    Chairman Isakson. Without objection.
    Senator Flake [continuing]. As well as several others that 
support the bill.
    [These letters appear in the Appendix.]

    Senator Flake. As you likely know, the State of Arizona has 
about a half a million veterans. These brave men and women have 
served in every conflict since World War II to present-day 
operations in the Middle East, and we are obviously proud to 
call them Arizonans.
    Ofttimes, when these soldiers return home from conflicts 
abroad, the transition back to civilian life proves to be its 
own battle, and with the support of family and friends and the 
tireless work of veterans service organizations, most are able 
to surmount these challenges.
    For those that lack a support system, these issues could 
run into--or lead to run-ins with the law. While there is no 
justification, obviously, for criminal behavior, it is 
important to recognize that certain actions may be symptomatic 
of the harrowing experiences that these veterans have endured 
during their time of service.
    By not providing treatment that actually addresses the 
underlying service-connected issues, our criminal justice 
system can create a vicious cycle.
    Now, to address the absence of veteran-specific treatment 
in our criminal justice system, the Department of Veterans 
Affairs created the Veterans Justice Outreach Program in 2009. 
That program established specialty courts that remove veterans 
from the regular criminal justice process and provide tailored 
treatments for underlying issues like Post Traumatic Stress and 
substance abuse.
    Veterans treatment courts have a proven track record of 
preventing initial incarceration and reducing recidivism, and 
the lifeblood of this program are the Veterans Justice Outreach 
specialists who link veterans to available court services. 
These outreach specialists identify veterans in jails and in 
local courts, assess their health status, and help to develop a 
rehabilitation program that is tailored to each of their needs.
    In April, I had the opportunity to observe the veterans 
docket and to see some of the most dedicated specialists while 
visiting the Mesa Municipal Court in Arizona. Let me tell you, 
there is no experience--or no substitute for seeing this 
experience firsthand.
    Even though it is a courtroom setting, there is a comradery 
and collaboration that you just do not see in a traditional 
courtroom setting, and that comes from having a judge and the 
hardworking staff there having served in the military 
themselves. They understand that coming home is not always 
easy, and though the program has experienced remarkable 
success, the demand for outreach specialists is outpacing the 
program's ability to serve all eligible veterans. This means 
that future veterans treatment courts cannot be established, 
existing courts go understaffed, and veterans go unserved.
    To ensure that we have--that our veterans receive swift and 
appropriate access to justice, I have introduced the Veterans 
Treatment Court Improvement Act. It will provide 50 additional 
outreach specialists for veterans treatment courts nationwide. 
By increasing the number of dedicated specialists at these 
facilities, it will decrease the number of veterans who end up 
getting lost in the criminal justice system.
    I am committed to work with the Committee on this common-
sense legislative fix that will connect more veterans with the 
treatments that they have earned through their service.
    Thank you again, Mr. Chairman, Mr. Ranking Member, and 
Members of the Committee.
    [The prepared statement of Senator Flake follows:]
    Prepared Statement of Hon. Jeff Flake, U.S. Senator from Arizona
    Thank you Chairman Isakson and Ranking Member Tester for allowing 
me to speak today in support of the Veterans Treatment Court 
Improvement Act. I am pleased to have joined with the Ranking Member to 
introduce this sensible piece of legislation.
    I would also like to take the opportunity now to thank the Veterans 
Service Organizations that support the bill, including The American 
Legion, AMVETS, Disabled American Veterans, and Paralyzed Veterans of 
America, each of which have a member testifying here today.
    Mr. Chairman, with your consent I will submit for the record 
letters from these four organizations, as well as several others, in 
support of the bill.
    As you likely know, the state of Arizona is home to more than half 
a million veterans. These brave men and women have served in every 
conflict from World War II to present day operations in the Middle 
East. I am proud to call them Arizonans.
    But, oftentimes, when these soldiers return home from conflicts 
abroad, the transition back to civilian life proves to be its own 
battle. With the support of family and friends, and the tireless work 
of Veterans Service Organizations, most are able to surmount these 
challenges.
    For those who lack a support system, these issues could lead to 
run-ins with the law. While there is no justification for criminal 
behavior, it is important to recognize when certain actions may be 
symptomatic of the harrowing experiences a veteran has endured during 
years of service.
    By not providing treatment that actually addresses the underlying 
service-connected issues, our criminal justice system can create a 
vicious cycle. To address the absence of veteran-specific treatment in 
our criminal justice system, the Department of Veterans Affairs created 
the Veterans Justice Outreach program in 2009.
    The program established specialty courts that remove veterans from 
the regular criminal justice process and provide tailored treatments 
for underlying issues like post-traumatic stress and substance abuse. 
Veterans treatment courts have a proven track record of preventing 
initial incarceration and reducing recidivism. The lifeblood of the 
program are the Veterans Justice Outreach specialists who link veterans 
to available court services. These outreach specialists identify 
veterans in jails and local courts, assess their health status, and 
help to develop a rehabilitation treatment program specific to each 
veteran's needs.
    In April, I had the opportunity to observe the veterans docket and 
meet with some of these dedicated specialists while visiting the Mesa 
Municipal Court in Arizona. Let me tell you, there is just no 
substitute for seeing this process firsthand. Even though it's a 
courtroom setting, there is a comradery and collaboration that you just 
don't see in traditional courtroom proceedings. That comes from having 
a judge and hardworking staff who have served in the military 
themselves. They understand that coming home isn't always easy.
    Though the program has experienced remarkable success, the demand 
for outreach specialists is outpacing the program's ability to serve 
all eligible veterans. This means that future veterans treatment courts 
cannot be established, existing courts will go understaffed, and 
veterans will go unserved.
    To ensure that our veterans receive swift and appropriate access to 
justice, I introduced the Veterans Treatment Court Improvement Act. 
This legislation will provide 50 additional outreach specialists for 
veterans treatment courts nationwide. By increasing the number of 
dedicated specialists at these facilities, we will decrease the number 
of veterans who will end up getting lost in the criminal justice 
system.
    I am committed to working with the Committee on a commonsense 
legislative fix that would connect more veterans with the treatments 
they have already earned with their service.
    Thank you.

    Chairman Isakson. Well, thank you, Senator Flake.
    I can tell you from my firsthand experience in Cobb County, 
GA, which is my home residence, where we have a drug court, the 
work that has been done in the drug treatment court is just 
amazing. The lives that have been changed is just amazing. It 
is a lot like the Court-Appointed Special Advocate Program for 
youthful offenders. It is a second chance, so to speak, to get 
a first impression for the veterans. I appreciate your emphasis 
and your work on that. I am glad you have introduced the 
legislation, and it will get a fair hearing.
    Senator Flake. Thank you.
    Chairman Isakson. Senator Inhofe.

              STATEMENT OF HON. JAMES M. INHOFE, 
                   U.S. SENATOR FROM OKLAHOMA

    Senator Inhofe. Thank you, Mr. Chairman.
    I would ask how you guys would feel if you experience what 
I experienced December 22, 2015. I picked up the USA Today 
paper, and on the front page above the fold was an article 
about how Oklahoma is doing such a lousy job with their 
veterans.
    We have had a lot of complaints. We have two major areas in 
Oklahoma--Muskogee and Oklahoma City--and we had felt it was 
mostly because of leadership.
    Anyway, the problems were very serious, and we investigated 
hundreds of inquiries, as you guys do, every time something 
like this might happen. Our veterans had been subjected to 
insufficient and possibly negligent care or denied access to 
rightfully-earned benefits.
    Now, we have been helped by Ralph Gigliotti. Ralph 
Gigliotti is one of the VISN directors, I guess, VISN 19 
director, and I could not have been happier with him. He came 
in, and he agreed with the problems that we had. He has been 
very supportive of us in the changes that we have to have on 
the ground to take care of the--and we solved the problems.
    There were two problems that took a long time for us to get 
around. One has been taken care of already, and that was the 
bill that gives a VISN the authority to come in and fire 
someone, fire them on the spot. If they come in and then find 
out that they have to wait 6 months before they get rid of 
somebody, it takes away all of the problems that otherwise can 
be handled by quickly getting with them. Of course, we took 
care of that in the legislation that we just passed recently 
giving them that authority.
    Now we have two new directors in both Oklahoma City and in 
Muskogee, and because of Gigliotti's and the new directors' 
leadership, Oklahoma's facilities are now really improving. In 
fact, they have gone from one-star to three-star facilities 
already since that happened in December 2015.
    Now, we were holding--in order to bring in a third party, 
which the VA did not want to do, I actually, Mr. Chairman, had 
to go down to the cloakroom and put a hold on our own 
President's nominee for IG. It took about 2 weeks after that 
before they would agree to finally let some third party come in 
with him. They did that. A great job was done by the third 
party. That happened to be--what was the name of that group?
    The Joint what? You have got to talk louder.
    Attendee. Joint Commission.
    Senator Inhofe. Very good. Joint Commission.
    They came in to investigate and really did a great job. Now 
the standards are going up and all that, but the problem is 
having that authority to go and seek this.
    So, the problem that I have in Oklahoma is not just in 
Oklahoma. I think it is probably in each State that is 
represented on the panel here. So, this is something that I 
cannot imagine anyone would be opposed to.
    Now, we address this along with my junior Senator, James 
Lankford, by introducing S. 1266, the Enhancing Veteran Care 
Act. It provides permanent authority for VISN directors, like 
Ralph Gigliotti, and medical center directors to contract with 
outside entities to do these kinds of investigations. There is 
no better way of getting through than to have another party 
looking over the shoulder of those who are doing 
investigations.
    It is something that is--I cannot imagine anyone would be 
opposed to and certainly is one that we will make sure that we 
give the right treatment to our veterans. I was hoping that you 
will be able to bring this up and pass it for our veterans' 
sake.
    [The prepared statement of Senator Inhofe follows:]
  Prepared Statement of Hon. James Inhofe, U.S. Senator from Oklahoma
    I would like to address the Committee on some of the VA health 
clinic challenges we have had in my state of Oklahoma.
    We have had serious problems at both VA centers in Oklahoma--
Muskogee and Oklahoma City. My office has investigated hundreds of 
inquiries from Oklahoma veterans who have been subjected to 
insufficient, and possibly negligent care, or denied access to 
rightfully earned benefits.
    We have been helped by Ralph Gigliotti, our VISN 19 director, who 
is outstanding. He has been very supportive of ensuring the changes 
that need to happen on the ground in Oklahoma actually take place.
    Both OK VA centers now have new directors, Wade Vlosich and Mark 
Morgan. Because of Gigliotti and the new directors' leadership, the 
Oklahoma facilities are implementing new processes and procedures that 
will improve care. The OKC center has gone from a one-star to a three-
star facility in the last year alone.
    It was only after I held the VA IG nomination on the Senate floor 
last year that the VA ensured us that they would send a third-party to 
investigate these facilities. The VA contracted with the Joint 
Commission to do an investigation of Oklahoma's facilities in 
conjunction with the VA Inspector General.
    It's important we hold care providers accountable to the highest 
standards of excellence for our veterans. Having this outside entity 
come in and compare the VA facilities to private sector health care 
facilities is helping identify clear problems for the local and 
regional directors to go after and fix. A fresh set of eyes, from 
outside the VA, will enhance everyone's efforts to ensure our VA 
facilities are world class.
    This is not just a problem in Oklahoma. Across the Nation, veterans 
have become all too familiar with the unsatisfactory care being 
provided through the VA health care system. Too often, internal VA 
reports and investigations do not match the facts on the ground, and 
the regional directors know this. As a result, many veterans and VA 
employees have lost faith in the agency and are not receiving the 
proper care they deserve.
    To address this I, along with the junior Senator from Oklahoma, 
James Lankford, introduced S. 1266, the Enhancing Veteran Care Act, 
which provides permanent authority for VISN directors, like Ralph 
Gigliotti, and medical center directors to contract with outside 
entities to do these kinds of investigations.
    There is no better group to give this contracting authority to than 
the regional VA directors who know firsthand the issues their medical 
facilities face and are directly responsible for bringing about change 
in the midst of excessive bureaucracy. I believe this to be an 
important authority that needs to be explicitly provided to them, so 
that more of the VA health center problems, which we hear about far too 
often, can be fully addressed.

    Thank you for having me today and I encourage swift passage of this 
important legislation.

    Chairman Isakson. We appreciate your introduction and you 
being here today. We will give it every due consideration. We 
are trying to make sure that we get everything out of the 
Committee before July recess or August recess or whenever the 
recess is----
    Senator Inhofe. You tell us. [Laughter.]
    Chairman Isakson [continuing]. And then get finished by the 
end of the year. We appreciate your effort very much, Senator 
Inhofe.
    Senator Inhofe. Yes, sir.
    Chairman Isakson. Senator Strange, welcome.

               STATEMENT OF HON. LUTHER STRANGE, 
                   U.S. SENATOR FROM ALABAMA

    Senator Strange. Thank you, Mr. Chairman and Ranking Member 
Tester.
    I would first like to thank the Committee for the ongoing 
work it is doing to champion the interests of our Nation's 
veterans. All the proposals here that have been presented are 
very noble bills that I think would make a difference. I know, 
as a former Attorney General, the veterans courts are 
particularly satisfying and effective in this area.
    There are lots of issues, of course, that divide us, but I 
am glad that we all come together when it comes to the care of 
the veterans who have served this country so long and hard.
    For so many who have served, the VA is what they rely upon. 
It is the face of the promise the Nation made to them to take 
care of them. It is critical that the VA facilities stand ready 
to meet the needs of that population.
    I am here today to introduce a bill that will improve the 
quality of service and care available to veterans by 
implementing needed reforms to the VA hiring and employee 
management systems.
    As the Members of this Committee know well, we are up 
against significant challenges in this effort. You know that a 
2016 Best Places to Work survey ranked the VA second to last 
among large agencies, second to last in executive leadership, 
and dead last in pay.
    It is vital that our veterans can count on high-quality 
services and care, and the first step in restoring that 
accountability is ensuring that the VA is equipped with 
talented professionals ready to meet their needs.
    The VA Quality Employment Act of 2017 would build on 
progress made already by the VA Accountability and 
Whistleblower Protection Act, which President Trump signed into 
law just last month. It would take a number of important 
additional steps to enable the agency to attract and retain top 
talent, hold poor performers accountable, and deliver services 
worthy of our Nation's heroes.
    First, it would establish health care and benefits 
fellowship programs connected to the private sector to train 
and retain a top-notch, service-oriented workforce. In today's 
evolving workforce providing opportunities for professional 
advancement and development is critical in motivating talented 
caregivers and administrators to commit to the VA.
    Second, the bill would provide for training human resource 
professionals on recruiting and retaining Veterans Health 
Administration employees and would create a database of VA job 
openings. Too often, the right candidates are unaware of the 
opportunities that desperately need filling.
    Third, it would direct the VA to conduct annual performance 
plans for political employees to ensure that the agency is in 
the hands of a high-quality leadership. Veterans should never 
be subjected to subpar care because politics got in the way of 
public service.
    In March, a companion bill, H.R. 1367, passed the House of 
Representatives unanimously by a vote of 412 to zero, a rare 
occurrence in Congress these days. The millions of veterans who 
rely on the VA deserve swift and decisive action in the Senate 
as well.
    So, I would like to urge my colleagues here today to 
recognize the need to improve the care we promise to those who 
protect our freedoms and join me in support of this legislation 
that will fill the urgent need and help the VA keep its 
covenant with our Nation's heroes.
    Mr. Chairman and Senator Tester, thank you again for the 
courtesy you have extended for allowing me to speak today, and 
I look forward to working with each one of you to advance this 
bill through the process. Thank you very much.
    [The prepared statement of Senator Strange follows:]
  Prepared Statement of Hon. Luther Strange, U.S. Senator from Alabama
    Chairman Isakson, Ranking Member Tester, I would first like to 
thank the Committee for its ongoing work to champion the interests of 
our Nation's veterans.
    There are a lot of issues that divide us these days, but taking 
care of those who have served must continue to be a unifying cause.
    For so many Americans who have served, Veterans Affairs' employees 
are relied upon as the face of a promise the Nation made to take care 
of them, and it is critical that VA facilities stand ready to meet the 
needs of our veteran population.
    I'm here today to introduce a bill that will improve the quality of 
services and care available to veterans by implementing needed reforms 
to the VA hiring and employee management systems.
    As Members of this Committee, you are each well aware of what we're 
up against in this effort. You know that a 2016 Best Places to Work 
survey ranked the VA second to last among large agencies, second to 
last in executive leadership, and dead last in pay.
    It is vital that our veterans can count on high-quality services 
and care, and the first step in restoring that accountability is 
ensuring that the VA is equipped with talented professionals ready to 
meet their needs.
    The VA Quality Employment Act of 2017 would build on the progress 
made by the VA Accountability and Whistleblower Protection Act, which 
President Trump signed into law just last month. It would take a number 
of important additional steps to enable the agency to attract and 
retain top talent, hold poor performance accountable, and deliver 
services worthy of our Nation's heroes:

          First, it would establish healthcare and benefits fellowship 
        programs connected to the private sector to train and retain a 
        top-notch, service-oriented workforce. In today's evolving 
        workforce, providing opportunities for professional development 
        is a critical component in motivating talented caregivers and 
        administrators to commit to the VA.
          Second, the bill would provide for training human resource 
        professionals on recruiting and retaining Veterans Health 
        Administration employees and create a database of VA job 
        openings. Too often, the right candidates are unaware of the 
        opportunities that desperately need filling.
          Third, it would direct the VA to conduct annual performance 
        plans for political employees to ensure that the agency is in 
        the hands of high-quality leadership. Veterans should never be 
        subject to sub-par care because politics got in the way of 
        public service.

    In March, a companion bill, H.R. 1367, passed the House of 
Representatives unanimously by a vote of 412-0. The millions of 
veterans who rely on the VA deserve swift and decisive action in the 
Senate, as well.
    I would like to urge my colleagues here today to recognize the need 
to improve the care we promise to those who protect our freedoms. Join 
me in support of legislation that will fill urgent needs and help the 
VA keep its covenant with our Nation's heroes.

    Mr. Chairman, Mr. Ranking Member, thank you again for the courtesy 
you've extended in allowing me to speak today. I look forward to 
working with each of you to deliver this important bill for our 
Nation's veterans.

    Chairman Isakson. Thank you very much, Senator Strange, 
Senator Inhofe, and to all the members who came and gave their 
time. Thanks for your interest in our veterans. We will be 
getting back to you shortly in trying to work together to see 
this all can become law. So, thank you.
    Senator Strange. Thank you very much.

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

    Chairman Isakson. We have two panels today to talk about 
the legislation that is before us, but before we do, I want to 
make a brief opening statement, as does the Ranking Member.
    Let me thank the Members of the Committee that are here 
today and make note that more often than not, attendance at the 
Veterans' Affairs Committee is better by percentage than almost 
any committee in the Senate, and I want to thank the Members of 
the Committee for their active engagement so far this year and 
allowing us to accomplish any number of things.
    To that end, there is an article that appeared in The New 
York Times about this Committee and the amazing amount we have 
accomplished in the last year together as Republicans and 
Democrats, to the credit of the Ranking Member who has worked 
so hard with me to make sure that we did not forget about each 
other while we kept our veterans first. Further, in the few 
challenges we have before this year is over, we are going to 
demonstrate once again we can find common ground to meet those 
challenges to confront both the VA and what is required of it 
as well as our veterans themselves.
    I want to let all the Members know, and, for the record, 
say publicly that it has been a complete team effort, with 
everybody on the Committee making an effort to contribute, 
Republican and Democrat alike. I am proud of what we have been 
able to do, and I think the rest of it is within our reach as 
long as we keep the same attitude, the same spirit, and same 
commitment of work that we have in the last few months.
    I want to thank the Ranking Member for his support. He 
called me from his tractor Saturday returning my call on 
something we are going to be talking about today, just to make 
sure we had every I dotted and T crossed. We try to communicate 
that well, so we do not ever catch each other by surprise. I 
want every Member to know how much we appreciate your effort 
and what you do.
    Ahead of us, before this year is out, is to make sure we 
deal with the Choice shortfall, dealing with modernization of 
the Choice Program for standards and requirements, dot the I's 
and cross the T's to make sure the appeals process gets put to 
bed, which is about done, and work with the House Members on 
the shortfall in terms of Choice to make sure it gets funded 
before the year is out in an appropriate way.
    That is a big lift that in many years would have seemed 
impossible and not in our reach, but this year, because of the 
work of the Committee, the spirit of the Committee, and the 
commitment to getting the job done for our veterans, I just 
believe we are going to do it. I am very proud to be a part of 
it.
    I want to thank everybody on the Committee for their effort 
and introduce the Ranking Member for his opening statement.

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

    Senator Tester. Well, thank you, Mr. Chairman. I want to 
thank you for calling maybe the most important hearing that we 
are going to have this year.
    Before I get into my prepared remarks, I just want to say 
thank you for your leadership. Your commitment to solid 
communication and making it so there are no surprises, has been 
critically important on this Committee to move the ball ahead.
    I think it is important that we recognize what we have 
accomplished, but I think it is also important to recognize 
what we have yet to accomplish. That is why this hearing today 
is so very, very important, because there are fewer things more 
important to an individual than their health.
    We are seeing the access to health care issues play out day 
in and day out here in the Senate, in the media, and back home. 
Today that discussion comes to the Veterans' Affairs Committee. 
The issue of where a veteran receives care and how that process 
is constructed has been looming over this Committee for years, 
and today we will hopefully get constructive feedback and 
guidance that moves us forward to a final product.
    I have had listening sessions back in Montana. Those 
veterans told me that the Choice Program has not improved 
access to care in Montana. In fact, if anything, it has made it 
worse. In the process, it has caused a lot of veterans and 
community providers to lose faith in the VA, and we have got a 
lot of work to do to win those folks back. We need a dramatic 
revamp of VA's community care program, and we need to be 
thoughtful in our approach.
    I said many times that I think we should be taking our cues 
from the veterans, and I believe that my community care bill 
does exactly that. Rather than just giving the veteran a card 
to seek care in the private sector, I believe the VA must 
continue to serve as a coordinator and primary provider of care 
while the private sector fills in the gaps in care after the VA 
takes into account the specific needs of an individual veteran.
    That is exactly what my discussion draft, the Improving 
Veterans Access to Community Care Act of 2017, would do. It 
would put the decision of where a veteran received care in the 
hands of a patient and provider, which is exactly where it 
should be. In my view, a doc and a veteran should talk about 
that veteran's specific needs and any challenges that veteran 
faces in receiving care. This approach understands that one 
size does not fit all when it comes to health care and outlines 
factors that could be considered when the docs and patients 
have that discussion. Those factors are not meant to be binding 
or cumbersome; they are meant to be a jumping-off point for the 
doc and the veteran to have a conversation about what that 
veteran needs.
    This common-sense approach takes the needs of the veterans 
in places like Montana under consideration, where local 
providers are often unable to absorb those veterans or to 
provide the specialized care that is required. Do not get me 
wrong. There is an important role for community care in the 
delivery of veterans' health, but when a veteran goes into the 
community for care, it should be based on what is best for the 
veteran. And sending veterans into the private sector does not 
absolve the VA of its responsibility for the care and benefits 
that veteran received. The VA can transfer that care, but it 
can never transfer the ultimate responsibility for that 
veteran's well-being. That is why my bill would treat 
disabilities incurred as a result of care received in the 
private sector just like disabilities that result from care 
received at the VA.
    I believe the VA is just as responsible when a veteran has 
had a bad experience with their local civilian facility as they 
are if that veteran was at a VA hospital. We cannot let VA lose 
oversight of the quality of care the veterans receive, 
regardless where it is. While we are focusing on where veterans 
get their care, we also need to address how we work to bolster 
VA's internal capacity to provide better care.
    That is where my Better Workforce for Veterans Act comes 
in. This workforce bill supported by my sometimes friend and 
foe----
    Is he here? Damn it. I hate to waste good comments. 
[Laughter.]
    Senator Tester [continuing]. Focuses on recruiting, hiring, 
and retaining a talented workforce for the VA. The VA has some 
well-known human capital challenges, and my bill begins to 
address them, legislation that I think makes a lot of sense, 
given the Office of Inspector General's findings that physician 
assistants are one of the top six critical-need occupations at 
VA is also on today's agenda.
    The Grow Our Own Directive: Physician Assistant Employment 
and Education Act of 2017 allows the Government to continue 
reaping returns on our investment in training medics and 
corpsmen by keeping these individuals in Government service. I 
introduced this legislation earlier this year with the support 
of Senators Brown and Moran, among others. It provides training 
and education opportunities for veterans who served as medics 
and corpsmen who agree to serve the VA in underserved areas. 
Once these veterans are certified as physician assistants, they 
would be required to work at the VA for at least 3 years.
    My bill also includes physician assistants in the Nurse 
Locality Pay System. Once we have these folks on board, we need 
to keep them there by paying them on par with what a PA in a 
local community is making.
    VA needs more PAs, and my legislation will help bring them 
on board and keep them there serving veterans. While we are 
examining these big-picture issues on where veterans get their 
care and how to improve VA workforce-related issues, we need to 
also make sure that we are improving the services VA provides 
to veterans in making sure programs that tend to help veterans 
evolve with the times. That is why, I along with Senator 
Murkowski and on this Committee, Senators Blumenthal, Brown, 
and Murray, introduced the Servicemembers and Veterans 
Empowerment and Support Act of 2017. The fact that anyone in 
uniform has to deal with sexual assault or harassment during 
the course of their service to our country is unacceptable.
    Following reports that nude photos of female servicemembers 
were posted on Facebook and other websites without the 
servicemembers' knowledge or consent, we introduced legislation 
to make it clear that servicemembers and veterans who have 
experienced online sexual harassments are able to access VA 
counseling and benefits.
    Mr. Chairman, earlier this year I was pleased that we would 
come together in a bipartisan manner to make some much needed 
changes to Choice. I really think we have an opportunity to do 
that again by coming to agreement on a path forward for 
community care. As we continue to work toward a compromise on 
community care legislation, I am hopeful that this hearing will 
help inform that effort in a big way.
    Thank you, Mr. Chairman. I also want to thank the Members 
of this Committee.
    Chairman Isakson. Thank you, Senator Tester. I am confident 
we can come to that agreement to make Choice work, make it work 
even better, and solve those problems that confront us today.
    Before we go to our panels, I see Senator Cassidy is here 
and has two bills that are on the agenda today. Senator Hirono 
is here and has one that carries her name, and Senator Heller 
was here, but he disappeared when I looked the other way a 
minute ago. So, I do not know if he is coming back or not.
    Did you want to say anything about yours, Senator Cassidy 
or Senator Hirono?
    Senator Cassidy. I yield, Mr. Chairman.

              STATEMENT OF HON. MAZIE K. HIRONO, 
                    U.S. SENATOR FROM HAWAII

    Senator Hirono. Well, let me add my thanks to you and the 
Ranking Member for the bipartisan work that we do in this 
Committee; this is well-deserved recognition.
    Regarding my bill, I am glad that the VA is supportive as 
well as the veterans organizations across the country, because 
we have a lot of veterans who need long-term care, and we want 
to keep those facilities supported.
    Thank you.
    Chairman Isakson. Senator Cassidy?

                STATEMENT OF HON. BILL CASSIDY, 
                  U.S. SENATOR FROM LOUISIANA

    Senator Cassidy. I only have one bill. You threw me for a 
little bit of a loop. I was thinking, ``Wait a second; do I 
have two?''
    So, ours is the Veterans Emergency Room Relief Act of 2017, 
where if a veteran has an urgent care need and he does not live 
near a VA hospital or if the VA hospital emergency room line is 
long, this would allow him or her to go to that urgent care 
center which the VA was contracted for a reasonable rate and 
for the veteran to receive their care there.
    The idea is that emergency rooms are roughly twice the cost 
of urgent care centers at least, and this would allow the 
veteran to receive the care at a lower-cost setting than in an 
emergency room. We think that it would save the VA money. It 
would also allow someone who might be dissuaded from receiving 
care because of long lines in an ER to perhaps receive that 
care that would be vital to health; because the line was 
shorter, it was more efficient to go through. It gives the 
veteran greater access to health care in their community.
    We also have a basic cost-sharing mechanism for urgent care 
visits and allowing the VA to establish some sort of cost 
sharing but excluding conditions such as service-related, those 
which require an admission, or other hardship for the veteran, 
et cetera, and then for the Secretary of Veterans Affairs to 
submit a report every 2 years regarding both urgent care 
utilization and the impact upon ER facilities. We think it is a 
good bill, and it has support of many of the veterans service 
organizations.
    Chairman Isakson. Thank you, Senator.
    Senator Sanders?

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

    Senator Sanders. Thanks, Mr. Chairman.
    I just wanted to say a few things. I think most 
importantly, what this Committee has got to do--and I think we 
do a pretty good job at it--is listen to the veteran service 
organizations and listen to the veterans of this country. What 
they tell us over and over again: ``The VA is not perfect. The 
VA has problems.'' But, what they are telling us is that the VA 
provides very high-quality care to veterans who are in the 
system. The veterans organizations want to see the VA 
strengthened. They want to see, among other things, the tens of 
thousands of vacancies which currently exist within the VA--
doctors, nurses, other medical personnel--they want to see 
those vacancies filled.
    I think when we talk about filling vacancies and attracting 
doctors, which is a difficult problem all across this country, 
especially in primary care, I want to reiterate my belief that 
we have got to expand the debt forgiveness program to attract 
more doctors and nurses and other personnel into the VA.
    I think there has been a lot of discussion--I know Senator 
Boozman has been involved in this--on the feeling that we do 
not want to see our veterans overmedicated. There are too many 
drugs. Opioids are used. We want to find other ways to ease 
pain, and I think the VA in general has done a pretty good job. 
I want to see that expanded, so those are some of the concerns 
that I am going to be focusing on, Mr. Chairman.
    Chairman Isakson. Well, I appreciate those comments.
    Senator Baldwin, who was here a little bit earlier, and 
Senator Johnson did a great job in terms of the Tomah problem, 
which was the lead problem on opioid overuse and over-
prescription at the VA. This Committee took strong action to 
give the VA the power it needed to see to it that operation was 
shut down and that practice was stopped. We find ourselves 
continuing to focus on opioids, as we will, because it is a 
major problem throughout the country.
    Your comment about the VSOs, I am very proud that at every 
hearing we have had in the 3 years that I have been on the 
Committee as Chairman, we have always had a panel of the VSOs 
represented. They will be here today on our second panel. I 
could not do the job I am called upon to do without their 
effort and their work. I acknowledge and appreciate their input 
every single day that we get it.
    As far as the empowerment of the Veterans Administration 
and the Veterans Health Administration, I think we have made 
some of the greatest steps forward, one in David Shulkin who 
was approved unanimously by the Senate, the only Presidential 
Cabinet appointee approved unanimously and who has demonstrated 
what he has done. He shows a love and respect for the veteran, 
a knowledge of health care, and a commitment to see to it the 
VA is everything it needs to be to serve our veterans and their 
health care needs in the years to come. I support that 150 
percent, and I appreciate your acknowledgment of those 
challenges. We are going to continue to work on those every 
single day.
    Does any other Member of the Committee have a comment to 
make before we go to the first panel? [No response.]
    Chairman Isakson. If not, Doctor, are you ready?
    Dr. Yehia. I am ready.
    Chairman Isakson. I always want to call him ``Dr. Yehia,'' 
and I think that is right, isn't it?
    Dr. Yehia. It is right.
    Chairman Isakson. I finally got it right this time.
    Dr. Yehia from the Veterans Administration, accompanied by 
Dr. Tom Lynch, Brad Flohr, and Carin Otero. We are glad to have 
you all here today. You have got plenty of support, Dr. Yehia. 
You are recognized for your testimony.

STATEMENT OF BALIGH R. YEHIA, M.D., DEPUTY UNDER SECRETARY FOR 
HEALTH FOR COMMUNITY CARE, VETERANS HEALTH ADMINISTRATION, U.S. 
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY TOM LYNCH, M.D., 
     ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH CLINICAL 
 OPERATIONS, VHA; BRAD FLOHR, SENIOR ADVISOR FOR COMPENSATION 
 SERVICES, VETERANS BENEFITS ADMINISTRATION; AND CARIN OTERO, 
ASSOCIATE DEPUTY ASSISTANT SECRETARY FOR HUMAN RESOURCES POLICY 
        AND PLANNING, HUMAN RESOURCES AND ADMINISTRATION

    Dr. Yehia. Good afternoon. Thank you, Mr. Chairman, Ranking 
Member Tester, and Members of the Committee. Thank you for 
inviting us here today to present our views on veterans' access 
to VA's programs and services.
    My written statement provides VA's detailed views on 11 of 
the bills on the agenda today, and in the interest of time, I 
would like to briefly touch on several of these bills before 
us.
    I did want to note that there are two bills that the 
Department was unable to provide views at this time, and we 
will get back to the Committee after the hearing.
    So, first, we support Senate Bill 115, which would allow VA 
to better care for veterans receiving live organ transplants.
    We also support increasing access to care through hiring 
more physician assistants, as broadly outlined in Senate Bill 
426, and extending VA's authority to provide nursing home care 
to certain severely disabled veterans, as Senate Bill 683 would 
do.
    We also appreciate Senate Bill 833, which is intended to 
improve access to care and benefits for a veteran and 
servicemembers who experience military sexual trauma.
    Ensuring that we hire and retain the highest-quality 
providers is critical to providing care to veterans, which is 
why we support many of the provisions in Senate Bill 1325, the 
Better Workforce for Veterans Act of 2017.
    We also support the intent of Senate Bill 1261, the 
Veterans Emergency Room Relief Act of 2017, which attempts to 
simplify and consolidate access to emergency and urgent care.
    However, there are several other bills on the agenda today 
that address important topics but, as written, would limit our 
ability to effectively manage VA programs and resources. For 
example, VA is already taking steps to hire more justice 
outreach specialists as would be required in Senate Bill 946, 
the Veterans Treatment Court Improvement Act of 2017.
    We are very committed to ensuring that veterans have access 
to care, both inside and outside the Department, which is why 
we support the principles in Senate Bill 1153, the Veterans 
ACCESS Act, although we are concerned that this bill could 
actually create some administrative burdens that would limit 
high-quality providers joining our community care network.
    We also do not support some of the provisions in Senate 
Bill 1266, the Enhancing Veteran Care Act. VA already has 
demonstrated an ability to provide comprehensive reports on 
quality care over several decades, and we think this 
legislation might be a little bit duplicative.
    Last, I want to focus on The Veterans Choice Act of 2017 
and the Improving Veterans Access to Community Care Act of 
2017. Let me say that we understand that the future of VA's 
community care program is one of the most important and 
possibly one of the most difficult items on the legislative 
agenda. We want to work with everyone to ensure that this 
legislation is as strong as possible. We believe that the law 
that is ultimately enacted should embrace a few broad 
principles. These principles are based on lessons learned 
through VA's existing community care programs, including the 
Choice Program, and discussions with their key stakeholders.
    First and foremost, the future community care program must 
empower the veteran and their care team so that the veteran 
gets the right care at the right time from the right provider.
    Second, the Department must be able to establish a high-
performing network of VA and community providers who can 
furnish the very best care. To do this, we must have 
flexibility, flexibility in payment rates and the type of 
agreements we form with providers. In addition, we must have 
flexibility in our ability to simplify our interactions with 
community providers so we can pay timely and accurately and 
that we can share information more easily between the two.
    Third, it is important that VA retain flexibility to adjust 
and adapt to an evolving health care landscape. Legislation 
that is too prescriptive in terms of rules, responsibilities, 
or processes can only limit our options in the future, which 
would lead to frustration from our veterans, our community 
providers, and VA employees. With the Choice Program, we have 
had five separate law changes in just under 3 years. That is 
not really a sustainable model. We believe that the best 
legislation would provide broad, general authority that VA 
could define and implement through regulation, policies, and 
contracts.
    Last, it is critical that the legislation provide VA with 
sufficient time to develop and lead to implementation. We know 
from our efforts in the Choice Program that a short period of 
implementation will not help veterans. Ideally, we would like 
to have a full year to establish provider networks, draft 
regulations, and build the necessary relationships and systems 
that will empower our veterans, community providers, and VA 
staff to deliver the best health care to our Nation's veterans.
    Mr. Chairman, this concludes my statement. I would be happy 
to answer any questions that you or Members of the Committee 
would have.
    [The prepared statement of Dr. Yehia follows:]
Prepared Statement of Baligh R. Yehia, M.D., Deputy Under Secretary For 
    Health For Community Care, Veterans Health Administration, U.S. 
                     Department of Veterans Affairs
    Good morning, Chairman Isakson, Ranking Member Tester, and Members 
of the Committee. Thank you for inviting us here today to present our 
views on several bills that would affect the Department of Veterans 
Affairs' (VA or Department) programs and services. Joining me today is 
Dr. Tom Lynch, Assistant Deputy Under Secretary for Health Clinical 
Operations, Veterans Health Administration (VHA); Brad Flohr, Senior 
Advisor for Compensation Services, Veterans Benefits Administration; 
and Carin Otero, Assistant Deputy Assistant Secretary for Human 
Resources Policy and Planning, Human Resources and Administration.
    This written statement includes VA's views on eleven significant 
bills on important topics. Because of the timing of receipt of two of 
the bills, we are not able to provide formal views in this statement on 
S. 1279, the Veterans Health Administration Reform Act of 2017 or the 
draft bill, ``The Department of Veterans Affairs Quality Employment Act 
of 2017.'' We also will follow up with the Committee on one section 
(section 10) of the Veterans Choice Act of 2017. We look forward to 
providing views at a later time and discussing these bills with you 
today.
                s. 115, veterans transplant coverage act
    S. 115 would add section 1788 to Title 38, authorizing the 
Secretary of Veterans Affairs (Secretary) to provide for an operation 
on a live donor to carry out a transplant procedure for an eligible 
Veteran, notwithstanding that the live donor may not be eligible for VA 
healthcare. VA would be required to provide to a live donor any care or 
services before and after conducting the transplant procedure that may 
be required in connection with the transplant.
    VA supports S. 115, contingent on the provision of additional 
resources to support implementation, although we recommend some 
clarifications in the bill language. We believe it would be appropriate 
to limit the duty and responsibility to furnish follow-on care and 
treatment of a living donor to two years after the procedure is 
performed by a VA facility. This would be consistent with the 
recommendations of the United Network for Organ Sharing and the Organ 
Procurement and Transplant Network. We further recommend that the duty 
to provide follow-on care and treatment should be limited to that which 
is ``directly related to'' the living donor procedure (rather than what 
``may be required in connection with such procedure,'' as the bill 
would provide).
    There are other potential issues related to organ transplantation 
that the bill does not address that we would be pleased to discuss with 
the Committee in its contemplation of this proposal.
    We estimate the bill as written would cost $1.8 million in Fiscal 
Year (FY) 2018, $9.7 million over 5 years, and $21.5 million over 10 
years.
  s. 426, grow our own directive: physician assistant employment and 
                         education act of 2017
    S. 426 would provide new authorities for VA to provide educational 
assistance and other benefits to support physician assistants (PA).
    Section 2 would require VA to carry out a pilot program to provide 
educational assistance to certain former members of the Armed Forces 
for education and training as PAs.
    Having a pilot program will help alleviate the healthcare workforce 
shortages in VA by requiring scholarship recipients to complete a 
service obligation at a VA healthcare facility after graduation and 
licensure/certification. Additionally, scholarships will enable 
students to gain academic credentials without additional debt burdens 
from student loans. Future benefits are gained in reduced recruitment 
costs as scholarship recipients will have obligated service agreements 
to fulfill. These service agreement obligations secure the graduates' 
services for up to three years, which reduces turnover and costs 
typically associated with the first two years of employment.
    While VA supports section 2, contingent on the provision of 
additional resources to support implementation, we believe that the 
Congress should provide more flexibility in implementation. The bill is 
very specific, including in areas such as directing the management 
structure of the pilot program and the specific criteria for 
participant eligibility. VA should be afforded the flexibility to 
implement such a program in a manner that can minimize any unintended 
consequences and promote consistency across Title 38 programs.
    We recommend removing language in paragraph (j) that would require 
the positions of Deputy Director for Education and Career Development 
for Physician Assistants and Deputy Director of Recruitment and 
Retention to be filled by a Veteran and a current employee. The 
limitation of filling the proposed Deputy Director positions with 
Veterans only (as opposed to employing Veteran preference) would 
significantly limit the pool of applicants with the necessary 
experience and skill sets necessary to successfully carry out the 
responsibilities of the positions, as well as potentially run afoul of 
Merit Systems Principles.
    The total cost of administering the pilot program under section 2 
would be $546,000 in FY 2018 and $2.9 million over 5 years.
    Section 3 would add a new section 7618A that would ensure that not 
fewer than 25 new scholarships in the Health Professional Scholarship 
Program are awarded each year to individuals for education and training 
to become physician assistants. It would also add a new section 7676 
that would similarly require that 25 new scholarships in the Employee 
Incentive Scholarship Program be awarded for education and training to 
become physician assistants.
    While VA supports section 3 in principle, and contingent on the 
provision of additional resources to support implementation, VA already 
has the authority to dedicate scholarships toward these professions. 
Similar to section 2, providing these scholarships will help VA address 
workforce shortages through the required service obligation.
    The total cost of section 3 of the Health Professional Scholarship 
Program (HPSP) with HPSP Stipend cost for 175 awards (35 per year) over 
five years would be $10.2 million.
    Section 4 would require the Secretary of Veterans Affairs to 
establish standards for the Department for using educational assistance 
programs to educate and hire PAs. This provision would require that the 
standards ensure that VA's Educational Debt Reduction Program (EDRP) is 
available to participants in the PA pilot program. To the maximum 
extent practicable, VA would be required for each year over a five year 
period to increase the scholarships amounts under subchapters II and VI 
of chapter 76, Title 38, and any other relevant educational assistance 
programs offered by VA for courses of education or training to become 
physician assistants.
    VA does not support this section because EDRP assistance is 
targeted for specific positions that are designated as difficult to 
recruit and retain. In order to meet local Veteran population needs, 
local medical centers have the flexibility to determine the positions 
that have the most critical need for EDRP awards and advertise 
accordingly. Loan repayment awards are an attractive tool; however, 
EDRP is a limited resource and offering EDRP to an entire occupational 
series would be contrary to the statutory mission of the program and 
would set a precedent for other occupations to seek similar authority.
    The PA occupation is recognized as a top 5 mission-critical 
occupation within VA, ranking fourth and tied with physical therapy, 
according to the January 2015 VA Office of Inspector General report 
after medical officer (physician), nurse, and psychologist.
    Over the last several fiscal years, the number of new PA hires has 
fluctuated between 250-350 annually. The number of EDRP awards made for 
newly hired PAs has gradually increased from 26 to 45 (62 percent 
increase) from FY 2014 to FY 2015, and currently comprises 13 percent 
of all new PA hires. In the FY 2015 EDRP award cycle, the average EDRP 
award for PAs was $63,000. Current projections estimate similar awards 
for the PA occupation based on qualifying student loan debt. Overall, 
the OIG's top 5 occupations represented 82 percent of all EDRP awards 
made in FY 2015.
    EDRP awards are typically five year awards. If EDRP was offered to 
every new PA hire, nearly $4.6M would be needed each year for new 
awards, and additional funding would be required to sustain current 
participants.
    Including EDRP in all announcements, as would be required by the 
mandated standards, would also give interested candidates for hire the 
impression that EDRP would be available. EDRP awards are not made until 
after qualifying student loan debt can be confirmed with education 
institutions and lenders, which can take several months and occurs 
after employees are onboard. Without significantly increasing EDRP 
funding, including EDRP in all PA vacancy announcements will prevent 
facilities from offering the award to other positions that are more 
difficult for recruitment and retention locally. Advertising EDRP in 
all PA announcements, without significantly increasing funding, is 
misleading and likely to disenfranchise new employees early in their VA 
career.
    Advertising EDRP for an entire occupation sets a precedent that 
will likely encourage other occupations to seek the same. Such costs 
are not only unsustainable, but in conflict with the statutory mission. 
PAs are nationally ranked as a mission-critical occupation; however, 
certain facilities report no issues recruiting PAs (i.e., Michael E 
DeBakey VA Medical Center in Houston, TX, has a strong PA program with 
academic affiliates and reports no issues hiring PAs). Requiring all 
facilities to advertise EDRP for positions would deny the facility the 
ability to make awards for other positions that are the most critical.
    Alternative approaches may be better suited for strengthening the 
PA occupation within VA, such as making compensation of PAs the primary 
driver in recruitment and retention.
    VA supports section 5 of the bill, contingent on the provision of 
additional resources to support implementation, which seeks to 
eliminate the pay disparity between VA and the private sector.
    The cost for 5,250 new EDRP awards over 5 years would be $68.2 
million. Salary and development costs are estimated at an additional 
$792,451, bringing the total cost of this proposal (including cost of 
living adjustments) to $69 million.
    s. 683, keeping our commitment to disabled veterans act of 2017
    S. 683 would amend 38 U.S.C. Sec. 1710A to extend until 
December 31, 2018, the period in which the Secretary shall provide 
nursing home care to certain Veterans.
    VA supports this provision, which would ensure that Veterans in 
need of nursing home care for a service-connected disability and any 
Veteran who has a service-connected disability rated at 70 percent or 
more are eligible to receive nursing home care.
    If the authority in section 1710A continues to be extended, VA 
estimates the cost would be $4.73 million in FY 2018, $25.13 million 
over 5 years, and $53 million over 10 years.
s. 833, servicemembers and veterans empowerment and support act of 2017
    Section 2(a) of S. 833 would amend 38 U.S.C. Sec. 1720D(a)(1) to 
authorize VA to provide a Veteran with counseling and care and services 
determined (by a VA mental health professional) to be needed to 
overcome psychological trauma resulting from cyber harassment of a 
sexual nature.
    VA supports this subsection in principle, but we do not believe it 
is necessary because of VA's current authority. Under section 1720D, VA 
is authorized to provide counseling and treatment for trauma resulting 
from sexual harassment (defined as ``repeated, unsolicited verbal or 
physical contact of a sexual nature which is threatening in 
character''), and this can include sexual harassment that is conducted 
through verbal or cyber contact, including the use of Internet social 
media services. We also note that the phrase ``cyber harassment of a 
sexual nature'' is ambiguous, and it is unclear exactly what the 
drafter intends to cover. It would also be helpful to clarify whether 
the bill is intended to extend eligibility to those who were the victim 
of cyber harassment in only one instance or if, as is the case with the 
definition of sexual harassment in 38 U.S.C. Sec. 1720D(f), the 
harassment must be ``repeated.'' As drafted, we presume the intent is 
to allow VA to define this term through rulemaking, but if there are 
specific parameters the drafter wishes to ensure are specified, 
including them in the bill text would be advisable.
    Additionally, it is unclear if the language as drafted would cover 
all of the types of cyber harassment incidents that are intended. As 
amended, section 1720D would still require that the cyber harassment 
occur while the Veteran or Servicemember was on active duty, active 
duty for training, or inactive duty training. However, it may not be 
clear exactly when the harassment occurs. For example, the harassment 
could occur when the content is created (e.g., a photograph or video is 
made), when the content is posted online, when the individual discovers 
the content is online, or when content that was posted with permission 
is shared with others without permission (e.g., if a photo or video 
that was only intended for a limited number of parties is made 
available to others). Depending upon which standard controls, different 
Veterans and Servicemembers would be eligible. Due to the intricacies 
of the subject, it would be beneficial if the legislation addressed 
``cyber-harassment'' in a separate subsection of section 1720D. We 
believe it would be prudent to phrase this authority in a way to ensure 
it does not become outdated by changes in technology. We would be happy 
to assist the Committee in exploring these issues further and in 
developing technical assistance to ensure the legislation reflects the 
drafter's intent.
    Section 2(b) would amend section 1720D(a)(2) to permit VA to 
provide without a referral needed counseling, care, and services for 
sexual trauma that was suffered by Servicemembers, including members of 
the National Guard and Reserves, during periods of active duty, active 
duty for training, or inactive duty training. Current law authorizes VA 
to provide services under this authority only to Servicemembers, 
including members of the National Guard and Reserve, who are serving on 
active duty.
    VA supports section 2(b), but notes this support is contingent upon 
additional resources to support implementation. While this provision is 
discretionary and could only be implemented in consultation with the 
Secretary of Defense, this subsection has potentially significant cost 
and workload implications that, without additional resources, could 
jeopardize VA's ability to provide timely services to Veterans.
    It is difficult to estimate the new demand for care that would be 
produced by section 2, as VA has no data currently available on how 
many members of the National Guard and Reserve (as well as other 
members of the Armed Forces) experienced military sexual trauma while 
on active duty, active duty for training, or inactive duty training. 
Similarly, it is impossible to know how many of these persons would 
seek care from VA, and how many would continue to seek care on an 
ongoing basis. While VA currently furnishes care to Servicemembers 
through sharing agreements and other arrangements, the Department of 
Defense (DOD) reimburses VA for such care. It is unclear if DOD would 
do so when the Servicemember is no longer in active duty, active duty 
for training, or inactive duty training.
    Section 3(a) would amend 38 U.S.C. Sec. 1154 by adding a new 
subsection (c). The current subsection (b) of section 1154 provides a 
liberal approach to evaluating claimed disabilities based on a 
Veteran's engagement in combat with the enemy. This provision 
acknowledges the disruptive ``circumstances, conditions, or hardships'' 
of combat, and the resulting incomplete record keeping, as the basis 
for a liberal approach to evaluating claims. The newly proposed 
subsection (c)(1) would establish a liberal standard of proof to ``any 
Veteran who claims that a covered mental health condition was incurred 
in or aggravated by military sexual trauma during active military, 
naval, or air service.''
    VA appreciates the purpose of section 3 but does not support it as 
written. Under subsection (c)(1) of 38 U.S.C. Sec. 1154, as proposed to 
be added, the military sexual trauma stressor/event would be required 
to be ``consistent with the circumstances, conditions, or hardships of 
. . . service'' in order to be associated with a current covered mental 
health condition. Although this language, as used in current section 
1154(b) in relation to conditions allegedly incurred or aggravated in 
combat makes sense for the specific disruptive circumstances of combat 
as a potential Post Traumatic Stress Disorder (PTSD) stressor, there 
are no specific circumstances, conditions, or hardships of service that 
are associated with military sexual trauma, which can occur at any time 
and any location during the period of service.
    Section 3(b) would add a new section 1164 to title 38 that would 
codify VA's current liberal approach for evaluating PTSD/military 
sexual trauma claims under its regulation at 38 CFR 3.304(f)(5). While 
VA supports this provision in principle, it would be preferable to 
allow VA the flexibility to revise its regulations based on experience 
without the need to seek statutory amendments, as would be required if 
the current regulation is codified in statute.
    VA does not have a cost estimate for this section at this time.
    Section 4 would require the Secretary of Defense to inform members 
of the Armed Forces of the eligibility of such members for services at 
VA's Vet Centers. The Secretary of Defense would be required to ensure 
that DOD's Sexual Assault Response Coordinators advise members of the 
Armed Forces who report instances of sexual trauma about their 
eligibility for services from VA's Vet Centers.
    While VA defers to the Secretary of Defense on the specific 
obligations this bill would impose, we support this section in 
principle. VA currently provides counseling for military sexual trauma 
to active duty Servicemembers and is pleased to do so. Informing 
Servicemembers of the benefits for which they are eligible is important 
to ensuring they receive the care and services they need. We note there 
may be technical issues with some of the bill language, but we would be 
happy to discuss this with the Committee with DOD's input as well. In 
addition, additional resources to support implementation may be 
required.
        s. 946, veterans treatment court improvement act of 2017
    S. 946 would require VA to hire additional Veterans Justice 
Outreach (VJO) Specialists to provide treatment court services to 
justice-involved Veterans. Specifically, S. 946 would require that VA 
hire not less than 50 VJO Specialists and place each such VJO 
Specialist at an eligible VA medical center (VAMC). The bill would 
require that the total number of VJO Specialists employed by the 
Department not be less than the sum of (a) the VJO Specialists employed 
on the day before the enactment of this provision; and (b) the number 
of VJO Specialists hired under this bill. The bill would require that 
the Secretary prioritize placement of the VJO Specialists at facilities 
that will create an affiliation with a Veterans treatment court that is 
established on or after the date of enactment of the bill, or one that 
was established prior to enactment but is not fully staffed with VJO 
Specialists. The bill would require the Secretary to submit a report to 
Congress on the progress and effects of implementing these provisions 
within one year, with new reports submitted annually after that. The 
bill would also require the Comptroller General to submit to Congress a 
report on the implementation of this authority and the effectiveness of 
the VJO Program. The bill would authorize to be appropriated $5.5 
million for each of fiscal years 2017 through 2027, and would require 
the Secretary to submit to Congress a report that identifies such 
legislative or administrative actions that would result in reduction in 
expenditures by the Department that are equal to or greater than the 
amounts authorized to be appropriated.
    VA supports the intent of this bill and is already working to hire 
more than the 50 additional VJO Specialists in FY 2017. However, the 
bill could ultimately result in a reduction of $5.5 million in funding 
to other programs (including possibly programs for homeless Veterans). 
Because of this potential reduction in funding, VA does not support the 
legislation as drafted. Demand for VJO Specialists has grown 
considerably over the past several years, partly as a result of the 
adoption of the Veterans Treatment Court model in new jurisdictions. 
Limited VJO staff resources have affected VA's ability to partner 
effectively with Veterans Treatment Courts, especially those newly 
established.
    As a technical matter, we note that provisions of section 2(e) of 
the bill concerning the authorization of appropriations may not 
accomplish the intended objective. We understand this provision is 
intended to ensure that the Secretary identifies offsets to fund the 
program required by this bill. However, the bill only requires the 
Secretary to report to Congress on legislative or administrative 
actions that would result in a reduction of expenditures equal to or 
greater than $5.5 million. To the extent that the Secretary identifies 
legislative actions that would result in a reduction of expenditures, 
there is no guarantee that Congress would take such actions. We further 
note that the offsets would likely affect adversely VA's ability to 
implement and run other programs, which could result in delays in the 
provision of benefits, healthcare, and other critical services to 
Veterans and other beneficiaries. Ultimately, we do not believe this is 
an appropriate mechanism for funding the program required by this 
section.
    We also note that the definition of ``local criminal justice 
system'' in section 2(f)(3) of the bill would exclude Federal law 
enforcement issues. We understand there are some Federal district 
courts that have Veterans treatment courts, and these would not be 
supported under this bill.
    While we estimate the hiring of 50 additional VJO Specialists would 
cost $5.5 million in FY 2018, because the bill would require VA to 
identify offsets, we believe the ultimate cost would be $0 in FY 2018 
and over both 5 and 10 years. We again caution that the costs for 
implementation would involve reductions to other VA programs.
    s. 1153, veterans acquiring community care expect safe services 
                               (access) 
                              act of 2017
    S. 1153 would require the Secretary of Veterans Affairs to deny or 
revoke eligibility of certain healthcare providers to provide non-VA 
healthcare services to Veterans. The bill would, in general, require 
that the Secretary deny or revoke the eligibility of a healthcare 
provider to provide non-Department healthcare services if the Secretary 
determines that: (1) the provider was removed from employment at VA due 
to conduct that violated a policy relating to the safe and appropriate 
delivery of healthcare; (2) the provider violated the requirements of a 
medical license; (3) the provider had a Department credential revoked 
that would impact that provider's ability to provide safe and 
appropriate healthcare; or, (4) the provider violated a law for which a 
term of imprisonment of more than one year may be imposed. The bill 
would permit, but not require, the denial, revocation, or suspension of 
the eligibility of a healthcare provider to furnish non-Department 
healthcare when the Secretary has a reasonable belief that such action 
is necessary to immediately protect the health, safety, or welfare of 
Veterans and: (1) the provider is under investigation by the medical 
licensing board of a State in which the provider is licensed or 
practices; (2) the provider has entered into a settlement agreement for 
a disciplinary charge related to the practice of medicine; or, (3) the 
Secretary otherwise determines that such action is appropriate under 
the circumstances. The bill would require that the Secretary suspend 
the eligibility of a healthcare provider to provide non-Department care 
if that provider is suspended from serving as a healthcare provider of 
the Department. The bill also would require that the Secretary review, 
within one year of enactment, each non-Department healthcare provider 
to identify whether he or she was an employee of the Department to 
determine if the provider meets any of the criteria for denial, 
revocation, or suspension of eligibility. Finally, the bill would 
require the Comptroller General to submit a report to Congress within 2 
years of enactment on the implementation of these authorities and its 
effects.
    VA supports the proposed legislation in principle and would 
appreciate the opportunity to work with Congress to develop a proposal 
that builds upon similar requirements already in place without creating 
the unnecessary administrative burdens we believe the bill would 
produce, as these burdens could negatively impact Veterans' access to 
quality care. Currently, VA procures most community care using Third 
Party Administrators (TPA), under Patient Centered Community Care 
(PC3)/Choice contracts, which include the development and maintenance 
of an adequate provider network of high quality, credentialed/certified 
healthcare providers. VA monitors adherence by performing quality 
checks through the use of a Quality Assurance Plan (QASP). As part of 
the QASP, VA utilizes a ``three lines of defense'' model to oversee the 
credentialing and certification process of network healthcare 
providers. These lines of defense involve both VA and the TPA 
performing ongoing reviews to ensure the quality of the providers in 
the network. Additionally, VA requires the contractor to report to VA, 
not more than 15 days after being notified, of the loss of or other 
adverse impact to a network provider's certification, credentialing, 
privileging, or licensing. Future acquisitions will carry similar 
criteria as they pertain to review of provider licensure and 
credentialing, as VA remains committed to developing contracts for high 
performing networks.
    Because of the measures already in place to ensure that VA only 
utilizes the highest quality providers in the community, VA is 
concerned that the administrative requirements of this legislation as 
written would have the potential to adversely impact Veteran access to 
community care as well as limit current and future contractors' ability 
to timely recruit and retain qualified providers within their networks.
    VA also has concerns relating to due process protections under the 
bill. To the extent VA relies on any fact that had not been established 
through a complete and fair process satisfying the requirements of due 
process (e.g., a criminal conviction, or a full investigation and 
determination by a State licensing board), the Agency's decision should 
be appealable. VA does not have an existing process that could 
accommodate such appeals. Affected providers must be given notice and 
an opportunity to be heard to contest such determinations or beliefs in 
order to satisfy due process requirements, but it is unclear how VA 
would provide for this.
    VA is unable to provide a cost estimate for this proposal as 
currently written because it is unclear what additional administrative 
requirements would be needed to ensure appropriate review and 
protections are in place.
          s. 1261, veterans emergency room relief act of 2017
    Section 2(a) of S. 1261 would add a new section 1725A to Title 38. 
This new section would require the Secretary to enter into contracts 
with urgent care providers under which the Secretary would pay the 
reasonable cost of urgent care provided to eligible Veterans. Eligible 
Veterans would be defined as Veterans who are enrolled in VA healthcare 
and who have received healthcare under chapter 17 during the preceding 
two year period. The bill would also require the Secretary to establish 
a cost-sharing amount that eligible Veterans would pay to the Secretary 
when receiving urgent care under this section. This cost-sharing 
measure would not apply to Veterans who are admitted to a hospital 
after the provision of urgent care or to Veterans receiving urgent care 
for a service-connected disability. VA would be the primary payer for 
care provided under this section. Section 2(b) would require the 
Secretary to establish a cost-sharing amount that Veterans would pay 
for the receipt of care at a VA emergency room, unless the Veteran is 
receiving care for a service-connected disability, is admitted to a 
hospital for treatment or observation after receiving emergency care, 
or meets a hardship exception established by the Secretary for purposes 
of this section. Under section 2(c), the Secretary could not require a 
Veteran to pay multiple cost-sharing amounts if the Veteran sought 
urgent care under section 1725A and at a VA emergency room for the same 
condition within a period of time determined by the Secretary. Finally, 
section 2(d) of the bill would require VA to submit a report to 
Congress within two years of enactment, and not less frequently than 
once every two years thereafter, on the use of urgent and emergency 
room care by Veterans.
    VA supports the intent of this bill, contingent on the provision of 
additional resources to support implementation. We would like the 
opportunity to work with the Committee on this proposal to ensure 
Veterans have access to timely and urgent care.
    We estimate the bill as written, with certain limiting assumptions, 
would cost $287.3 million in FY 2018, $1.525 billion over 5 years, and 
$3.298 billion over 10 years.
                  s. 1266, enhancing veteran care act
    S. 1266 would authorize the Secretary to contract with a nonprofit 
organization that accredits healthcare organizations and programs to 
investigate a VAMC to assess and report deficiencies of the facility. 
The Secretary would be required to delegate this contracting authority 
to the Director of the Veterans Integrated Service Network (VISN) in 
which the medical center is located or to the VAMC Director. Before 
entering into a contract, the VISN Director or VAMC Director would be 
required to notify the Secretary, the VA OIG, and the Comptroller 
General of the United States to ensure that the investigation conducted 
by the contracted entity is coordinated with any investigation 
conducted by one of these entities. Nothing in this bill would be 
construed to prevent the OIG from conducting any review, audit, 
evaluation, or inspection, or to modify the requirement that employees 
assist with any review, audit, evaluation, or inspection of the OIG.
    VA does not support S. 1266. VA believes that this legislation is 
unnecessary and runs counter to long-standing procedures governing 
quality of care investigations. Within the VHA, the Office of the 
Medical Inspector (OMI) and other offices, including the Office of 
Compliance and Business Integrity, the National Center for Ethics in 
Healthcare, and the Office of Internal Audit and Risk Assessment, are 
integral elements of VHA's oversight and compliance program, with 
responsibility for assessing the quality of VA healthcare through site-
specific investigations and system-wide assessments. Through 
coordination of all of these resources, VA is able to carry out a wide 
range of investigations of whistleblower allegations, patient 
complaints, compliance violations, and ethics questions, among other 
issues. VA is also equipped to produce comprehensive reports with 
actionable recommendations and to follow-up with line managers to 
ensure fulfillment of corrective actions. VA has successfully managed 
the volume of cases. Furthermore, the OIG has the statutory 
responsibility for conducting assessments, reporting deficiencies, and 
ensuring corrective actions at VA facilities. Given these existing 
functions within VHA and OIG, the bill would mandate an unnecessary 
additional function.
    VA has demonstrated an ability to manage a large caseload and 
provide comprehensive reports. VA has the infrastructure in place to 
conduct timely quality-of-care investigations in VA health facilities 
and a professional staff with decades of experience in conducting such 
reviews. Many of our investigators have worked in VA medical centers 
and are intimately familiar with their operations, policies, 
procedures, and unique culture. We are concerned that requiring the 
organizations that perform accreditations to investigate the same 
medical facilities they accredit could result in a potential conflict 
of interest. Accrediting organizations do not routinely conduct 
investigations of the type envisioned by the bill. VA believes that by 
relying on its internal systems and specific experience in these types 
of investigations, the intended objective of the bill can be achieved 
in the most efficient and Veteran friendly way possible.
    We are unable to provide a cost estimate for this bill, as it is 
unclear how often and when such investigations would occur, or how much 
they would cost.
           s. 1325, better workforce for veterans act of 2017
    The draft bill, ``Better Workforce for Veterans Act of 2017,'' 
contains a number of provisions intended to improve the authorities of 
the Secretary to hire, recruit, and train employees of the Department.
    Section 101(a) would create a new section 718 that would authorize 
the Secretary to recruit and appoint qualified recent graduates and 
post-secondary students to competitive service positions within the 
Department, notwithstanding certain provisions of Title 5. The 
Secretary would only be authorized to appoint no more than a number 
equal to 15 percent of the number of hires made into professional and 
administrative occupations at the GS-11 level or below (or equivalent) 
during the previous fiscal year. The Secretary would be required to 
develop regulations governing this authority. To the extent 
practicable, the Secretary would be required to publicly advertise 
positions available under this section within certain constraints.
    VA supports the concept of this provision, but also would like to 
note that the Administration authored a similar proposal that would be 
applicable to all agencies, and transmitted it for consideration in the 
FY 2018 National Defense Authorization Act (FY 2018 NDAA). This would 
provide greater flexibility to hire students and recent college 
graduates, providing an immediate opportunity for new employees to 
begin their careers with VA. The Administration would prefer a 
Government-wide solution that would provide a significant recruitment 
benefit if all agencies were able to utilize it.
    Section 101(b) would create a new section 719 that would require 
the Secretary to prescribe regulations to allow for excepted service 
appointments of certain students and recent graduates leading to 
conversion to career or career conditional employment.
    VA defers to OPM on implementation of this provision as an 
important element to implementing the program authorized by section 
101(a) for certain students and interns. OPM would be best suited to 
provide any necessary technical drafting assistance to align these 
authorities with OPM's current Government-wide Pathways Program.
    Section 102 would amend section 3304(a)(3)(B) of Title 5 to permit 
the Secretary to appoint directly for positions for which there is a 
severe shortage of highly qualified candidates. OPM would have the 
authority to determine what positions would qualify, as well as having 
the ability to delegate the authority to make those determinations.
    VA supports this provision as this would provide greater 
flexibility to directly reach applicants when we have a severe shortage 
of highly qualified candidates. This would help the Department address 
some of its most critical vacancies.
    Section 103 would create a new section 712 to authorize the 
Secretary to appoint a former Federal employee to a high-demand 
position within the Department for which the former Federal employee is 
highly qualified without regard to provisions concerning competitive 
appointments. The former Federal employee could be appointed to a 
position at a higher grade or with more promotion potential than the 
position the employee previously held. Within 18 months of enactment, 
the Inspector General of the Department would be required to conduct an 
audit of the use of this authority by the Secretary and report to 
Congress on the results of that audit.
    VA defers to OPM on this provision. Currently, we could hire 
someone non-competitively to a position at the same level they 
previously held, while this provision would allow VA to hire someone to 
a higher level than they previously held. Therefore, implementation 
would need to be measured, with appropriate controls in place to 
prevent misuse.
    Section 104 would create a new section 720 to require the Secretary 
to develop and implement a resume-based application method for 
applications for appointment to senior executive positions within VA. 
The application would have to be, to the extent practicable, comparable 
to the resume-based application method for the Senior Executive Service 
(SES) developed by the Office of Personnel Management (OPM), and would 
have to be used for initial applications for a position as a senior 
executive to the extent such use will be more efficient and effective 
and less burdensome for all participants. The Secretary would be 
authorized to make an initial career appointment of an individual to a 
position as a senior executive if a review board convened by VA 
certifies the executive and managerial qualifications of the 
individual.
    At this time, VA does not support this provision because we do not 
believe it is necessary. Resume-based application is allowed under 
current rules, and VA would like to maintain flexibility in hiring and 
assessment. VA currently uses a resume-based system for executive 
recruitment for its medical center Director positions, and with the 
recently enacted Department of Veterans Affairs Accountability and 
Whistleblower Protection Act of 2017 (Public Law 115-41), signed 
June 23, 2017, VA now has direct hiring authority for these and VISN 
Director positions. We continuously evaluate our hiring methods, 
timeframes, and outcomes to identify opportunities for improvement, and 
we would be happy to share our findings with the Committee.
    Section 105 would establish a new section 721 that would require 
the Secretary to establish and periodically review a single database 
that lists each vacant position in VA that the Secretary determines is 
critical to VA's mission, difficult to fill, or both. If the Secretary 
determines that an applicant for a position listed in the database is 
qualified for such position, but the Secretary does not select such 
applicant, the Secretary, at the election of the applicant, would be 
required to consider the applicant for other, similar vacant positions 
listed in the database. If the Secretary did not fill a vacant position 
listed in the database after an appropriate time (as determined by the 
Secretary), the Secretary would be required to ensure that applicants 
who were not selected for other positions but who meet the 
qualification requirements are considered. The Secretary would also be 
required to use the database to assist in filling such positions. 
Within one year of enactment, the Secretary would be required to submit 
a report to Congress on the use and efficacy of the database 
established under this section.
    We support the concept of identifying and maintaining a database of 
vacancies, but do not support this particular provision. VA completed 
the implementation of a commercial software product as the core 
foundation to our new enterprise automated human resources system. We 
will implement an enhancement in FY 2018 to manage positions, which 
will provide real-time vacancy information. With the systems we 
currently have in place and in development, we believe we can meet the 
intent of this provision without legislation, and in a way that is less 
administratively burdensome.
    Section 106 would create a new section 722 that would require the 
Secretary to measure and collect information on indicators of hiring 
effectiveness concerning certain identified factors related to 
recruiting and hiring candidates, as well as the satisfaction of 
employees, newly hired employees, and applicants. To the extent 
practicable, and in a manner protecting personally identifiable 
information, the Secretary would be required to collect and report data 
disaggregated by facility and VISN to ensure the data is collected from 
human resources offices throughout VA. The Secretary would be required 
to submit an annual report to Congress on the information collected, 
and to make such information publicly available.
    As written, we do not support this provision. We are concerned the 
vagueness of the language could result in application to virtually 
every aspect of the recruitment process. The terminology in this 
provision includes subjective terms, and we believe some provisions may 
be inconsistent internally. In addition, these provisions could be 
inconsistent with other agencies' recruitment and hiring information. 
We have a number of technical comments and recommendations and would be 
glad to share those with the Committee. We also would request that the 
Committee solicit OPM for technical drafting assistance on this 
provision.
    Section 107 would create a new section 723 requiring the Secretary 
to develop and carry out a standardized, anonymous, voluntary exit 
survey for career and non-career employees who voluntarily separate 
from VA. The survey would have to ask questions regarding the reasons 
for leaving, any efforts made to retain the individual, the extent of 
job satisfaction and engagement, the intent of the employee to remain 
in or leave Federal employment, and other matters considered 
appropriate by the Secretary. The Secretary would be required to share 
the results of the survey with the directors and managers VA facilities 
and VISNs, and the Secretary would be required to report annually on 
the aggregate results of the exit survey.
    We do not support this provision because we believe it is 
unnecessary, given that we already use exit surveys that capture almost 
all of the content this legislation would require.
    Section 108 would amend section 2108(1) of Title 5 concerning 
Veteran preference so that any Veteran who served a total of more than 
180 days would qualify, rather than only those who served more than 180 
consecutive days.
    We note that this provision would amend title 5 and apply to the 
entire Federal Government. As a result, we defer to OPM on this 
provision.
    Section 109 would amend section 705(a) of the Veterans Access, 
Choice, and Accountability Act of 2014 to clarify that recruitment, 
relocation, or retention incentives are not subject to the limitations 
on awards and bonuses available in the Department.
    VA supports this provision. Currently, the limitations on awards 
and bonuses include recruitment, retention, and relocation incentives, 
which have severely limited the Department's ability to offer 
incentives to hire and retain critical positions. Under these 
limitations, the Department has attempted to reserve the bulk of the 
funds that are available to provide incentives to positions, 
particularly medical professionals with specialized skills and 
expertise that would be difficult or impossible to replace. This has 
resulted in an inequitable treatment among employees, as there are 
fewer resources available for those otherwise deserving and equally 
dedicated employees.
    If this authority were enacted, VA would reallocate funds already 
appropriated for recruitment and retention of highly qualified 
employees.
    Section 110 would amend section 7309 of Title 38 to remove the 
requirements that the Chief Officer of VA's Readjustment Counseling 
Service (RCS) must have at least 3 years of experience providing direct 
counseling services or outreach services through RCS, as well as 3 
years of experience administrating direct counseling services or 
outreach services through RCS.
    VA supports this provision. This would provide greater flexibility 
to appoint the Chief Officer of RCS, which oversees VA's Vet Centers, a 
critical component to providing Veterans and Servicemembers 
readjustment counseling and other services.
    There would be no costs associated with this provision.
    Section 111 would require, within 120 days of the date of the 
enactment of this Act, the Secretary to submit a report to Congress on 
vacancies within the Veterans Health Administration. This report would 
have to include vacancies of personnel appointed under section 7401 of 
title 38, vacancies of human resource specialists in VHA, a description 
of any impediments to filling certain vacancies, and an update on the 
implementation of several plans and reports.
    We do not believe section 111 is necessary, but we do not oppose 
this requirement. Until the system enhancement previously mentioned is 
implemented in FY 2018, collecting this information is a manual and 
intensive effort. As a result, we are concerned that the 120 day 
deadline would be difficult to meet. We believe that we would be in a 
better position to gather this information within the next year.
    Section 201 would create a new section 724 providing that for any 
reduction in force by VA, competing employees would be released with 
due effect to the following in order of priority: tenure of employment, 
military preference, efficiency or performance ratings, and length of 
service.
    We do not oppose section 201 because this would only change the 
order of consideration for how reductions in force would occur. 
However, we would defer to OPM, to ensure that reduction in force 
procedures remain consistent across the Government. We note that for 
hybrid title 38 positions, we think it would be appropriate to also 
consider the level and type of licensure, as well as the scope of 
practice, in making such determinations.
    Section 202 would create a new section 725 authorizing the 
Secretary to arrange, with the agreement of a private-sector 
organization, for the temporary assignment of VA employees to such 
organization to occupy a position in that organization and for the 
private sector employee who held that position to temporarily occupy 
the position of the VA employee. In essence, these employees would be 
trading positions for a temporary period. The VA employee would return 
to work for the Department, and if either employee failed to carry out 
the agreement, the employee would be liable to the United States for 
payment of all expenses of the assignment, with certain exceptions; 
such liability would be a debt that could be waived if the Secretary 
determined collecting it would be against equity and good conscience 
and not in the best interests of the United States. The VA employee 
would be prohibited from using pre-decisional, draft deliberative, or 
other information for the benefit or advantage of the private sector 
organization. Assignments would be for periods between 3 months and 4 
years. VA employees assigned to the private sector organization would 
be considered, during the period of assignment to be on detail to a 
regular work assignment in the Department for all purposes. The private 
sector employee assigned to VA employment would generally not be 
considered a Federal employee with certain exceptions and would have 
other constraints imposed upon the scope of that employee's work with 
the Department. The private sector organization would be prohibited 
from charging VA, as direct or indirect costs under a Federal contract, 
for the pay or benefits paid by the organization to the employee 
assigned to VA. The Secretary would be required to take into account 
certain considerations in operating this program.
    In theory, VA supports the concept of rotational assignments for 
professional development, and notes that the Administration submitted, 
in the context of the FY 2018 NDAA, a similar proposal to provide 
governmentwide authority for industry exchange programs. We note, 
however, that the potential for conflicts of interest in this provision 
are significant, notwithstanding the language in the bill attempting to 
limit this. There are several areas where this provision is ambiguous, 
and we would appreciate the opportunity to discuss this further with 
the Committee prior to taking a position on this section. We would 
recommend that the Committee work with the Office of Government Ethics 
on the appropriate language to address issues related to conflicts of 
interest.
    Section 203 would amend section 7306 to allow for the appointment 
of VISN Directors in addition to medical center Directors to suit the 
needs of the Department. It would also remove the requirement for these 
Directors to be qualified doctors of medicine, or doctors or dental 
surgery or dental medicine. It would further amend that section to 
allow the Secretary to establish qualifications for these Directors and 
appoint them under this authority. The Secretary and the Director would 
be required to enter into an agreement that permits employees appointed 
under this authority to transfer to SES positions in other Federal 
agencies and to be deemed career appointees who are not subject to 
competition or certification by a qualifications review board.
    Section 207 of the Department of Veterans Affairs Accountability 
and Whistleblower Protection Act of 2017 (Public Law 115-41), signed 
June 23, 2017, significantly amended VA's authority to hire directly 
VISN and medical center Directors. In this context, we would like the 
opportunity to discuss this proposal further with OPM and the Committee 
to consider the effects of these proposed changes before taking a 
position on this section.
    Section 204 would create a new subchapter VII in chapter 74 
concerning pay for medical center Directors and VISN Directors. The new 
section 7481 would provide that pay for these Directors would consist 
of basic pay and market pay, which would be determined by the Secretary 
on a case-by-case basis and consist of pay intended to reflect the 
needs of the Department with respect to recruitment and retention of 
such Directors. The bill would impose other requirements in terms of 
determining market pay under this section. The Secretary would be 
required, not less frequently than once every 2 years, to set forth 
within defined parameters Department-wide minimum and maximum amounts 
for total pay for Directors, and to publish such limits in the Federal 
Register. Pay under this section would be considered pay for all 
purposes, including retirement benefits. A decrease in the pay of a 
Director resulting from an adjustment in market pay could not be 
considered an adverse action, while a decrease resulting from an 
involuntary reassignment in connection with a disciplinary action would 
not be subject to appeal or judicial review. The OPM Director would be 
required to undertake periodic reviews of the Secretary's 
determinations and certify to Congress each year whether or not the 
market pay is in accordance with the requirements of this section. If 
the Director determined the amounts were not in accordance with the 
requirements of this section, the Director would report to Congress on 
such determination as soon as practicable after making such 
determination.
    We appreciate the Committee's interest in this regard. Similar to 
section 203, we note that given the recent change (Public Law 115-41) 
in our appointment authority for VISN and medical center Directors, we 
would like to discuss this proposal further with OPM and the Committee 
prior to taking a position on the specific provisions in this section. 
We anticipate there would be additional costs to implement this 
section.
    Section 205 would create a new section 7413 that would require the 
Secretary to provide to VHA human resources professionals training on 
how best to recruit and retain VHA employees. The Secretary would 
provide such training in a manner considered appropriate considering 
budget, travel, and other constraints. The Secretary would be required 
to ensure that each VHA human resources professional received such 
training as soon as practicable after being hired and annually 
thereafter. The Secretary would be required to ensure that a medical 
center Director, VISN Director, or senior officer at Central Office 
certified that the professional completed such training. The Secretary 
would be required to report annually on the training provided under 
this authority, including the cost of such training, and the number of 
professionals who receive such training.
    We do not support section 205 because VA already has the authority 
to conduct such training. VA provides training to human resources 
professionals currently, and we are concerned that the specific 
requirements in this provision could constrain our ability to adapt 
training to emerging needs. We also have some technical concerns with 
this provision that we will share with the Committee.
    Section 206 would require the Secretary to include education and 
training of marriage and family therapists and licensed professional 
mental health counselors in carrying out the education and training 
programs conducted under section 7302(a)(1). The Secretary would be 
required, to the degree practicable, to ensure that the licensing and 
credentialing standards for therapists and counselors participating in 
this program are the same as the licensing and credentialing standards 
for eligibility of other participants in the program. Finally, the 
Secretary would be required to apportion funding for education and 
training equally among the professions included in the program.
    In general, we currently have the authority to carry out this 
section. VA has already established training programs for licensed 
professional mental health counselors and marriage and family 
therapists. We are concerned with the potential effect this could have 
on the quality of the education and training standards, and we would 
appreciate the opportunity to discuss this further with the Committee. 
We are also concerned that the language, particularly in subsection (c) 
of this provision, is too prescriptive and could limit VA's flexibility 
to adjust training needs and resources to meet operational needs.
    Section 207 would require, within 180 days of the date of enactment 
of this Act, the Secretary and the Surgeon General to enter into a 
memorandum of understanding (MOU) for the assignment of not fewer than 
500 commissioned officers of the Regular Corps of the Public Health 
Service to VA. The Secretary would reimburse the Surgeon General for 
expenses incurred in assigning commissioned officers to VA. Within 1 
year of enactment, the Secretary and Surgeon General would each be 
required to submit to Congress a report on the MOU and the commissioned 
officers assigned under this authority.
    We do not support this provision because it is unnecessary. VA and 
the Department of Health and Human Services (HHS) signed an MOU earlier 
this year to allow for commissioned officers of the Public Health 
Service to serve in VA. We would like the opportunity to discuss this 
further with the Committee and HHS to determine what, if any, 
legislative authority we need in this area.
    Section 208(a) and (b) would require, within 1 year of the date of 
enactment of this Act, the Under Secretary for Health to develop a 
comprehensive competency assessment tool for VHA human resources 
employees to assess the knowledge of such employees on how employees 
appointed under section 7401(1) are treated differently than employees 
appointed under other authorities. Within 2 years of the date of 
enactment of this Act, and once every 2 years thereafter, the Secretary 
would have to submit a certification to Congress as to whether an 
assessment of all VHA human resources employees was conducted and 
whether such employees used the results of such assessment to identify 
and address competency gaps. Within 18 months of the date of enactment 
of this Act, the Under Secretary for Health would be required to 
evaluate the extent to which these training strategies are effective at 
improving the skills and competencies of VHA human resources employees.
    Section 208(c) would require, within 1 year of enactment, the Under 
Secretary for Health to establish clear lines of authority that provide 
the Assistant Deputy Under Secretary for Health for Workforce Services 
the ability to oversee and hold the heads of the human resources 
offices of VA medical centers accountable for implementing initiatives 
to improve human resources processes and for ensuring employees 
undertake the assessment required under subsection (a). Within 1 year 
of enactment of this Act, the Secretary would be required to clarify 
the lines of authority and processes for the Under Secretary for Health 
and the Assistant Secretary for Human Resources and Administration with 
respect to overseeing holding the VISN and VA medical center Directors 
accountable for the consistent application of Federal classification 
policies.
    Section 208(d) would require the Secretary to ensure the Under 
Secretary for Health and the Assistant Secretary for Human Resources 
and Administration are responsible for monitoring the status of 
corrective actions taken at human resources offices of VA medical 
centers and that such actions are implemented.
    Section 208(e) would require the Secretary to ensure that 
meaningful distinctions are made in performance ratings for VHA 
employees.
    Section 208(f) would require, within 1 year of enactment of this 
Act, the Under Secretary for Health and the Assistant Secretary for 
Human Resources and Administration to develop a plan to implement a 
modern information technology (IT) system to support employee 
performance management processes.
    Section 208(g) would require, within 1 year of enactment of this 
Act, the Under Secretary for Health to establish clear lines of 
authority and accountability for developing, implementing, and 
monitoring strategies for improving employee engagement across VHA. The 
Under Secretary for Health would be required to report to Congress on 
whether VHA should establish an employee engagement office at the 
headquarters level with appropriate oversight of VISN and VA medical 
center employee engagement initiatives.
    We do not believe this section is necessary. We are currently 
implementing the requirements of these provisions based on the 
recommendation of a Government Accountability Office (GAO) report (GAO 
17-30). We also have some technical concerns we believe need to be 
addressed, and we will be glad to provide those to the Committee.
    Section 208(h) would require, within 1 year of enactment, the 
Comptroller General to examine the overlapping functions of human 
resource structures within VHA and the Office of the Assistant 
Secretary of Human Resources, whether there are opportunities to 
centralize offices and tasks that are duplicative, and whether the use 
of multiple hiring structures has had an effect on the speed with which 
VA hires new employees. The Comptroller General would report to 
Congress on the Comptroller General's findings.
    VA defers to the Comptroller General on this provision.
    Section 209 would require, within 120 days of enactment of this 
Act, the Secretary to report to Congress on the effect the freeze on 
the hiring of Federal civilian employees ordered by the President on 
January 23, 2017, has had on the ability of VA to provide care and 
services to Veterans.
    We do not believe this is necessary, and do not support it, as the 
hiring freeze was only in effect, at most, for a limited number of 
positions not related to patient care or access. We also do not believe 
it would be possible to identify to any meaningful degree any effects 
that may have occurred as a result of the hiring freeze.
    Section 210 would require, within 180 days of enactment of this 
Act, the Secretary to report to Congress on how the Secretary plans to 
implement the portions of the plan of the OPM Director to reduce the 
size of the Federal workforce through attrition as it pertains to VA.
    We believe this provision is unnecessary. VA is working to 
implement an agency reform plan, consistent with the OMB Director's 
requirements. We are looking at how we will be filling administrative 
positions that become vacant, along with other potential actions, and 
will be updating these plans and assessments in the future. We would be 
happy to share with the Committee the plan the Department submits to 
OMB when it is available.
    Section 211 would require, within 180 days of enactment of this 
Act, the Secretary to publish online information on staffing levels for 
nurses at each VA medical facility. The head of each medical facility 
would be required to update the information as changes to the staffing 
level of nurses at the facility occur. The Secretary would be required 
to consult with Centers for Medicare & Medicaid Services in developing 
the information required by this section. The Secretary would be 
required to submit a report to Congress discussing and assessing the 
use by medical center Directors of authorities to provide nurses pay 
that reflects market conditions, the adequacy of training resources for 
nurse recruiters, the key recruitment and retention incentives of VHA 
for nurses, and other factors.
    We do not support this provision for two major reasons. First, the 
staffing levels referenced in the bill are not defined. Second, the 
actual number of nurses varies on an almost daily basis given the 
volatility in terms of staffing. It would be incredibly cumbersome to 
maintain this information and update it in real time. We already report 
to Congress each year on efforts to provide nurses greater pay, and 
this report would be duplicative of that effort.
    Section 212 would require, within 1 year of enactment of this Act, 
the Secretary, in consultation with the OPM Director, to ensure that 
the job description, position classification, and grade for each 
position as a police officer or firefighter in VA are in accordance 
with standards for the classification of such positions prepared by 
OPM. The Secretary would be required to develop a staffing model for 
the positions of police officers and firefighters within the 
Department. The VA Inspector General would be required to conduct an 
audit of VA's efforts to recruit and retain police officers and 
firefighters and report to the Secretary and Congress on the audit's 
findings. Finally, the Secretary would be required to report to 
Congress on the use by medical center Directors of special pay 
incentives to recruit and retain trained and qualified police officers 
and the steps the Secretary plans to take to address the critical 
shortage of police officers throughout the Department.
    We have some concerns with this provision. We believe the reviews 
required by this section could require a considerable amount of 
resources. We would like the opportunity to discuss this proposal 
further with the Committee and OPM to determine what we may be able to 
do currently to address the Committee's concerns and interests in this 
matter.
    Section 213 would require, within 1 year of enactment of this Act, 
the VA Inspector General to complete a study on how VHA communicates 
its directives, policies, and handbooks to the field, including the 
compliance with such documents, and the effectiveness of each VISN in 
disseminating information to employees within the Network and Veterans 
served by the Network.
    The Department defers to the Inspector General on this provision.
    As noted above, VA will be providing follow-up views for the record 
on S. 1279, the Veterans Health Administration Reform Act, the draft 
Department of Veterans Affairs Quality Employment Act of 2017, and 
section 10 of the Veterans Choice Act of 2017.
                  s. xxxx, veterans choice act of 2017
    The draft Veterans Choice Act of 2017 contains a number of 
provisions intended to improve VA's community care program. Community 
care has helped significantly expand access to care for Veterans 
nationally and plays an important role in VA's effort to build a 
modern, integrated healthcare network.
    Section 3(a) of the bill would amend section 1703 of title 38 to 
authorize the Veterans Choice Program. Under this Program, all enrolled 
Veterans would be eligible to elect to receive hospital care, medical 
services, mental health services, and certain diagnostic services, 
outpatient dental services, and diagnostic services from specified 
eligible providers. These services could be provided through 
telemedicine, at the election of the Veteran. The Secretary would be 
required to enter into consolidated, competitively bid regional 
contacts with healthcare organizations or third party administrators to 
establish networks of eligible providers for the purpose of providing 
sufficient access to care and services. The bill would define various 
responsibilities for these organizations or administrators, including 
enrolling covered Veterans, conducting referrals and authorizations, 
customer service, and maintaining an interoperable electronic health 
record. These parties would be required to leverage advanced technology 
to allow Veterans to make their own appointments, including online and 
through smart phone applications. Veterans who need assistance making 
their appointments could receive assistance from the organization or 
administrator or the Secretary. The organizations or administrators 
would be required to meet capability, capacity, and access standards 
established by the Secretary, including those established pursuant to 
sections 9 and 10 of this bill. Providers who currently furnish care or 
services under another authority would be offered the opportunity to 
furnish care and services through this Program.
    Under the Veterans Choice Program, the rates paid for care or 
services could not exceed the Medicare rate, except in highly rural 
areas, in the State of Alaska, in a State with an All-Payer Model 
Agreement that became effective on January 1, 2014, or at other rates 
established by the Secretary if no Medicare rate exists. The Secretary 
would be authorized to recover from a third party for any care 
furnished for a non-service-connected disability, and the Secretary 
would be responsible for paying the copayment, deductible, or 
coinsurance charged to the Veteran for care or services. Veterans could 
not be required to pay a greater amount for receiving care or services 
than they would if they had received comparable care or services at a 
VA medical facility or from a VA medical provider.
    The proposed amendments to section 1703 would impose other 
requirements. For example, VA would have to ensure the Veterans Health 
Identification Card issued to every enrolled Veteran includes the words 
``Choice eligible'' and additional information needed to serve as an 
identification card for the Program. Additionally, the Secretary would 
be required to monitor a number of quality and access standards related 
to the care furnished under this Program. These changes would become 
effective upon the termination of the current Veterans Choice Program 
operated pursuant to section 101 of the Veterans Access, Choice, and 
Accountability Act of 2014.
    We support many of the principles in the proposed section 1703. We 
appreciate that the section's eligibility criteria would be simple to 
administer by making every enrolled Veteran eligible to participate. We 
also appreciate the flexibility in terms of eligible providers, and the 
regional network model generally matches our current plans with the 
Community Care Network solicitation. We also appreciate the section's 
recognition of the importance of ensuring quality care is furnished to 
Veterans through this Program.
    However, we have some significant concerns with certain provisions 
of proposed section 1703. In many areas, there are provisions that are 
overly prescriptive and that would narrow the Secretary's authority to 
adjust to evolving situations. For example, the Secretary would be 
prohibited from directing Veterans to certain health care providers. 
While we support Veterans' choosing their own providers, we understand 
that many Veterans do not express a specific preference for an 
individual provider, and this language could restrict our ability to 
direct Veterans to high-performing providers who are available. Also, 
the responsibilities of the regional networks are too specific--we 
would prefer the language be silent on these matters so that we can 
adjust responsibilities between VA and our regional networks to ensure 
the best services are available for Veterans. Furthermore, the language 
concerning payment rates is too limiting. There will be situations 
where VA will need to pay more than the Medicare rate other than in 
highly rural areas, the State of Alaska, and States with All-Payer 
Model Agreements. We have serious concerns with the language in 
proposed 1703(h), which would require the Secretary to pay the amount 
of a Veteran's copayment, deductible, or coinsurance. This would be 
inconsistent with private sector and VA's current practice. Section 
1729 currently provides that Veterans are not required to pay a 
copayment, deductible, or coinsurance required under the terms of their 
health insurance for care and services furnished by the Department. 
Moreover, requiring the Department to pay a Veteran's copayment, 
deductible, or coinsurance could significantly increase the 
Department's expenses, including its administrative costs, in ways that 
we cannot currently project given the variability in insurance plans 
and payment responsibilities for the millions of Veterans with such 
insurance. While we support the principle of ensuring quality care, we 
are concerned that some of the language in proposed 1703(l) would be 
too prescriptive, and we would prefer more general language.
    Requiring that the words ``Choice eligible'' appear on a Veterans 
Health Identification Card (VHIC), as provided for in proposed section 
1703(k), would create redundancy and be extremely costly. The bill 
would make any enrolled Veteran eligible for Choice, and all enrolled 
Veterans are issued VHICs, so any person with a VHIC would already 
establish his or her eligibility by virtue of having the VHIC. 
Requiring Veterans to have a VHIC with the words ``Choice eligible'' 
would also produce greater demands on Veterans who would have to come 
to a VA facility to receive an updated version of their VHIC.
    Finally, we are concerned that there is no transition period 
contemplated by section 3(a)(3). The new 1703 would take effect 
immediately upon the expiration of the current Veterans Choice Program, 
based on the exhaustion of the Veterans Choice Fund. We believe that 
either a clear timeline (such as one year from enactment) or an event 
within the Department's control (such as the publication of 
regulations) would be preferable for the transition between the current 
Choice Program and the future Choice Program. We also may encounter 
problems where individual authorizations made under the current 1703 
would no longer have any legal authority for payment upon this 
transition, as this provision would completely rewrite section 1703. 
While the Department would try to reduce the potential for this issue, 
we would not be able to eliminate this problem.
    Section 3(b) would prohibit VA from entering into or renewing any 
contract or agreement under a non-Department provider program, which 
would include the current Veterans Choice Program; the Patient-Centered 
Community Care (PC3) program; the Project Access Received Closer to 
Home (ARCH) program; VA's retail pharmacy network; agreements entered 
into with DOD, IHS, or other Federal agencies; agreements entered into 
with academic affiliates of VA; agreements to furnish care, including 
on a fee basis; or agreements with non-governmental entities. If the 
Secretary continued to administer any of these programs after the date 
on which the new Veterans Choice Program begins, they could only be 
administered under that Program. The Secretary would be required to 
ensure continuity of care by making services available through regional 
contracts or other agreements entered into under the new Veterans 
Choice Program.
    We are very concerned with this provision and do not support it. It 
would require VA to renegotiate, reissue, or terminate every agreement 
and contract, regardless of the terms or conditions of such an 
agreement permitting extensions or other flexible authorities. We 
believe this could affect such agreements as those with DOD, IHS, and 
tribal health programs, as well as with our academic affiliates and 
contractors. This would include thousands of agreements, would be very 
difficult and costly to do, and would not produce any clear, tangible 
benefit. If these agreements would also now be subject to the 
limitations in proposed section 1703, this provision could put 
conditions on these agreements that would be unacceptable to certain 
providers or in certain areas. This could also potentially impact our 
relationships with certain providers, such as IHS and tribal health 
programs, which require consultation prior to changes. We also note, 
given the breadth of section 3(b)(4)(E), that extended care services 
procured from the community would be included, but note that the 
language for the Veterans Choice Program in section 1703 does not 
address such services; as a result, it is unclear what terms and 
conditions would apply to these services.
    Section 4 would establish a new section 1703A authorizing VA to 
enter into Veterans Care Agreements (VCA). VCAs could be entered into 
when the Secretary is not feasibly able to furnish hospital care, 
medical services, or extended care services at VA facilities or when 
such care or services are not available under the Veterans Choice 
Program. Providers could opt to enter into a VCA, at the discretion of 
the eligible provider. The eligibility of Veterans for care would be 
the same as if they received care in a VA facility. The Secretary would 
be prohibited from directing Veterans seeking care or services to 
healthcare providers who have entered into contracts or sharing 
agreements under different authorities, except for Veterans Choice 
Agreements authorized under section 101 of the Veterans Access, Choice, 
and Accountability Act of 2014 or under the regional contracts or other 
arrangements made under section 1703, as revised by section 3 of this 
bill.
    The Secretary would be required to establish a process for the 
certification of eligible providers. VCAs would have to include certain 
terms, including accepting payment at Medicare rates (except in highly 
rural or underserved areas), accepting payment as payment in full, and 
other terms and conditions. Each VCA would permit the provider to 
submit to the Secretary clinical justification for any services 
furnished without authorization when seeking payment, and the Secretary 
would review these submissions on a case-by-case basis in determining 
whether or to pay the provider for such services. The Secretary would 
be required to review periodically VCAs of a material size to determine 
whether it is feasible and advisable to furnish the care and services 
at a VA facility or through contracts or sharing agreements. VCAs would 
not be subject to laws requiring competitive procedures in selecting 
the party with which to enter the agreement. Parties entering into a 
VCA would not be treated as a Federal contractor by the Office of 
Federal Contract Compliance Programs (OFCCP) of the Department of 
Labor, and they would not be subject to any laws that such a provider 
would not be subject to under the original Medicare fee-for-service 
program under Parts A and B of title XVIII of the Social Security Act 
(42 U.S.C. 1395 et seq.), except for laws applying to integrity, 
ethics, fraud, or that subject a person to civil or criminal penalties. 
Title VII of the Civil Rights Act of 1964 (42 U.S.C. 2000c et seq.) 
would apply to parties entering into a VCA. The Secretary would be 
required to establish a system or systems, consistent with those used 
by the Centers for Medicare and Medicaid Services, to monitor the 
quality of care provided and would be required to establish 
administrative procedures for dispute resolution. The Secretary would 
be required to prescribe an interim final rule within 1 year of 
enactment to carry out this section.
    We generally support this provision, but have some concerns we 
would like to address. In particular, proposed section 
1703A(a)(2)(A)(ii) would prohibit the Secretary from entering into a 
VCA if care or services are available under the new Veterans Choice 
Program. Although we appreciate the intent of this provision, we 
believe there may be situations where the clinical need of the Veteran 
will require the use of a VCA notwithstanding the availability of such 
services under the Choice Program. For example, a Veteran may require a 
certain type of orthopedic procedure, and while orthopedics in general 
are ``available'' under a contract, the specific procedure or a 
specialist may not be included within the contract, or would only be 
available at a lesser quality. In other situations, a Veteran may elect 
to receive care from a certain provider that would be ideally suited to 
furnishing the care required, but who is not a member of the network. 
We want to ensure we have flexibility in situations like these to 
deliver the care the Veteran requires in a timely and appropriate way. 
We also note these provisions apply for when the Secretary may ``enter 
into'' agreements, rather than ``use'' agreements. We have found, 
through our experience with the current Veterans Choice Program that it 
is more efficient to enter into these agreements before they are needed 
to ensure that there is no delay in the receipt of care by eligible 
Veterans. We believe the language could be modified slightly to impose 
restrictions on the utilization of VCAs to ensure the integrity and use 
of the network of providers under the new Veterans Choice Program.
    Proposed section 1703A(e)(2) is unclear, and depending upon what 
the intent is, we may or may not support it. If the provision is 
intended to simply allow providers to submit claims for care that was 
unconnected or unrelated to the services VA originally authorized, we 
are concerned this could create situations where VA pays for services 
that were neither authorized nor clinically needed. This would create a 
significant administrative burden on both the providers and VA. If, on 
the other hand, this is intended to apply only in limited circumstances 
for care that VA would have authorized, then we have no objection to 
it.
    Regarding proposed section 1703A(g), VA agrees with the idea of 
monitoring how VCAs are utilized by VA. However, we are concerned that 
the threshold for when an agreement for the purchase of extended care 
services is considered to be of ``material size,'' i.e., exceeding 
``$1,000,000 annually,'' is too low. Costs for long term extended care 
and nursing home care costs can easily exceed this level. The threshold 
also does not account for providers who may have a national presence.
    Section 5(a) would establish a new section 1703B concerning payment 
of non-Department healthcare providers. Specifically, VA would be 
required to comply with the provisions in this section and in chapter 
39 of title 31 (the Prompt Payment Act). Non-Department providers would 
be required to submit a claim for reimbursement within 180 days, and 
the Secretary would have to pay claims according to specified time 
standards or else interest would accrue on the amount owed. If a 
provider submits a clean claim, VA would have to pay the claim within 
30 days if it was submitted electronically or 45 days if it was 
submitted other than electronically. If a claim were not clean, the 
Secretary would have to inform the provider within 10 days on the steps 
that would be needed to make it clean. By January 1, 2020, the 
Secretary would only be authorized to accept claims electronically 
except in certain circumstances.
    We generally support section 5(a), but have some concerns with a 
few of the provisions. For example, we think there should be more 
flexibility to accept paper claims from smaller providers, such as 
Homemaker/Home Health Aides. We are also concerned that, as written, 
this language could require that late payments of providers who have 
entered into contracts with the Regional Networks could subject VA to 
interest payments, even though VA has no privity of contract with these 
providers and is paying the Network on time. Finally, we do not believe 
the Committee had transactions between VA and other Federal entities in 
mind when it included a prompt payment standard in the draft bill. An 
exception could be added in this section to address this issue.
    Section 5(b) would require the Secretary, not later than 2 years 
after the date of the enactment of this Act, to enter into an agreement 
with a third-party entity to process claims for reimbursement through 
an electronic interface.
    We are concerned about the intended scope of this provision. If the 
electronic interface processing the claims is only preparing them for 
adjudication and approval by VA, we do not support this provision 
because VA is currently working on a process internally that would 
perform this function. If the term ``process'' is intended to cover 
adjudication and payment as well, we would like to discuss with the 
Committee our reservations about such an arrangement and propose 
potential alternatives instead.
    Section 6 would amend section 1745 to authorize the Secretary to 
enter into agreements with State Veterans Homes that would not be 
subject to laws requiring competitive procedures in selecting the party 
with which to enter the agreement. State Homes entering into these 
agreements would not be subject to any laws that such a provider would 
not be subject to under the original Medicare fee-for-service program 
under Parts A and B of title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.), except for laws applying to integrity, ethics, 
fraud, or that subject a person to civil or criminal penalties. Title 
VII of the Civil Rights Act of 1964 (42 U.S.C. 2000c et seq.) would 
apply to State homes entering into these agreements. These changes 
would become effective upon the Secretary's publishing regulations to 
implement these new authorities.
    We generally support section 6, although, we have similar concerns 
to those we expressed regarding section 4 with respect to the 
applicability of certain laws.
    Section 7 would amend section 1705 to require the Secretary, upon 
the enrollment of a Veteran in the VA healthcare system, to assign the 
Veteran to a dedicated primary care provider of the Department, unless 
the Veteran elects to choose a primary care provider from among the 
healthcare providers furnishing care in the network established under 
the new Veterans Choice Program.
    We do not support section 7 because this would require all enrolled 
Veterans to be enrolled in provider panels, even if we do not furnish 
care to those Veterans. We typically only assign Veterans to a panel 
once they have expressed interest in receiving care from the 
Department. We are concerned that assigning other Veterans to panels 
will complicate our projection models for demand and our estimates for 
resources for our facilities. We are also concerned that the ability of 
a Veteran to elect to choose a primary care provider from among VA's 
network of community providers could allow for the control and 
coordination of care, including the authorization of care (and the 
obligation of Federal funds), to move to a non-Federal agent, which 
presents issues concerning the proper use of appropriated funds.
    Section 8 would require the Secretary to enter into national 
contracts with private healthcare providers to make dialysis treatments 
available in the community. Veterans would be able to choose the 
provider from which they would receive dialysis services. Under 
subsection (c), the Secretary could not pay more than the Medicare rate 
for the same dialysis services or treatment.
    While we support the intent of this proposal, we are concerned that 
this could potentially limit the Department's ability to furnish 
dialysis care. This provision would limit VA to paying the Medicare 
rate; we currently pay more than the Medicare rate in certain 
circumstances, and it is unclear if we could enter into contracts for 
the same care at a reduced rate. If we were unable to enter into these 
contracts, VA would not be able to provide this essential clinical 
service.
    Section 9 would require VA to establish a demand profile with 
respect to each health service furnished under the laws administered by 
the Secretary. The demand profile would have to include various 
factors, such as the number of requests for services, the number of 
appointments (both in VA and the community), the capacity of the 
Department to provide such services, and an assessment of the need for 
community care for the service. The Secretary would use these profiles 
to inform the capability and capacity of the provider networks 
established in the new Veterans Choice Program. Within 120 days of the 
date of enactment of this Act, the Secretary would be required to 
submit to Congress a strategic plan with a 5 year forecast on the 
demand for care and the Department's capacity and capability to satisfy 
that demand within its facilities. The Secretary would have to update 
the strategic plan annually.
    VA agrees in concept with the provisions in section 9; however, we 
believe this provision is not necessary as VA has currently embarked 
upon a national market-by-market assessment effort that will produce 
the same level of information called for in the bill. VA's market-by-
market assessment is in response to a requirement in section 240 of 
Division A of Public Law 114-223, the ``Military Construction, Veterans 
Affairs, and Related Agencies Appropriations Act, 2017.'' That law 
requires VA to develop a national realignment strategy. As a result, 
the assessment of VA's 98 marketplaces across the United States is 
currently underway.
    Section 10 would require the Secretary to establish uniform access 
standards for furnishing healthcare services, including through 
community providers, for urgent care, routine care, referral or 
specialty care, and wellness or preventive care. These access standards 
would have to include the average time a Veteran is expected to wait to 
receive an appointment, the average time a Veteran is expected to drive 
to arrive at an appointment, the average time a Veteran is expected to 
wait at a facility to receive healthcare services, and such other 
factors as the Secretary considers appropriate. The Secretary would be 
required to coordinate with DOD, the Department of Health and Human 
Services (HHS), private entities, and other non-governmental entities 
in establishing these standards. The Secretary would be required to 
submit a report to Congress within 120 days of the date of the 
enactment of this Act detailing the standards established under this 
section.
    We do not have views on section 10 at this time.
    Section 11 would require the Secretary, within 1 year of enactment, 
to procure a commercial, off-the-shelf electronic health record 
platform that conforms to the standards of interoperability required 
under section 713 of the National Defense Authorization Act for Fiscal 
Year 2014. The bill would define a number of requirements for this 
system, including its interoperability with DOD's systems and private 
sector systems and compliance with national standards identified by the 
VA and the DOD Interagency Program Office in collaboration with HHS' 
Office of the National Coordinator for Health Information Technology.
    VA does not believe section 11 is necessary because the Secretary 
has already announced his intention to procure a commercial system for 
VA's Electronic Health Record capability. Similar to our concern with 
other provisions, we note that the specificity in this provision could 
limit the Secretary's ability to ensure this new system is responsive 
to Veterans' needs.
    Finally, section 12 would make various conforming amendments to 
reflect the changes made by section 3 of this bill by updating 
references in other statutes to VA's community care authorities.
    We support section 12 as a measure to consolidate VA's community 
care programs.
    We are unable to provide cost estimates on the bill at this time 
but will follow up after the hearing with any estimates we can develop 
and our thoughts on the potential budget implications. We will also 
provide technical comments for your consideration.
    s. xxxx, improving veterans access to community care act of 2017
    The draft Improving Veterans Access to Community Care Act of 2017 
also contains a number of provisions intended to improve VA's community 
care program.
    Section 101(a)(1) would create a new section 1703A, establishing 
the Veterans Community Care Program. Many of the terms and conditions 
governing this Program would be similar to those applicable to the 
existing Veterans Choice Program. Under this new Program, hospital care 
and medical services would be furnished to eligible Veterans at the 
election of the Veteran through contracts or agreements with eligible 
providers. The Secretary would be responsible for coordinating care and 
services, including ensuring that an eligible Veteran receives an 
appointment for care and services within the wait-time goals of the 
Veterans Health Administration (VHA). To be eligible under the Program, 
Veterans would have to be enrolled in VA healthcare and meet one of the 
following criteria: reside in a location, other than Guam, American 
Samoa, or the Republic of the Philippines that requires the Veteran to 
travel by air, boat or ferry to reach a VA medical facility; be 
enrolled in Project ARCH; the Veteran and the Veteran's VA provider 
determine the Veteran should be eligible based upon the eligibility 
criteria in the current Veterans Choice Program, namely being unable to 
schedule an appointment within the clinically indicated timeframe, 
residing more than 40 miles driving distance from the nearest VA 
medical facility with a full-time primary care physician, residing 
within a State without a full-service VA medical center, or facing an 
unusual or excessive burden in accessing services from a VA medical 
facility. The Veteran and provider could also determine whether the 
Veteran should be eligible under the Program based upon a compelling 
reason that the Veteran needs to receive care and services from a non-
Department facility. The Secretary would be required to establish a 
process to review any disagreement between Veterans and their 
providers, and the Secretary would make the final determination as to 
the eligibility of the Veteran.
    While we appreciate the intent of the eligibility criteria for 
Veterans, we are concerned with how this program is structured. We 
fully agree that the provider-patient relationship should be the basis 
for eligibility to receive community care. However, the draft bill 
would combine this approach with the current administrative eligibility 
criteria in the Choice Program. We believe this would result in an 
ultimately confusing ``hybrid'' standard that would be difficult for 
providers to apply. In addition, we believe continuing to use 
administrative criteria would be inappropriate, as they are arbitrary 
in nature and not informed by the patient-provider relationship. The 
proposed approach would also be unduly limiting in terms of the types 
of clinical factors that a provider could consider; for example, a 
Veteran who lived across the street from a full-service VA medical 
center with no wait times and who was fully ambulatory would not appear 
to qualify under any of these provisions, and yet the Veteran may 
require a certain type of service that would be best delivered by a 
community provider. We would like to work with the Committee to better 
understand the underlying issue that proposed subsection (b)(2), 
concerning the review of provider determinations, is intended to 
address.
    Under section 1703A, providers would have to meet the same 
eligibility criteria in the current Veterans Choice Program to 
participate in the new Program, including maintaining the same or 
similar credentials and licenses as VA providers. The Secretary would 
be authorized to create a tiered provider network, but would not be 
able to prioritize providers in a tier over providers in any other tier 
in a manner that limits the choice of an eligible Veteran to select 
that provider. The Secretary would be required to enter into contracts 
with eligible providers for furnishing care and services, but before 
entering into such a contract, the Secretary would be required, to the 
maximum extent practicable and consistent with the requirements of this 
section, to furnish care and services with eligible providers pursuant 
to sharing agreements, existing contracts, or other processes available 
for procuring care. In this section, the term ``contract'' would have 
the definition given that term in subpart 2.101 of the Federal 
Acquisition Regulations. Providers would be paid under a negotiated 
rate that, to the extent practicable, would not exceed the Medicare 
rate, with limited exceptions for highly rural areas, Alaska, and 
States with an All-Payer Model Agreement. Eligible providers would be 
prohibited from collecting any amount greater than the negotiated rate. 
The Secretary would be authorized in negotiating rates to incorporate 
the use of value-based reimbursement models to promote the provision of 
high-quality care. The Secretary would be authorized to collect from 
third-parties the costs of furnishing care for non-service-connected 
disabilities under this section, and such collections would be 
deposited into the Medical Community Care account and remain available 
until expended.
    We do not support the provision requiring providers to maintain the 
same or similar credentials and licenses as VA providers; while this is 
a requirement in the current Veterans Choice Program, we have found it 
to be administratively difficult (and at times impossible) to implement 
in certain situations. We believe strongly in the importance of 
ensuring our providers furnish quality care, but recommend a different 
approach than this obligation. We are also concerned that some of the 
language regarding the terms of the agreements with providers 
contemplates a direct relationship between VA and the providers, rather 
than a relationship between VA and a network administrator, and a 
separate relationship between the administrator and the provider. 
Similarly, we do not support the provision that would require the 
deposit of collected funds into the Medical Community Care account. 
Funds collected by VA under sections 1725 and 1729 of title 38, and 
section 2651 of title 42 are currently deposited in the Medical Care 
Collections Fund, where they may be used to support both VA and 
community care. We believe creating a separate collection account would 
be duplicative and would limit our funding flexibility. Finally, we 
note that referencing the definition of ``third party'' in section 1729 
produces a narrower effect than if the definition in section 1725 were 
referenced.
    The Secretary would be required to provide Veterans information 
about this Program upon their enrollment and when they become eligible 
based on a determination between the Veteran and his or her provider. 
The Secretary would be required to ensure that follow up care, 
including specialty and ancillary services deemed necessary, are 
furnished through the Program at the election of the Veteran. Veterans 
would be required to pay a copayment for care under this Program, but 
the copayment could be no more than what the Veteran would owe if such 
care or services were furnished directly by the Department. The 
Secretary would also be required to establish a claims processing 
system to ensure prompt and accurate payment of bills and claims for 
authorized care. Under subsection (j), a Veteran's election to receive 
care under this Program would serve as written consent for purposes of 
section 7332(b)(1), which governs the disclosure of certain protected 
health information. Providers would be required under subsection (k)(1) 
to submit copies of the Veteran's medical records upon the completion 
of the provision of such care and services, but these records could not 
be required prior to reimbursement. Under subsection (m), the Secretary 
would be required to track missed appointments to ensure the Department 
does not pay for care or services that were not rendered.
    We note that subsection (j) is no longer needed given the 
amendments to section 7332 made by Public Law 115-26. In terms of 
subsection (k)(1), we believe it would be better for the records to be 
required as determined by the Secretary to ensure that the records are 
provided in a timely fashion and that care provided by VA and others is 
informed. We also recommend against including subsection (m), regarding 
the tracking of missed appointments, as our experience with the current 
Veterans Choice Program has proven this difficult to implement. We have 
taken other precautions to ensure the Department is not paying for care 
and services that were not provided, and we believe this approach is 
more suitable for the legislation's intent.
    Section 101(a)(3) would terminate the current Veterans Choice 
Program authority and make other conforming amendments.
    We do not support this provision, as the Department will need a 
transition period during which it can prepare for the future of 
community care while still ensuring Veterans receive care through the 
current Choice Program.
    Section 101(a)(4) would require a report within 1 year of the date 
of enactment of this Act providing information about services rendered 
under the new Program.
    We note that subparagraph (D) of this provision would require a 
report on the results of a survey of Veterans who have received care or 
services under this program. Given the time it may take us to develop a 
survey, VA may not be able to gather meaningful information in the time 
between OMB approval of the information collection and the reporting 
deadline. Regarding subparagraph (E), which would require an assessment 
of the effect of furnishing care and services under new section 1703A 
on wait times, we have not found reliable data that would support a 
firm assessment through the current Choice Program, and we believe we 
would encounter the same issues under this proposal.
    Section 101(b) would provide that services under various programs 
and authorities be considered services under the Veterans Community 
Care Program established under the new section 1703A, including PC3, 
contracts through VA's retail pharmacy network, VCAs, and healthcare 
agreements with other Federal and non-Federal agencies.
    We are not sure exactly what it means for services under another 
program to be ``considered'' services under the Veterans Community Care 
Program. If this would require that all of the agreements and programs 
identified in this subsection meet the terms and conditions of the 
Veterans Community Care Program, we would not support that requirement.
    Section 101(c) would state that all amounts required to carry out 
the new Program would be derived from the Medical Community Care 
account, and that all amounts in the Veterans Choice Fund would be 
transferred to the Medical Community Care account. Section 802 of the 
Veterans Access, Choice, and Accountability Act of 2014 would be 
repealed, and conforming amendments would be made to section 4003 of 
the Surface Transportation and Veterans Health Care Choice Improvement 
Act of 2015.
    We agree with the importance of consolidating funding for community 
care, but we recommend that the transfer of funds from and the repeal 
of the Veterans Choice Fund only apply to unobligated funds and provide 
a delayed effective date to support the transition from the current 
program to the future program.
    Section 101(d) would require, within 90 days of the enactment of 
this Act, the Secretary to establish consistent criteria and standards 
for furnishing non-Department care, including the eligibility 
requirements of providers and reimbursement rates (which, to the extent 
practicable, would be the Medicare rate). These standards would not 
apply to the Veterans Community Care Program established under section 
101(a)(1).
    We support the intent of subsection (d). We have minor technical 
recommendations that we would be pleased to discuss with the Committee.
    Section 101(e) would require the Secretary to establish a working 
group to assess the feasibility and advisability of considering under 
subsection (b) services under healthcare agreements with healthcare 
providers of the Indian Health Service (IHS) and tribal health programs 
to be provided under the Veterans Community Care Program. The working 
group would include representatives of IHS, tribal health programs, and 
Veterans who receive services from either IHS or tribal health 
programs. Within 180 days of enactment of this Act, the working group 
would be required to submit a report to the Secretary on the 
feasibility and advisability of considering such services to be 
services under the Veterans Community Care Program, and within 90 days 
of receiving this report, the Secretary would be required to submit a 
report to Congress on the feasibility and advisability of implementing 
the working group's recommendations.
    We do not oppose greater coordination and discussion with IHS or 
tribal health programs, but we do not believe the timelines in the 
legislation are realistic. We also do not believe it is necessary to 
require this coordination in law, as we are already working with these 
groups to improve cultural understanding and resource sharing. We also 
note that the Federal Advisory Committee Act (FACA) would likely apply 
to the working group, given the inclusion of non-government personnel.
    Section 102(a) would create a new section 1703B regarding prompt 
payment of providers. It would require substantially the same things 
required by section 5(a) of the draft Veterans Choice Act of 2017, with 
a few exceptions. For example, this bill would authorize the Secretary 
to accept claims and medical records submitted other than 
electronically if the Secretary determines the provider is unable to 
submit claims or medical records electronically. It would also 
authorize the Secretary to accept non-electronic claims if the 
Secretary determines doing so is necessary for the timely processing of 
claims due to a failure or serious malfunction of the electronic 
interface of the Department (required in section 102(b)) for submitting 
claims.
    As discussed with respect to section 5(a) of the draft Veterans 
Choice Act of 2017, we generally support these provisions and 
appreciate the flexibility contained in this version.
    Section 102(b) would require, not later than January 1, 2019, the 
Chief Information Officer of the Department to establish an electronic 
interface for healthcare providers to submit claims for reimbursement 
under section 1703B. The bill would define various requirements in 
terms of functions of the interface and protection of information. By 
January 1, 2018, or before entering into a contract to procure or 
design and build such an interface, the Secretary would be required to 
conduct an analysis to determine whether it would be better to build or 
buy such an interface and submit a report on such analysis to Congress. 
The bill would define various requirements of this analysis and report, 
and the Secretary would not be authorized to spend any amounts to 
procure or design and build the electronic interface until 60 days 
after the required report is submitted to Congress.
    We are concerned about the intended scope of this provision. If the 
electronic interface processing the claims is only preparing them for 
adjudication and approval by VA, we do not support this provision 
because VA is currently working on a process internally that would 
perform this function. If the provision is intended to cover 
adjudication and payment as well, we would like to discuss with the 
Committee our reservations about such an arrangement and propose 
potential alternatives instead. We also caution that the deadline in 
subsection (b)(2) of January 1, 2018, for making a decision to 
internally design and build or enter into a contract to procure an 
electronic interface is likely too soon, given the uncertainty 
regarding community care funding, continuing developments of the design 
of the new EHR, and the potential implications to other information 
technology projects.
    Section 103 would amend 38 U.S.C. Sec. 1151(a) by adding a 
paragraph that would require VA to pay compensation if a Veteran's 
disability or death was caused by hospital care or medical services 
furnished under proposed section 1703A of title 38, United States Code, 
and the proximate cause of the disability or death was carelessness, 
negligence, lack of proper skill, error in judgment, or similar 
instance of fault by the provider or an event not reasonably 
foreseeable.
    VA fully supports ensuring that Veterans have access to high 
quality care, and that they are made whole in the event of a medical 
error. However, VA does not support this provision as written based on 
several concerns. First, section 103 would expand section 1151(a) to 
require VA benefit payments where the ``proximate cause'' of a 
Veteran's disability or death was the negligence of a non-Department 
healthcare provider or an unforeseeable event occurring during 
treatment by such a provider. The ``term 'proximate cause' is used to 
label generically the judicial tools used to limit a person's 
responsibility for the consequences of that person's own acts. At 
bottom, the notion of proximate cause reflects 'ideas of what justice 
demands, or of what is administratively possible and convenient.''' 
Holmes v. Sec. Investor Prot. Corp., 503 U.S. 258, 268 (1992) (quoting 
W. Keeton, D. Dobbs, R. Keeton, & D. Owen, PROSSER AND KEETON ON LAW OF 
TORTS Sec. 41, p. 264 (5th ed. 1984)). Section 103 would make the 
Federal Government liable for disability or death that is the proximate 
result of a non-Department medical provider's negligence or an 
unforeseeable event. This is contrary to the basic principle of 
American law, which holds an individual legally responsible for 
injuries caused by his or her negligent conduct.
    Second, VA adjudicators would be required to develop evidence 
regarding care that is not provided by VA employees or in VA 
facilities, including DOD and other Federal healthcare providers and 
academic affiliates, and to determine whether a Veteran's disability 
was proximately caused by negligence on the part of the community 
provider or an unforeseeable event occurring during non-Department 
medical care. See 38 U.S.C. Sec. 5103A. This would entail gathering 
medical and other records from community providers as well as expert 
medical opinions about whether the event that occurred during the non-
Department treatment was not foreseeable. This development burden of 
obtaining and evaluating evidence from non-Department providers and 
facilities can be expected to slow the adjudication of other Veterans' 
claims for benefits and potentially add to the disability compensation 
backlog.
    Third, under 38 U.S.C. Sec. 1151(b), a recovery under the Federal 
Tort Claims Act as a result of a judgment or settlement for a 
disability or death for which compensation is awarded under 38 U.S.C. 
Sec. 1151(a) results in a suspension of the section 1151 benefits until 
the amount of the judgment or settlement is recouped. In contrast, 
section 103 does not provide for a suspension of compensation for any 
recovery by a Veteran or Veteran's survivors from the non-Department 
provider as a result of a private lawsuit based upon the same 
disability or death. As a result, a Veteran or a Veteran's survivor 
could receive a recovery of both section 1151 benefits and tort damages 
based upon a judgment or settlement. This would create an inequity by 
allowing duplicative recovery for the same disability or death for 
persons whose entitlement is based on care furnished by community 
providers.
    We have not yet had time to estimate the costs for section 103. 
However, we do know that, in FY 2016, 2.2 million Veterans received 
care from community providers under existing VA statutory authorities. 
During the first three quarters of FY 2017, 1.2 million Veterans have 
received such care. VA purchases care from more than 500,000 community 
providers, and the number continues to grow. VA's FY 2018 budget 
requests a 13 percent increase in funding for community care. As a 
result, VA could potentially be liable for section 1151 benefits for 
any of these 2 million Veterans who suffer additional disability or 
death due to negligence or an unforeseeable event caused by community 
care provided by community providers despite the absence of a causal 
connection between the additional disability or death and VA medical 
treatment.
    Section 104 would add a sunset provision to section 1703 of title 
38 terminating that program on December 31, 2018. It would make other 
conforming amendments similar to those proposed in section 12 of the 
draft Veterans Choice Act of 2017.
    We support section 104.
    Section 201 would add a new section 1703C to authorize the 
Secretary to enter into VCAs, similar to the authority that would be 
provided under section 4 of the draft Veterans Choice Act of 2017. 
However, there are a few differences in the proposed section 1703C that 
section 201 would create. First, the draft Veterans Choice Act of 2017 
would require that care be unavailable under the Veterans Choice 
Program established in that draft bill prior to entering into a VCA, 
while the Improving Veterans Access to Community Care Act of 2017 has 
no such limitation. The draft Veterans Choice Act of 2017 would 
authorize providers to opt out of a VCA, but the Improving Veterans 
Access to Community Care Act of 2017 does not include this provision. 
The draft Veterans Choice Act of 2017 would limit the ability of the 
Secretary to direct patients to providers that have entered into 
contracts or agreements under other authorities, while the Improving 
Veterans Access to Community Care Act of 2017 does not include such a 
restriction. The draft Improving Veterans Access to Community Care Act 
of 2017 would include greater flexibility in terms of the Medicare rate 
through inclusion of the phrase ``to the extent practicable'' in 
prescribing the rates the Secretary would pay under VCAs. While we 
believe the draft Veterans Choice Act of 2017 would allow the 
Secretary, on a case-by-case basis, to determine whether or not to pay 
for care not authorized, the Improving Veterans Access to Community 
Care Act of 2017 would allow the Secretary to pay a provider who 
provides services in the course of treatment pursuant to an agreement 
with the Secretary but is not a party to the agreement. Finally, the 
draft Veterans Choice Act of 2017 would state uniformly that the OFCCP 
would not have authority over parties to a VCA, while, through section 
205, the Improving Veterans Access to Community Care Act of 2017 would 
apply the limits established for the TRICARE Program in Directive 2014-
01 of OFCCP to any healthcare provider entering into an agreement or 
contract with VA under section 1703A, 1703C, or 1745.
    We support section 201 and prefer those provisions that differ from 
the draft Veterans Choice Act of 2017.
    Section 205 would apply the OFCCP moratorium to VA, and VA supports 
that provision. We recommend against including a specific deadline, as 
that would allow flexibility in the event that the OFCCP Directive is 
further revised. Many of the technical concerns we identified with the 
draft Veterans Choice Act of 2017 regarding VCAs apply here as well, 
and we look forward to working with the Committee and the Department of 
Labor to address concerns.
    Section 202 would modify VA's authority under section 1745 and is 
identical to section 6 of the draft Veterans Choice Act of 2017.
    VA's views on that provision apply here as well.
    Section 203 would amend section 106 of the Veterans Access, Choice, 
and Accountability Act of 2014 to require that, at the beginning of 
each fiscal year, the Secretary to transfer to VHA an amount equal to 
the estimated amount required to furnish hospital care, medical 
services, and other healthcare through non-Department providers during 
the fiscal year. The Secretary would be authorized to make adjustments 
to the amount transferred to accommodate variances in demand for such 
care and services from non-Department providers.
    We support section 203 because this would provide greater 
flexibility to adjust resource allocations based upon actual demand.
    Section 204 would create a new section 1730B, which would allow the 
Secretary, notwithstanding sections 1341(a)(1) and 1501 of title 31, to 
record an obligation of the United States for non-Department care on 
the date on which a claim for payment is approved, rather than the date 
on which the care or services are authorized.
    VA understands this provision is intended to bring the Department 
closer to industry practices in terms of allocating resources for care 
and developing better estimates concerning our community care 
liabilities. VA appreciates the Committee's willingness to engage on 
this issue given our prior discussions on this, and we look forward to 
working with you further on this proposal.
    Section 205 of the bill is discussed above in the analysis of 
section 201, and the Department's views on this provision are provided 
in that discussion.
    We are unable to provide cost estimates on the bill at this time 
but will follow up after the hearing with any estimates we can develop 
and our thoughts on the potential budget implications. We will also 
provide technical comments for your consideration.

    Mr. Chairman, this concludes my statement. I would be happy to 
answer any questions you or Members of the Committee may have.

    Chairman Isakson. Thank you for your testimony. I want to 
start out with where you ended up talking about Choice, because 
that is the critical thing we have facing us.
    I want to start off by saying in every meeting you and I 
have had or every meeting you have been in where I have been 
and vice versa, it is patently clear that this Committee's 
commitment is for a robust VA health system for our veterans. 
Is that not correct?
    Dr. Yehia. That is correct.
    Chairman Isakson. I have not yet seen a proposal from the 
VA that did anything to undermine that being the case. In fact, 
that is what you want too.
    Dr. Yehia. That is right.
    Chairman Isakson. That being the end, there have been some 
who feared the Choice Program might be a route away from VA 
health care to a privatized health service. Is that not true?
    Dr. Yehia. Some have that concern.
    Chairman Isakson. Nothing we have done would either ratify 
that concern or in any way indicate that is the way we are 
moving. In fact--and you do not have to agree with anything I 
say if you do not want to, by the way. [Laughter.]
    But, in fact, it acts as a force multiplier to give us 
professionals to handle the needs of veterans in a timely 
fashion and a route for our veterans to get timely health. Is 
that not correct?
    Dr. Yehia. Mm-hmm.
    Chairman Isakson. You said you needed four or five things, 
but most importantly, it was flexibility and time; flexibility 
to deal with the differences that the various regions of the 
country would offer, which probably is the number 1 place you 
need flexibility, as well as the time to put it in place. It is 
true that a lot of the problems in the initial Choice bill, 
simply we did not have enough time, and we over-bureaucratized 
the decisions to the point that it made it more cumbersome than 
smooth. Is that not correct?
    Dr. Yehia. That is correct.
    Chairman Isakson. So, you all have been working at the VA 
hard and long to come up with the type of systems that will 
give you the satisfaction that we have the discipline that we 
need without the over-bureaucratization of the process. Is that 
not true?
    Dr. Yehia. Yeah.
    Chairman Isakson. Most important in that is your number 1 
item, which is to enhance the experience of the veteran and the 
decisions to be made by the veteran and their doctor within the 
VA. Is that not correct?
    Dr. Yehia. That is correct.
    Chairman Isakson. I think that is an important point for 
all of us to understand. A lot of these cases are not a one-
time doctor's visit for a sore throat. Many of them are a 
condition that is going to take treatment over time, and with 
the VA doctor being a quarterback and the veteran in 
consultation with the doctor making the decisions on their 
health care, you have the perfect pairing. Is that not correct?
    Dr. Yehia. Yes. It is that dyad of the doctor and the 
patient together to determine what makes the best sense for 
that veteran in front of them.
    Chairman Isakson. I intend, as one Member of the Committee 
in anticipation on what we do to lead up to the completion of 
the improvement in Choice, to see to it that you do have the 
flexibility and the time, and that we never diminish the role 
of the Veterans Administration's health services and the lives 
of our veterans today or the lives of our veterans in the 
future.
    I want to personally thank you for the countless hours you 
have spent on some of the challenges we have been trying to 
meet over the last few months to lead us to a point in time to 
make the right decisions as far as that is concerned.
    Dr. Yehia. Thank you, Chairman.
    Chairman Isakson. I have one other question. That was more 
of a statement than a question, but I have one other thing I 
would like to ask you about. How many different community care 
programs do we fund out of the VA right now for choice?
    Dr. Yehia. We gave about seven to eight different programs.
    Chairman Isakson. Is there any reason those could not be 
consolidated into one?
    Dr. Yehia. We would prefer that they be consolidated into 
one.
    Chairman Isakson. This is not a setup by the way. I know 
this is going to sound like a setup, but Dr. Yehia is so smart, 
he just led me right into this. So, I am playing straight man. 
Is it not true that if they were all one, we would not have 
these periodic crisis problems where we have run out of money 
when we really have not run out of money?
    Dr. Yehia. That is exactly right. We need one program with 
a set of rules that is flexible enough, puts the veteran in the 
middle, and we want to move toward one pot of money to 
administer that program.
    Chairman Isakson. The important thing I am trying to make 
in this statement is that we have got a situation right now 
where we are running out of money, but we are running out of 
money in one fund. So, we have got to take it out of another 
fund, where if it was all in the same fund, you would better 
manage your money. You would better have accountability on your 
money, and you would not have the type of crisis problems that 
we have had.
    Dr. Yehia. That is right.
    Chairman Isakson. That is one thing we want to try to be 
sure we fix in terms of Choice as we work toward that at the 
end of this year.
    All right. Let us see. I guess the Ranking Member is gone. 
Senator Sanders?
    Senator Sanders. Thanks, Mr. Chairman, and thank you, Dr. 
Yehia.
    Well, I am one of those people, as you know, Mr. Chairman, 
who believes that in the Congress, there are those who believe 
that we should privatize Social Security, privatize Medicare, 
privatize Medicaid, privatize the Postal Service, and want to 
go after the Veterans Administration. I do not think that is 
hyperbole; I think that is a fact. I think there are folks who 
spend hundreds of millions of dollars in the political process 
who want to do just that, so I have that concern.
    But, here is my concern now. I think we can deal with this 
problem, and I think Dr. Cassidy made a good point a few 
minutes ago. It is not a complicated issue, which I think there 
is a lot of agreement.
    Number 1, there is some veteran in South Dakota or Vermont 
who lives a zillion miles away from a VA hospital. Should that 
person be able to get the health care across the street in 
their community? Who would argue against that?
    If Dr. Cassidy mentioned the VA has a long waiting line, 
people cannot even get in, so their choice is going to an 
emergency room, which is double the price of other types of 
health care. What is the problem with that? I do not see any.
    But, here is the problem I see, Mr. Chairman, and that is 
while we want to give veterans choice, we do not want to do it 
in a way which dismantles the VA. What I worry about is that at 
a time when the VA has 45,000 vacancies, when many parts of 
this country are understaffed, there may well be funding coming 
out of the VA to fund the Choice Program, and that does concern 
me very, very much.
    I think the answer is that we want to, first of all, given 
the fact that there is overwhelming--Dr. Yehia, I do not know 
if you have this information or not, but every internal poll--
and maybe the service organizations have more on hand, but 
every internal poll that they do seems to indicate tremendous 
support for the VA, the desire to maintain the VA, desire not 
to see the VA privatize. Does that sound familiar to you?
    Dr. Yehia. Yes.
    Senator Sanders. All right. So, we want to maintain the 
strength of the VA, and what we do not want to do is, piece by 
piece, dismantle the VA and put that money into the Choice 
Program.
    I have no problem with when people want to have the 
opportunity, need the opportunity to get care outside of the VA 
when it is reasonable. Count me in. That is common sense. I 
will not allow the VA to be dismembered.
    Last point. It is very easy to criticize the VA. They are 
the largest integrated health care system in this country. You 
have got 131 medical centers, hundreds and hundreds of CBOCs, 
et cetera, et cetera? Every day there is going to be a problem. 
We forget that the private health care system is somewhat 
dysfunctional in America today.
    We forget that today in the private-sector system, hundreds 
of people will die because of medical malpractice in hospitals, 
care they are not getting or mistakes that are being made, and 
that very often--we heard from Dr. Shulkin, you will recall at 
the last hearing, that recent studies from--I think it was JAMA 
or the AMA indicated that on studies that are on many of these 
issues, the VA ends up doing better than the private sector.
    So, our job is to strengthen the VA, to make it the best 
that it can, and where appropriate, to make sure that people do 
have the opportunity to go outside of the VA.
    Thank you very much, Mr. Chairman.
    Chairman Isakson. Well, thank you for your statement, 
Senator Sanders.
    And, let me just say for the record, the first challenge I 
was handed when I became Chairman was the Denver hospital, 
which was being closed and unfinished, finished at about 40 
percent. We are finishing that hospital, spending $1.4 billion 
on an opening, and it is a VA hospital. If there was ever an 
intent of anybody to go from VA to a privatized situation, that 
would have been it, but we made it work. We found the funds. We 
got it done.
    You look through everything that we have done. There is a 
total commitment on the part of this Committee and its Members 
to make sure veterans' health services is the best health 
service they can be and our veterans get the best services they 
can get, or else we would not be here right now. I agree with 
you 100 percent.
    If there is an enemy out there somewhere, we will watch out 
for them together. OK?
    That said, Senator Boozman.

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

    Senator Boozman. Thank you much, Mr. Chairman. I appreciate 
you and the Ranking Member for going forward with this hearing 
so that we can discuss these bills.
    I understand the Senator's concern, Senator Sanders, 
regarding, again, any effort to dismantle the VA. I do think 
that the changes that we have done so far are being very 
positive, especially in rural States like mine, like Arkansas, 
where the reality is that people have to travel extended 
distances.
    I think we can be very, very proud of that. I think we need 
to build on it, again, making sure that we do protect the VA 
infrastructure that we have and make sure that it works as well 
as it can for the benefit of our veterans.
    A couple weeks ago, there were news articles about the 
significant shortage of critical nursing staff at our VA 
medical facility in Little Rock, and I say that because it is 
not just in my State, but it is throughout the country. Can you 
speak to the broader state of nursing staffing nationwide, what 
we are doing in that regard?
    Senator Sanders said we have got that problem in the VA. We 
have got that nationwide, as far as he mentioned, incentives to 
try and get nurses to practice in the VA versus private care. 
Probably the pay is not as good in the VA, so----
    Dr. Yehia. Yeah. I am going to turn it over to my 
colleague, Dr. Lynch.
    Dr. Lynch. I could not agree with you more, Senator. I 
think nursing has been a problem for all of health care.
    We have been working aggressively in Little Rock. We have 
had our chief nursing officer working with the facility to 
identify staff and nursing to get to the facility, but we have 
also been looking at our system as an enterprise and 
identifying where we have the opportunity to look for pay 
supplements that can make us competitive with the private 
sector. But, it is a problem, and it is one that we share with 
the health care sector, and we have to be on top of it.
    Senator Boozman. I agree totally, and again, it is 
something that because it is a problem nationwide in the 
private sector also, you all can have a tremendous influence 
and be a leader in the direction forward.
    I would like to talk a little bit, Dr. Yehia, about the 
Veterans Treatment Court Improvement Act, sponsored by Senators 
Flake, Manchin, Tester, and Tillis. I have seen a number of the 
veterans courts, and they do a tremendous job.
    In fact, today I was visiting with the Association of Drug 
Court Professionals, and they tell me that 92.5 percent do not 
reoffend within 3 years. That statistic is amazing compared to 
other alternatives.
    But, in doing that, having success, long-term success and 
also short term, where you have got the veterans who do not 
have to go off someplace to serve time--they are there in the 
community that they are from--when they go off--invariably 
these folks many times are helping to support the family--you 
leave the family destitute.
    I know you have said that you have some concerns about 
perhaps that affecting the homeless programs and things like 
that. Can you talk a little bit about that and tell us why it 
is not a great idea to support the drug courts all that we can?
    Dr. Lynch. Let me take that one, if you would, Senator.
    Number 1, we already have plans to hire 50 or more new 
Veterans Justice Outreach representatives for VA. Our concern 
with the bill is the requirement for an offset for that salary 
of $5.5 million. We have already committed to hire. We would 
prefer not to have to offset against other parts of our 
program, such as homeless, to find funds for that $5.5 million 
when, in fact, we have already committed to hire those 
individuals. That is our concern, not the hiring of the 
individuals, not the good work that the program is doing, but 
we are trying not to harm other programs within VA by the 
required offset.
    Senator Boozman. Yeah. Hopefully, we can work on that. Many 
of the homeless are having problems with drugs, alcohol, and 
other things, but I would argue that the human cost, the cost 
to the VA, again, in not rehabilitating these individuals, them 
going off and coming back with the same problem, because they 
are not going to have the 97 percent success rate that we see, 
is going to cost you a heck of a lot more money down the line.
    So, let us work with you. I hope we can get that worked out 
because it really is a very, very important program. It is 
doing a tremendous job.
    Dr. Lynch. Absolutely.
    Senator Boozman. Thank you.
    Chairman Isakson. Thank you, Senator Boozman.
    Senator Hirono.
    Senator Hirono. Thank you, Mr. Chairman.
    I would like to thank Senators Collins, King, and Markey 
for their close sponsorship of S. 683, my Keeping Our 
Commitment to Disabled Veterans Act, which would ensure 
coverage for around 350 veterans in Hawaii, some 20,000 
veterans across the country, and in Hawaii at non-public and 
private nursing home care facilities across the State who 
depend on VA reimbursement for their health care needs.
    On February 17, I visited Hale Makua Health Services on 
Maui, which operates the only two freestanding nursing homes on 
that island. They would be impacted by a lapse in the program 
that I just mentioned. Wes Lo, who is the CEO of Hale Makua, 
said that passing this bill is needed so that more veterans on 
Maui will be able to receive around-the-clock nursing care and 
supervision in his facilities.
    We must keep our commitment to these veterans, which is why 
I am grateful to the VA and the veterans service organizations 
here today for their testimony in support of the bill.
    I wanted to ask you, Mr. Yehia, could you share with the 
Committee how a lapse in the support for this program, funding 
for this program, would impact the veterans at Hale Makua and 
the over 20,000 veterans in facilities across the country with 
VA reimbursement, and what would VA do if such a lapse 
occurred?
    Dr. Yehia. Well, we are definitely very supportive of the 
bill, and Dr. Lynch can provide a little bit more context on 
what would happen.
    Dr. Lynch. We run in or have run into problems with lapses 
in the past. These are not good things to have.
    Senator Hirono. Mm-hmm.
    Dr. Lynch. We have to look for workarounds to keep the 
veteran in the nursing home and to give them the care that they 
need. So, anything we can do to continue legislation that keeps 
the veteran in the nursing home and provides the care they need 
is strongly supported by the VA. We do not want to be in a 
position where a bill would lapse.
    Senator Hirono. Do you feel pretty confident that we will 
not let this program lapse? Because otherwise you have to have 
a Plan B.
    Dr. Lynch. I am hoping with the support from your 
colleagues----
    Senator Hirono. Yes.
    Dr. Lynch [continuing]. That we can pass the legislation 
and we do not face that problem.
    Senator Hirono. Yes.
    Dr. Lynch. If we face the problem, VA will work to solve 
it.
    Senator Hirono. The 350----
    Dr. Lynch. But, I am hoping we do not get there.
    Senator Hirono [continuing]. Veterans in Hawaii, that is 
really a large number of veterans who would be impacted.
    Dr. Yehia, in your testimony, you state that if the 
disabled veteran nursing home care authority continues to be 
extended, VA estimates the cost would be $4.73 million in 
fiscal year 2018, $25.13 million over 5 years, and $53 million 
over 10 years. What would you attribute to the bulk of this 
increasing cost? Is it that we have more veterans who will need 
this kind of care? Is it that the cost of the care is rising or 
a combination?
    Dr. Lynch. Cost of health care is going up across the 
country, and so we have to allow for that increase.
    But, generally, it is a rising population. We know if we 
look at our geriatric population, we are seeing an increase 
over the next 20 years. It is the Silver Tsunami, and we have 
to be prepared to address those veterans.
    Senator Hirono. When you say Silver Tsunami, that is an age 
group of what?
    Dr. Lynch. That could be an age group, depending upon who 
you are and what your age is, anywhere from 50 to 75.
    Senator Hirono. So, that is a growing group of veterans 
that will need----
    Dr. Lynch. The geriatric population is one of our most 
rapidly growing sets of populations within the VA. Yes.
    Senator Hirono. There is a certain percentage of them who 
will need this kind of intensive----
    Dr. Lynch. Our goal, quite honestly, as you bring up the 
point--our goal is to try to keep people out of institutions 
and to try to keep them in their home or home environment. But, 
there are some veterans, regardless of the support that we can 
provide, that are going to need nursing homes. Yes.
    Senator Hirono. Let me turn to the Veterans Choice Act, and 
at some point, maybe I will submit a question to you as to what 
would be the top three changes that you would make to the 
Choice Program to make it better.
    I know that you are very concerned with the provisions of 
the draft Veterans Choice Act of 2017 that would require VA to 
renegotiate, reissue, or terminate every agreement and 
contract, regardless of the terms or conditions of such an 
agreement permitting extensions or other flexible authorities. 
Your testimony states that this provision would affect such 
agreements as those with the Department of Defense, Indian 
Health Services, and Tribal Health Programs, as well as with 
your academic affiliates and contractors.
    Could you confirm whether this provision would also impact 
the existing agreement that VA has under the Choice Program 
with the Native Hawaiian Health Centers, and if so, what would 
VA do to renegotiate the contract you have with the Native 
Hawaiian Health Centers?
    Dr. Yehia. Our partnerships with our Indian Health Service 
and the Tribal Health Partners is outside of the Choice Act, so 
we have different arrangements with them. As we consider 
consolidating community care, that is--those are some of the 
relationships we want to ensure that we maintain. So, I think 
this will be important as we come up with a draft legislation 
that does not harm some of those key partners that we have and 
ensuring that we have the flexibility to partner wherever we 
need to with some governing rules overarching them.
    Senator Hirono. I think it is important, since the need is 
great, that the kind of contracts you have will enable the 
Indian Health Services and the Native Hawaiian Health Services 
to continue to be a part of the providing of services. So, 
thank you.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you.
    Senator Rounds.

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

    Senator Rounds. Thank you, Mr. Chairman.
    We are fortunate in South Dakota that we have three VA 
facilities: one in Sioux Falls, one in Hot Springs, one in 
Sturgis. Last year all three received five-star ratings. This 
year two of the three have five-star. One is a four. But, there 
is about a 300-mile spread between the facilities, and for that 
reason, we had a real interest in seeing Choice not only be 
successful, but be improved. That is one of the reasons we had 
authored a proposal that made the VA a primary payer rather 
than a secondary, and that cleaned up a lot of the challenges 
that we had in some of the rural parts of the United States.
    Dr. Yehia, the discussion draft for the Veterans Access to 
Community Care Act--Senator Tester is the primary--affords 
substantially less choice to veterans than the discussion draft 
for the Chairman's proposal. I am open-minded on the issue of 
finding some common ground, but so far, I just do not see a 
downside to giving the veteran the final say on where he or she 
gets their health care.
    I think of a veteran that lives in Miller, SD, or in 
Winner, SD, more than 150 miles away from another facility. To 
suggest to them that they need to go to a facility in order to 
get permission to see their family physician in a local area 
seems to be a little bit challenging. I would just like your 
thoughts on it, please.
    Dr. Yehia. Sure. The Secretary articulated this as little 
bit, maybe about a month or so ago, in front of the Committee.
    What we are talking about really is that relationship 
between a patient and their doctor. I am a practicing provider 
in the VA system, and my patients want to know who is the best 
cardiologist in the community, where they should get their 
health care. We believe it is important for that dialog to 
occur because it actually empowers a veteran to make an 
informed decision about where they should best get their health 
care. We want to provide them with some guidance based on if we 
offer the service, is it accessible, and is it feasible for you 
to drive to receive that care.
    In the construct, though, as described, I think we are more 
about how do we empower the veteran with information to make 
the best decision that is right for them.
    Senator Rounds. I think the idea of providing the veteran 
with an opportunity is very appropriate, but I think requiring 
permission from the VA to make that is probably where I would 
have a concern. Would you see a difference between or would you 
see a different approach, perhaps, than what you would find 
within the bill today?
    Dr. Yehia. So, two items there. I think the intent is not 
to have them drive to have that discussion, and I think there 
are many different avenues, whether it is through a phone call 
or virtual or email or an in-person visit. I think that is 
important, that you can get in contact with your care team, 
more than just driving over there.
    In my experience as a clinician, for the most part, there 
is high degree of concordance between the patient and the 
doctor.
    Senator Rounds. One of the reasons--excuse me.
    Dr. Yehia. Yeah.
    Senator Rounds. One of the reasons why the Choice Program 
was actually put in place in the first place is because not 
only do people live more than 40 miles away, but also because 
they were waiting for more than 30 days to actually make 
contact with the physician. It seems to me that what we are 
going back to is something similar to that, once again, where 
we are saying in order to get your local care, you need to have 
that contact. How do we assure them that they have that contact 
when they need it?
    Dr. Yehia. Yeah.
    Senator Rounds. Would it not seem more appropriate to offer 
it, make it available, encourage it, but still allow that 
individual to be able to access local care when they feel it 
necessary, and would not that be even more empowerment for that 
veteran to make that decision?
    Dr. Yehia. I think some of the challenges that we have been 
facing with the current Choice Program are these 30 and 40 
rules, which are very administrative. When I went to medical 
school, there was nothing about 30 days or 40 miles.
    Senator Rounds. Yeah.
    Dr. Yehia. There are certain patients that I need to be 
seeing in 2 days, not in 30 days, and the law does not allow 
for that. Or there might be folks that live 15 miles away from 
the VA, but if they are getting chemotherapy every day, it 
might make sense for them to get it closer to their home.
    We are actually looking for more flexibility and empowering 
that veteran, that veteran patient, and their care team to make 
those decisions, because I actually think there are situations 
that arise today where the Choice Act is not able to allow 
access to the community as much as it should.
    Senator Rounds. Well, I most certainly want to make sure 
that that veteran has the ability to access local care in a 
timely fashion, and I like the idea of having access to a VA 
physician where there is an opportunity to do so. But, as you 
recall, the reason for the Choice Program in the first place 
was the failure of the VA to be able to provide those services 
in a timely fashion.
    Dr. Yehia. Yeah.
    Senator Rounds. I hate to lose the protections that our 
rural VA members have received through Choice. I would not want 
to go back on that arrangement right now and lose those 
protections and those capabilities that they have got right 
now.
    Dr. Yehia. Well, I look forward to working with you and 
others because I think there are opportunities there to figure 
out how to craft and ensure that those veterans, especially the 
highly-rural veterans, continue to receive the care that they 
need.
    Senator Rounds. Thank you.
    Dr. Yehia. Yeah.
    Senator Rounds. Thank you, Mr. Chairman.
    Chairman Isakson. Excellent point, Senator Rounds. I 
appreciate your pointing that out. That is one thing we are 
going to be dealing with as we get to the final decisions on 
this Choice Program, making it work, but not forgetting what 
got us to Choice in the first place, which was people not 
getting appointments within 30 days and sometimes 90 days. 
People who lived 40 miles away could not get an appointment at 
any time. So, we have got to remember why we got to where we 
are and not allow ourselves to slip back and get there again.
    Senator Tillis.

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

    Senator Tillis. Thank you, Mr. Chair. Thank you all for 
being here.
    Just a real quick one. I want to go back to some questions 
related to Senator Boozman's comments around the Veterans 
Treatment Court Improvement Act. I am a cosponsor of that bill. 
I appreciate Senator Flake's work on it. The VSOs, I think, 
support--all the VSOs support it. You all support it with 
provisions.
    Could you drill down a little bit more on things that we 
need to work on that cause you concern?
    Dr. Lynch. Senator, I think, number 1, we support it, and 
in fact, we are already in the process of hiring 50 or more 
specialists to work in the Veterans Justice Outreach Program.
    Our main concern is the requirement for an offset to the 
salary. We already have committed to the hire. We are concerned 
that if we have to offset that salary, we may have to take it 
from other wraparound programs that we provide to veterans, 
perhaps the homeless, perhaps in social work or caregiver.
    Senator Tillis. So, it is purely the pay-for?
    Dr. Lynch. Right now the main concern is having to pull 
money when we do not think we need to do that, sir.
    Senator Tillis. I want to go back also the discussion we 
are having about maybe different directions on what some people 
refer to as Choice 2.0. You are familiar with some of the 
proposals out there.
    How do we bridge the gap? I think there are some legitimate 
concerns that have been expressed on both sides, but how do we 
bridge the gap, and how do we provide you all with flexibility? 
I want you to answer that question, but I have to go back to 
something that I do in every one of these committees.
    Some believe that there is an effort to privatize the VA. I 
have to continue to say that the hospitals that I have in North 
Carolina, the health care centers that I have in North 
Carolina, the brick-and-mortar presences of the VA are 
critically important elements to anything that we do in the 
future. This is about figuring out how to redouble our efforts 
with non-VA care, which it still continues to be a significant 
amount of how we have provided care for quite some time, and 
then getting choice right.
    Can you give us some thoughts on how we bridge the gap and 
get to a bill that has bipartisan support and gets to the 
President's desk?
    Dr. Yehia. Absolutely. One of the things that I noticed for 
every bill, on the Choice bills today on the docket, what I 
have noticed when I was looking through them is that they are 
touching on the key important aspects that need to be 
addressed. They are addressing eligibility. They are addressing 
how we design the network. They are addressing provider 
payments. They are addressing provider agreements. So, I think 
that is a very good step forward. For the most part, the key 
elements that need to be there are there.
    We just need to figure out how--every one of them has 
different strengths and weaknesses.
    Senator Tillis. If you were to--if you were to back off of 
maybe the universe of ideas to the specific things that you 
think that you need the authority to move forward with, what 
would that look like?
    Dr. Yehia. I think that, just very broadly, there are a 
couple of key things that would help us continue to improve the 
program. One is we have learned through our experience of 
Choice today that being overly prescriptive ends up hampering 
us, and that is one of the reasons why in partnership, the 
Congress has passed more than five legislative changes to the 
program.
    Ensuring that there is enough flexibility to allow us to 
adjust to different geographies, different veteran populations, 
and different types of providers will be key. Some of the bills 
that are on discussion today are very prescriptive of you can 
only pay the Medicare rate and nothing above that. Well, there 
might be certain areas of the country that that is not the 
going rate, and we might lose on high-quality providers. So, 
there are a number of those sort of examples that I think with 
a couple tweaks here and there, we can get to a more robust 
place that allows this new modernized single program to adapt 
to the different veteran populations across the U.S.
    Senator Tillis. Yeah. I think that is one thing that is 
important, is for you all to provide feedback. I would be happy 
to meet with you, but the folks who are moving the bill, to a 
certain extent, sometimes I think we have gone too far. Then, 
the reworks that you have talked about have cost us time and 
possibly money and resources that could be spent on other areas 
that you are working on. So, it would be very helpful to get 
ahead of that and say it is a great thought but a potential 
distraction based on what we need to accomplish on a more 
immediate basis.
    Dr. Yehia. That is right.
    Senator Tillis. I appreciate the opportunity to speak with 
you all about that. Thank you very much.
    Dr. Yehia. We would be happy to do that.
    Senator Tillis. Thank you, Mr. Chair.
    Chairman Isakson. Thank you very much, Senator Tillis, and 
thanks to the members of the VA for your being here for this 
panel. We appreciate your testimony.
    Senator Tester. I got to go yet.
    Chairman Isakson. Oh, I am sorry.
    Senator Tester. That is all right.
    Chairman Isakson. I thank you for----
    Senator Tester. I tell you, there goes the relationship 
right down the tubes. [Laughter.]
    Chairman Isakson. Senator Tester.
    Senator Tester. It is perfectly all right.
    Chairman Isakson. Take as much time as you want.
    Senator Tester. No, no, no. It is perfectly all right.
    First of all, thank you for being here. I do have a few 
questions.
    I think what gives some people (at least on this side) 
heartburn, but I think it gives you guys heartburn too on the 
other side, is the President came out and said guys ought to 
have a card, let them go wherever they want. The ultimate end 
result of that would be a VA that no longer exists, maybe not 
in the short term, but certainly in the long term. So, I think 
that is where part of the heartburn comes from.
    I think, Senator Rounds, when you look at the VA, you look 
at it from a South Dakota rural perspective, which is the way 
you should, so I do not think we are this far off. I mean, I 
think we are--you are looking at it as a challenge like 
somebody who has to drive 300 miles, and other people are 
looking at the VAs sitting there and there is another facility 
right beside it and should the VA be involved in those 
decisions. So, hopefully, we can get to a point on that.
    Look, a couple things I want to talk to you, Dr. Yehia, 
about, and one of them is responsibility. I said it before on 
this Committee that you can outsource the service, but I do not 
know that you can outsource responsibility. I just want to know 
your perspective on that in that whether you think the VA 
should be held responsible in the end for somebody that you 
guys are going to--I cannot remember the word--you are going to 
certify them as being somewhere that the veteran can go and 
ends up getting bad service. What should be the role of the VA 
in that under Choice 2.0?
    Dr. Yehia. Let me provide some broad comments, and I will 
turn it over to Mr. Flohr to provide a little bit more detail.
    Senator Tester. Sure.
    Dr. Yehia. So, in general, we absolutely agree that the 
network that VA builds, whether it is inside or outside, needs 
to deliver high-quality care, which we are responsible for 
building that network, ensuring top quality providers, and 
helping the veteran navigate and coordinate that care. So, I 
think, in general, from a principle perspective, that is the 
case.
    I know that in one of the provisions of the bill, there is 
specific language about if there is a veteran that gets injured 
or harmed from a malpractice or not getting the right service 
in the community, what sort of--how are they made whole again?
    Senator Tester. Right.
    Dr. Yehia. Now, I will ask Mr. Flohr to just comment a 
little bit on that from VBA.
    Senator Tester. Yeah. Go ahead.
    Mr. Flohr. Thank you.
    Yes. It is VBA that makes decisions----
    Senator Tester. Yeah.
    Mr. Flohr [continuing]. On whether or not a veteran has 
been harmed through----
    Senator Tester. Right.
    Mr. Flohr [continuing]. Medical care in VHA.
    Senator Tester. Yep.
    Mr. Flohr. I just saw this bill in the last couple of days.
    Senator Tester. Yeah.
    Mr. Flohr. I have not really had a chance to study it. I am 
not sure how that would--I do know that I did a little 
research, and I found that approximately 47 percent of 
clinicians have been sued at one point or another in their 
lives and their career.
    Senator Tester. Yeah.
    Mr. Flohr. How that would impact a private provider in 
terms of the insurance that they have, their malpractice 
insurance, whether that would go up if they were seeing more 
patients or veterans----
    Senator Tester. Veterans.
    Mr. Flohr [continuing]. So, I just do not know at this 
time.
    Senator Tester. Yeah.
    Mr. Flohr. I do not know what the impact would be on our 
workload.
    Senator Tester. Yep. Well, look, I mean, I guess I see your 
hesitancy for it because you do not know how that is going to 
impact your budget going forward.
    Mr. Flohr. Correct.
    Senator Tester. But, on the other side, when the rubber 
hits the road, it is your responsibility. They signed up. You 
said you are going to give VA care. It is your responsibility.
    Mr. Flohr. Bottom line is we are here to assist veterans--
--
    Senator Tester. That is right.
    Mr. Flohr [continuing]. And make sure they get all the 
care----
    Senator Tester. So----
    Mr. Flohr [continuing]. And benefits they need.
    Senator Tester. Let me ask you how this--would this be part 
of the accreditation process with the hospitals? You have got 
electronic medical records or medical records, period, even if 
they are not electronic. Is there something we need to be doing 
in this bill to ensure that that information, what work has 
been done on that veteran outside the VA is wholly transferable 
to inside the VA?
    Dr. Yehia. Luckily, both bills have some of those 
provisions in there, which is what are the criteria for a 
provider to enter into the network, and I call that really the 
first line of defense----
    Senator Tester. Good.
    Dr. Yehia [continuing]. Because having a medical license 
and credentialing is really the first one.
    Then, we want to go above that and look at what are the 
outcomes, what is the service, and make that as transparent as 
possible to a veteran so they can choose between providers, 
which one is best for them.
    Senator Tester. The only thing I would caution you on is 
some of the same concerns that Senator Rounds had. In some of 
the more frontier areas, these are very small hospitals that 
oftentimes do not have access to enough money, especially 
depending on what we do with health care here at this level. 
So, be aware of that.
    The last thing I would ask you, before I turn it back to 
the Chairman, is cost. We are paying the bill whether it is 
done inside the VA or outside the VA. Have you guys or any of 
your sharp-penciled people--I will call them that--done any 
assessments on cost compared to VA-delivered health care, 
whether it would be up, down, static?
    Dr. Yehia. You mean a delivery of VA services----
    Senator Tester. Yep.
    Dr. Yehia [continuing]. Versus the community?
    Senator Tester. VA versus community care and what those 
costs might be because--and the Chairman remembers we got into 
a pretty vibrant discussion with one of our Members as to what 
the cost for community care is from the Congressional Budget 
Office, I believe. So, have you guys done any of that kind of 
work?
    Dr. Yehia. From an apples-to-apples way of looking, if a 
colonoscopy is done in the VA versus the community, I do not 
have that off the top of my head, but there have been a lot of 
cost estimates that have been done on what would happen if 
there was full access, full choice between the VA and the 
community.
    Senator Tester. Yeah.
    Dr. Yehia. The Secretary mentioned this about a month or so 
ago. It could add up to about $20 billion more a year. The 
Commission on Care had a range from about $5 billion to $35 
billion additional per year.
    Senator Tester. Is that per year or over 10 years?
    Dr. Yehia. Per year.
    Senator Tester. OK.
    Dr. Yehia. There have been some other studies that have 
looked at that, so that is an important consideration.
    Senator Tester. OK. Have you guys picked a favorite of the 
three bills that are up there between Isakson, myself, and 
Crapo? [Laughter.]
    Dr. Yehia. We have not picked a favorite. I think each of 
them has, like I said before, really--they are addressing the 
key issues, which is important, and there is strength and 
weakness for all.
    So, I think across the three, there is real goodness there 
to move us to that consolidated program that we need.
    Senator Tester. All right. Thank you, Mr. Chairman.
    Chairman Isakson. Spoken like an excellent politician. We 
appreciate that. [Laughter.]
    Senator Manchin.

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

    Senator Manchin. Thank you, Mr. Chairman. Thank you all.
    There is a fundamental debate around the third-party 
administrators, and one argument in the VA is--one argument is 
that the VA cannot handle the task of scheduling and 
administering a non-VA care program, so the private sector has 
got to step in.
    The second argument is that third-party administrators do 
not take care of our veterans, plus we cannot do oversight over 
them. This may be the biggest fight in a non-VA care debate 
that we are going to be encountering. I will tell you that when 
I visit veterans in Beckley or in my Clarksburg VA hospitals, 
they really do not like the third-party administrators because 
veterans do not think those docs know them, do not know their 
concerns, their needs, and how to take care of them.
    So, my question is, are you all capable and ready to 
administer a robust non-VA care program and on their own if 
that is the path that we are going to go down? How are you 
going to get them up to speed of the care that the VA and the 
veteran needs?
    Dr. Yehia. So, I think there is a need and a role for third 
parties as we move into the future.
    I think one of the lessons learned from our various town 
halls, interacting with veterans and community providers is we 
outsourced the relationship, and that has been critical. 
Veterans want a relationship with their VA provider or between 
doctors; sometimes that was hampered during our existing 
relationships today with a contractor.
    So, moving forward, I think what would be important is for 
those veteran-facing and community-facing functions, it is 
important that those relationships interact between a doctor 
and a doctor or between a patient and a doctor and do not have 
someone else in there. A case in point has really been in our 
pilots in Alaska and in Fargo that have really shown that--and 
soon to be in Montana--that having that relationship is 
critical.
    Now, I do want to say that----
    Senator Manchin. How are you preparing--how are you 
preparing a non-VA caregiver to understand this veteran and 
understand their care? I speak specifically to opiates.
    Dr. Yehia. Sure.
    Senator Manchin. We got a lot of pill mills. We got a lot 
of doctors pushing pills.
    Dr. Yehia. So----
    Senator Manchin. What guarantees that you are not going to 
be sending one to one of these pill mills?
    Dr. Yehia. Exactly. That is part of the discussion that we 
were just having about ensuring that there are high-quality 
providers in the network.
    Senator Manchin. Who does that?
    Dr. Yehia. It is really a two-step process. One is we want 
to ensure we set the standards. Some of them are actually in 
the current bills we are discussing today of who can enter the 
network, and then we need oversight from our contracting 
partners to----
    Senator Manchin. Doctor, what I am asking is who in--are 
you capable in the VA of qualifying and overseeing these 
people? Do you have continuing education? What are you doing to 
ensure that if we send a veteran from Beckley and Clarksburg--
--
    Dr. Yehia. Sure.
    Senator Manchin [continuing]. Outside of their arena, they 
are going to not be getting somebody taking advantage of them 
and has basically the skill sets to take care of them?
    Dr. Yehia. So, we rely on our contracting partners to 
ensure that we have quality providers, and then what we do 
offer is CME, continuing medical education, free of charge that 
the VA has put on to not only address things such a opioids----
    Senator Manchin. Is it mandatory, or is it----
    Dr. Yehia. It is voluntary right now for the community 
providers.
    Senator Manchin. Why would it be voluntary?
    Dr. Yehia. There are a lot of various State rules that look 
at--some are more mandatory, depending on the State that you 
are in.
    Senator Manchin. Yeah, but you got the paycheck. You got 
the pay--I mean the checkbook. If you tell me I got to do 
something in order to qualify, I am going to do it.
    Dr. Yehia. Well, in some areas, we definitely have that 
market power where they are seeing a lot of veterans, but in 
some--in other areas, especially in highly-rural, if you put a 
lot of burdens on the community providers and they are seeing a 
few, handful of veterans, they just will not sign up.
    Our goal is to be more of having a carrot rather than a 
stick. We would like to really identify those providers that 
have completed that training, that are providing high quality, 
and say, you know, ``These are our preferred providers. We 
would like you to consider them.'' So we have to be cognizant 
of really the amount of market share that we have in each area 
and not putting overly prescriptions on the docs, because then 
they might not want to take care of our veterans.
    Senator Manchin. Can we bring that to a higher profile so 
we can identify those people that do and do not?
    Dr. Yehia. Absolutely.
    Senator Manchin. I mean, the community is going to have to 
get involved.
    Dr. Yehia. Yeah.
    Senator Manchin. We all talk a good game. We are all out 
here showing all of our support for the VA during election 
time. During the non-election time, these people still need the 
same care.
    Dr. Yehia. Yeah. I think there is a lot----
    Senator Manchin. That is community involvement.
    Dr. Yehia. I agree with you. I think there is a lot of 
opportunity to get the hospital associations, the medical 
groups, all kind of involved in helping educate not only about 
military culture competency, but specifically opioids and 
prescribing. Happy to work with you on that.
    Chairman Isakson. Thank you, Senator Manchin.
    Thanks to all the panelists for being here today. Thanks 
for your time, Dr. Yehia. We appreciate it very much.
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal 
    to Baligh R. Yehia, M.D., Deputy Under Secretary for Health for 
  Community Care, Veterans Health Administration, U.S. Department of 
                            Veterans Affairs
    The Choice Program is not working for health care providers or 
veterans. A primary challenge with Choice is that patients are unable 
to effectively connect with their providers, and authorizations for 
care are delayed. Veterans can end up waiting for health care services, 
and providers wait for payment in a way that defeats the entire 
intended purpose of cutting wait times for treatments.
    Dr. Yehia, I'd like to share the story from one provider at the 
Hospital for Special Care in New Britain, Connecticut with you:

    The Hospital for Special Care Pulmonary Rehabilitation program 
provides therapy that can reduce hospitalizations and exacerbations for 
patients with lung disease. This New Britain hospital offers a 
multidisciplinary, ``gold standard'' pulmonary rehab program that 
addresses quality of life, anxiety and depression, nutrition, and other 
concerns for patients with chronic lung disease.
    Prior to the VA Choice program, there was a functioning system in 
place to facilitate referrals. At the Newington VA, the Non-VA Care 
Department ensured that private providers had all documentation 
necessary, including referral, agreement as a payor, and medical 
records. They were very efficient and cooperative, and understood the 
medical necessity of Pulmonary Rehab.
    But, after VA Choice, providers at the Hospital for Special Care 
have expressed concerns. In the case of one patient treated for chronic 
lung disease, the physician's note stated that he wanted this patient 
to attend the Hospital for Special Care Pulmonary Rehabilitation 
Program. VA Choice delayed the sending of authorization paperwork and 
during that time, the patient was hospitalized twice. The referral was 
discontinued on two occasions, even though the physician's notes stated 
that he wanted the patient to attend our program. At this point, my 
Connecticut office intervened to get this veteran the health care that 
he required.

    Question 1.  Dr. Yehia, such barriers to care are exactly the 
opposite of what Congress intended with the Veterans Choice Program. 
Which legislation on the hearing agenda today do you believe will best 
address the shortcomings of the current Choice Program?
    Response. We appreciate the opportunity to work with the Committee 
to review proposed legislation to improve VA community care for 
Veterans. A principle we all agree on is making sure that VA is 
organized around and focused on the needs of Veterans. This means 
making community care simple to understand and easy to administer, 
which is our vision for this program. With that in mind, while we 
support many of the provisions in the three proposed bills on the 
agenda, as explained in our testimony, there are some provisions that, 
while well-intended, we believe would create added complexity or impose 
restrictions that would reduce our flexibility and ability to 
efficiently meet Veterans' health care needs.
    The future of VA's community care program is one of the most 
important and possibly most difficult items on the legislative agenda. 
We want to work with everyone to ensure the legislation that shapes 
this future is as strong as possible. VA is working on developing its 
proposal and intends to share this with the Committee in the near 
future.

    Question 2.  What else should Congress do to cure this failure?
    Response. In regards to the current program, VA has worked closely 
with Congress to enact changes to the original law which have created 
more flexibility in the Veterans Choice Program and enabled more 
Veterans to use the program. VA has also worked closely with our 
contracting partners to modify the contracts and business processes. 
This has enabled the contractors to make payments to community 
providers more timely and provide more timely appointments for 
Veterans. VA has also developed and implemented tools to assist in 
sharing health information with the community providers to ensure 
better care coordination for Veterans.
    We believe the legislation that is ultimately enacted should 
embrace a few broad principles; these principles are based on lessons 
learned through VA's community care program and the Veterans Choice 
Program.
    The future community care program must empower the Veteran and his 
or her provider to get the right care at the right time from the right 
provider. VA must be able to establish a high-performing network of VA 
and community providers who can furnish the very best care for 
Veterans. To do this, we must have flexibility in terms of payment 
rates and the types of agreements we form with providers. In addition, 
we must also have the flexibility to simplify our interactions with 
providers to ensure we pay them on time, and can easily share 
information with them.
    It is also imperative that VA retain flexibility to adjust and 
adapt to an evolving health care landscape. Legislation that is too 
prescriptive in terms of rules, responsibilities, or processes can only 
limit our options, leading to frustration by Veterans and community 
providers alike. The law establishing the Choice Program was amended 
five times in less than three years. That is not a sustainable model. 
We believe the best legislation in this area would provide broad, 
general authority that VA could further narrow and implement through 
regulations, policy, and contracts. We have been working with your 
staffs and our VSO partners over the past 15 months on these proposals 
and will continue to do so once legislation is enacted to ensure that 
the best ideas are incorporated in the new program.
    Last, it is critical that the legislation provide VA sufficient 
time for development and implementation. We know from our efforts with 
the current Choice Program that a rushed period of implementation will 
not help Veterans or VA. Ideally, we would have a full year to 
establish provider networks, draft regulations, and build the 
relationships and systems that will empower Veterans, VA, and community 
providers to offer the very best health care services to our Veterans.

    Chairman Isakson. It is time for our second panel. Will 
they please come forward. [Pause.]
    Well, thank you for being here today. We appreciate your 
patience, and as was said about you during the hearing, we 
greatly appreciate the VSOs' support, their counsel, and their 
input, which will be very valuable and important to us as we go 
forward on the legislation pending here. We are glad to have 
you today, and we appreciate you coming to testify.
    Our four witnesses from the veterans service 
organizations--first of all, Mr. Lou Celli. Lou, we are glad to 
have you back; we always appreciate the input of The American 
Legion. I just sent my dues check in last week, by the way, so 
I am good for another year.
    Mr. Celli. We are going to check.
    Chairman Isakson. Please do. [Laughter.]
    Amy Webb of AMVETS. Amy, we are glad to have you here 
today. Adrian Atizado is back with us, the Disabled American 
Veterans; and Gabriel Stultz, legislative counsel, Paralyzed 
Veterans of America. Thank you all for being here.
    We will start with you, Lou.

 STATEMENT OF LOUIS CELLI, DIRECTOR, NATIONAL VETERANS AFFAIRS 
        AND REHABILITATION DIVISION, THE AMERICAN LEGION

    Mr. Celli. The American Legion is proud to support the 
slate of bills being considered today and will touch briefly on 
them as we move toward the discussion on the future of Choice. 
As we all know, it is the big topic coming up for today's 
discussion.
    Chairman Isakson, Ranking Member Tester, and distinguished, 
dedicated defenders of veterans who proudly serve on this 
Committee, on behalf of Charles Schmidt, the national commander 
of the largest veterans service organization in the United 
States of America, representing more than 2.2 million dues-
paying members, combined with our American Legion family, whose 
numbers exceed 3.5 million voters living in every State and 
American territory, it is my duty and honor to present The 
American Legion's position on the bills being discussed here 
today.
    The American Legion supports the Veterans Transplant Act. 
We appreciate that VA is concerned about the increase in 
administrative burden that this will cause, but The American 
Legion believes this is imperative to be able to track and 
monitor the biological implants that are being surgically 
inserted into our veterans' bodies. Infectious trends, possible 
recalls, longevity studies all require tracking. It just makes 
sense.
    Senate Bill 426, the draft bill to improving hiring 
efficiencies all have our full support. Keeping VA staffed with 
equal medical and support staff is critical to ensuring VA can 
operate efficiently, effectively, and be the best possible 
steward of the taxpayers' dollars.
    Every vacancy at VA pushes appointments further behind and 
care into the community, a trend that needs to be monitored 
closely. VA has some of the most advanced resources in the 
country and in the world and should be an employer of choice 
for rising physicians building their career. We need to ensure 
that VA and the Secretary have the tools necessary to properly 
staff their agency.
    Senate Bill 683, the VA nursing home care is a no-brainer.
    Senate Bill 833, VA has an obligation to care for us who 
suffer illness or injury based on their honorable service, but 
when their honorable service is disrespected and denigrated by 
fellow servicemembers, we not only have an obligation to 
support and defend our comrades by prosecuting offenders to the 
fullest extent of the law, we have an obligation to apologize 
for not protecting them and to ensure we care for them with 
every available resource that we have, and at a minimum, that 
includes VA health care. I am surprised that this even needs 
legislation to accomplish it in the first place, and yes, we 
support it.
    The American Legion has always supported veteran treatment 
courts, and this bill will help provide the liaison services 
that veterans and the judicial system need to support this 
important program. The American Legion supports Senate Bill 
946.
    The Veterans ACCESS Act simply closes a loophole that puts 
veterans at risk. If a physician gets fired from VA for not 
being able to perform his or her job, why would it be OK for VA 
to then contract with them and send veterans to them, anyway? 
We support keeping bad actors away from our veterans, and we 
support this bill.
    The Enhancing Veteran Care Act is an interesting concept 
and probably what the VA OIG should be doing but, sadly, does 
not. VA tells us that they have tiger teams that descend on 
poorly performing facilities to help rehabilitate them. An 
ounce of prevention is worth a pound of cure. The American 
Legion has been doing this for a very long time, over 10 years, 
visiting facilities, working with leadership, rendering 
reports, and sharing best practices through our System Worth 
Saving Program. We support Senate Bill 1266 because the bill 
exposes a need within the structure of the system that 
currently is unmet, but we still think that this should be a 
function of the Inspector General's office.
    In our written testimony about the Draft Quality Employment 
VA bill, The American Legion discusses this proposed 
legislation extensively, but in short, we want to highlight to 
this Committee that the VA has a variety of authorities and 
resources at their disposal that can increase competitive 
staffing levels at VA without the need for additional 
legislation. We call on VA to start exploring these options. 
This includes residency programs, public-private partnerships, 
and space-sharing programs instituting a VA medical school, 
temporary physician-sharing assignments between Level 1 and 
Level 3 facilities, and more that are all within VA's authority 
to execute now.
    In our written presentation, The American Legion outlines 
the need for consolidation and unification of community care 
contracting practices, recommendations for public-private 
partnerships, suggestions on ways to increase capacity and 
innovations that will support VA sustainability, and ensure VA 
remains a world leader in education, science, and health care, 
their three statutory pillars that VA was built on.
    Over the past year, VA has worked closely with this 
Committee and veterans service organizations to come up with a 
plan on where the future of VA health care is headed. Through 
all of this, we believe the Secretary's CARE Plan most closely 
represents what The American Legion supports: consolidated, 
integrated, heads-up health care. We call on this Committee to 
work with the Secretary and the VSO community to put a plan in 
place that is comprehensive, sustainable, affordable, and 
veteran-centric, and we believe that the CARE Plan hits all of 
those points.
    We look forward to our continued work together with this 
Committee and the Secretary to build a 21st century world-class 
VA health care system that your Nation's warriors have earned.
    [The prepared statement of Mr. Celli follows:]
Prepared Statement of Louis J. Celli, Jr., Director, National Veterans 
        Affairs and Rehabilitation Division, The American Legion

 
------------------------------------------------------------------------
  Bill #         Bill Name or Subject                  Position
------------------------------------------------------------------------
   S. 115 The Veterans Transplant          Support
           Coverage Act
------------------------------------------------------------------------
   S. 426 Grow Our Own Directive
          Physician Assistant Employment   Support
           and Education Act of 2017
------------------------------------------------------------------------
   S. 683 Keeping Our Commitment to        Support
           Disabled Veterans Act of 2017
------------------------------------------------------------------------
    Draft To improve the hiring,           Support
     Bill  training, and efficiency of
           acquisition personnel and
           organizations of the
           Department of Veterans
           Affairs, and for other
           purposes
------------------------------------------------------------------------
   S. 833 Servicemembers and Veterans      Support
           Empowerment and Support Act of
           2017
------------------------------------------------------------------------
   S. 946 Veterans Treatment Court         Support
           Improvement Act of 2017
------------------------------------------------------------------------
  S. 1153 Veterans ACCESS Act              Support
------------------------------------------------------------------------
  S. 1261 Veterans Emergency Room Relief   Support
           Act of 2017
------------------------------------------------------------------------
  S. 1266 Enhancing Veteran Care Act       Support
------------------------------------------------------------------------
  S. 1279 Veterans Health Administration   Refer to Choice Program-
           Reform Act of 2017               Community Care Option
                                            Section
------------------------------------------------------------------------
    Draft Veterans Choice Act of 2017      Refer to Choice Program-
Discussio                                   Community Care Option
        n                                   Section
------------------------------------------------------------------------
    Draft Improving Veterans Access to     Refer to Choice Program-
Discussio  Care in the Community Act of     Community Care Option
        n  2017                             Section
------------------------------------------------------------------------
  S. 1325 Better Workforce for Veterans    Support
           Act of 2017
------------------------------------------------------------------------
Discussio The Department of Veterans       Support
  n Draft  Affairs Quality Employment Act
           of 2017
------------------------------------------------------------------------


    When The American Legion testified at the June 7, 2017 Senate 
hearing, we went on record stating The American Legion believes in a 
strong, robust veterans' healthcare system that is designed to treat 
the unique needs of those men and women who have served their country. 
As we testify today, The American Legion's commitment to helping 
Congress and VA build a strong robust veterans' healthcare system is 
even stronger.
    Chairman Isakson, Ranking Member Tester, and distinguished Members 
of the Committee; On behalf of our National Commander, Charles E. 
Schmidt, and the over 2 million members of The American Legion, we 
thank you for this opportunity to testify regarding The American 
Legion's position on pending legislation before this Committee. We 
appreciate the Committee focusing on these critical issues that will 
affect veterans and their families.
              s. 115: the veterans transplant coverage act
A bill to amend Title 38, United States Code, to authorize the 
        Secretary of Veterans Affairs to provide for an operation on a 
        live donor for purposes of conducting a transplant procedure 
        for a veteran, and for other purposes.
    The Department of Veterans Affairs (VA) Veterans Health 
Administration (VHA) has been providing transplant services since 1961 
when Dr. Thomas E. Starzl, performed the first-ever transplant of a 
human liver at the Denver VA hospital on May 5, 1963.
    This bill, if enacted into law, would authorize the Secretary of 
Veterans Affairs to provide organ transplants to veterans from a live 
donor regardless of whether that donor is a veteran. This bill would 
allow veterans who are waiting a lengthy amount of time for VA 
transplant services to receive those services out in the community at 
VA expense.
    In 2015, the VA Office of Inspector General (VAOIG) issued Report 
No. 15-00187-25, Alleged Program Inefficiencies and Delayed Care, VHA's 
National Transplant Program. VAOIG substantiated that some patients 
referred for liver transplant evaluations at all VATCs experienced 
delays. VAOIG estimated that 6.9 percent of emergency referrals were 
not responded to in VHA's electronic transplant referral system within 
48 hours, as required (95 percent confidence interval (CI): 1.67-
24.42). Among stable patient referrals, VAOIG estimated that 9.6 
percent of referrals were not responded to in VHA's electronic 
transplant referral system within 5 business days, as required (95 
percent CI: 6.36-14.28). About half of stable patients who were deemed 
eligible for further evaluation did not receive an initial patient 
evaluation within 30 days, as required.\1\
---------------------------------------------------------------------------
    \1\ VAOIG Report No, 15-00187-25 (Nov 2015): Alleged Program 
Inefficiencies and Delayed Care, VHA's National Transplant Program
---------------------------------------------------------------------------
    According to statistics obtained from the Department of Health and 
Human Services, as of June 30, 2017, there were 117,636 people needing 
a lifesaving organ transplant (total waiting list candidates).\2\ Of 
those, 75,958 people are active waiting list candidates. In accordance 
with VHA Policy Directive 2012-018, Solid Organ and Bone Marrow 
Transplantation, VA can only accept living donors into VA's transplant 
program.
---------------------------------------------------------------------------
    \2\ Organ Procurement and Transplantation Network: https://
optn.transplant.hrsa.gov/
---------------------------------------------------------------------------
    Through American Legion Resolutions No. 25, The American Legion 
Support of the VA Organ Transplant Program The American Legion supports 
a system of organ distribution that will ensure that veteran patients 
receive equitable consideration when in need of transplants, and No. 
46, Department of Veterans Affairs (VA) Non-VA Care Programs, that the 
Department of Veterans Affairs (VA) develop a well-defined and 
consistent non-VA care coordination program, policy and procedure that 
includes a patient-centered care strategy which takes veterans' unique 
medical injuries and illnesses as well as their travel and distance 
into account.\3\ \4\
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    \3\ The American Legion Resolution No. 25 (May 2004): The American 
Legion Support of the VA Organ Transplant Program
    \4\ The American Legion Resolution No. 46 (Oct. 2012): Department 
of Veterans Affairs (VA) Non-VA Care Programs
---------------------------------------------------------------------------
    The American Legion supports S. 115.
  s. 426: grow our own directive: physician assistant employment and 
                         education act of 2017
A bill to increase educational assistance provided by the Department of 
        Veterans Affairs for education and training of physician 
        assistants of the Department, to establish pay grades and 
        require competitive pay for physician assistants of the 
        Department, and for other purposes.
    S. 426 will authorize the Grow Our Own Directive (GOOD) Pilot 
Program for five years to advance training and education opportunities 
for participants of the Intermediate Care Technician (ICT) program who 
agree to work in VA facilities in underserved states, and former 
servicemembers with military health experience. Once these veterans are 
certified as Physician Assistants, they will be required to work at the 
VA for at least three years.
    Physician Assistants are one of the most in-demand positions at the 
VA. In 2016, it was reported that there is a 23 percent vacancy rate in 
the VA for physician assistants. According to the Veterans Affairs 
Physicians Assistants Association, there are an estimated 30,000 open 
Physician Assistant positions in the United States, making it difficult 
for the VA to recruit and retain physician assistants.\5\
---------------------------------------------------------------------------
    \5\ USA Today (Aug 20, 2015): Half of critical positions open at 
some VA hospitals.
---------------------------------------------------------------------------
    Reports from our legionnaires who are involved in VA facilities at 
the state level suggest that the reason for this is not a lack of 
quality candidates, but rather process and pipeline barriers. For a 
Veterans Health Administration (VHA) facility to hire one person for a 
clinical position it can involve up to 18 steps--from getting approval 
for the job posting, to running credential checks--and can take from 
four to eight months to complete. By that time, candidates have often 
accepted a job elsewhere.
    The ICT program is a common sense initiative for the VA to fill 
these vacancies. Created in 2012, the scope of practice for the role of 
an ICT is more advanced than a traditional VA EMT. ICTs are configured 
for the medic and corpsmen skill set and provide a high level clinical 
support to nurses and physicians. Additionally, the position was 
designed as an initial entry springboard for qualified veterans to 
explore further career opportunities in healthcare. Unfortunately, the 
program continues to suffer from a lack of training opportunities for 
participants to utilize to advance their careers at the VA.
    S. 426 would provide this training by establishing the Grow Our Own 
Directive (GOOD) Pilot Program for 5 years, which would provide 
scholarships to cover the cost of obtaining a master's degree in 
Physician Assistant Studies. This would make good on the promise and 
potential of the ICT Program in leveraging the skill sets of our medics 
and corpsmen, as well as help solve long-standing recruitment issues 
facing VHA.
    Through American Legion Resolution 338: Support Licensure and 
Certification of Servicemembers, Veterans and Spouses resolves that The 
American Legion supports efforts to eliminate employment barriers that 
impede the timely and successful transfer of military job skills to the 
civilian labor market.\6\
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    \6\ The American Legion Resolution No. 338 (2016): Support 
Licensure and Certification of Servicemembers, Veterans and Spouses
---------------------------------------------------------------------------
    The American Legion supports S. 426.
    s. 683: keeping our commitment to disabled veterans act of 2017
A bill to amend Title 38, United States Code, to extend the requirement 
        to provide nursing home care to certain veterans with service-
        connected disabilities.
    Public Law 114-228, Section 1710A, Required Nursing Home Care, was 
signed into law September 29, 2016, and is due to expire December 31, 
2017.\7\
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    \7\ Public Law 114-228 (114th Congress): https://www.gpo.gov/fdsys/
pkg/PLAW-114publ228/ html/PLAW-114publ228.htm
---------------------------------------------------------------------------
    The American Legion Resolution No. 377, Support for Veteran Quality 
of Life, supports any legislation and programs within VA that will 
enhance, promote, restore or preserve benefits for veterans and their 
dependents, including, but not limited to, the following: timely access 
to quality VA health care; timely decisions on claims and receipt of 
earned benefits; and final resting places in national shrines and with 
lasting tributes that commemorates their service.\8\
---------------------------------------------------------------------------
    \8\ The American Legion Resolution No. 377 (Sept. 2016): Support 
for Veteran Quality of Life.
---------------------------------------------------------------------------
    By extending the date and not allowing this critical authority to 
expire, the lives of veterans with service-connected disabilities will 
continue to be enhanced.
    The American Legion supports the passage of S. 683.
s. 833: servicemembers and veterans empowerment and support act of 2017
A bill to amend Title 38, United States Code, to expand health care and 
        benefits from the Department of Veterans Affairs for military 
        sexual trauma, and for other purposes.
    The American Legion supports safe and dignified service for all 
servicemember regardless of pay category, period if service, or duty 
assignment. The Department of Defense has instituted a zero tolerance 
policy for sexual harassment cases, and The American Legion agrees. 
Unfortunately, despite existing laws and military regulations, sexual 
harassment still happens far too much, and when it does servicemembers 
should be able to receive appropriate counseling and care from the 
Department of Veterans Affairs to overcome any health-related 
conditions related to sexual harassment or assault. For this reason, 
The American Legion passed Resolution No. 67 Military Sexual Trauma and 
Resolution No. 15, Support Veteran Status for National Guard and 
Reserve Servicemembers.\9\ \10\
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    \9\ The American Legion Resolution No. 67 (August 26, 2014): 
Military Sexual Trauma
    \10\ The American Legion Resolution No. 15 (August 30, 2016): 
Support Veteran Status for National Guard and Reserve Servicemembers
---------------------------------------------------------------------------
    The American Legion supports S. 833.
        s. 946: veterans treatment court improvement act of 2017
A bill to require the Secretary of Veterans Affairs to hire additional 
        veterans justice outreach specialists to provide treatment 
        court services to justice-involved veterans, and for other 
        purposes.
    When veterans return from combat, some turn to drugs or alcohol to 
cope with mental health issues related to Post Traumatic Stress 
Disorder (PTSD) and/or Traumatic Brain Injury (TBI). Thus, many 
returning veterans are entering the criminal justice system to face 
charges stemming from these issues. In 2008, a judge in Buffalo, NY, 
created the first Veterans Treatment Court after seeing an increase in 
veterans' hearings on his dockets. Veteran Treatment Courts are a 
hybrid of drug and mental health courts. They have evolved out of the 
growing need for a treatment court model designed specifically for 
justice-involved veterans to maximize efficiency and economize 
resources while making use of the distinct military culture consistent 
among veterans.
    In 2016, The American Legion approved Resolution No. 145, Veteran 
Treatment Courts which specifically calls for continuing to fund and 
expand Veterans Treatment Courts and hire more staff to expand the 
Veterans Justice Outreach program and policies.\11\
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    \11\ The American Legion Resolution No. 145 (August 30, 2016): 
Veteran Treatment Courts
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    The American Legion supports S. 946.
                      s. 1153: veterans access act
A bill to prohibit or suspend certain health care providers from 
        providing non-Department of Veterans Affairs health care 
        services to veterans, and for other purposes.
    The American Legion plays a lead role in VA healthcare reform by 
working with providers, patients, the public and other stakeholders in 
communities to improve access, quality and accountability.
    This bill, as written, would protect veterans seeking care through 
VA community care programs like the Choice Program, from being treated 
by doctors who have been terminated or who have been suspended by the 
VA.
    The American Legion System Worth Saving (SWS) facility visits and 
Regional Office Action Reviews (ROAR) provide unequaled firsthand 
knowledge of the challenges and opportunities VA faces in the 
communities it serves. The American Legion's national staff also 
closely monitors reports from the Government Accountability Office, 
Congress, VAOIG, media and multiple other sources to identify 
facilities that are experiencing challenges so solutions can be found 
together.
    There are numerous reasons a physician can lose their license to 
practice. If a VA physician hired to care for a veteran is terminated 
by VA for any reasons cited in this bill, The American Legion agrees 
with Congress, VA should not be permitted to refer veterans outside the 
department to these non-VA providers. No veteran should be put in a 
position of being referred to a non-VA physician who was terminated 
from the VA due to negligence of duties.
    The American Legion Resolution No. 3, Department of Veterans 
Affairs Accountability, supports any legislation that provides the 
Secretary of Veterans Affairs the authority to remove any individual 
from the Department of Veterans Affairs if the Secretary determines the 
performance of the individual warrants such removal.\12\ Once a VA 
physician is removed from VA due to performance, The American Legion 
believes Congress and VA has a sacred duty to ensure that our Nation's 
veterans are protected and receive the best health care available 
regardless of whether the care is provided by VA or a non-VA physician.
---------------------------------------------------------------------------
    \12\ The American Legion Resolution No. 3 (August 2016): Department 
of Veterans Affairs Accountability
---------------------------------------------------------------------------
    The American Legion supports S. 1153.
          s. 1261: veterans emergency room relief act of 2017
A bill to amend Title 38, United States Code, to require the Secretary 
        of Veterans Affairs to pay the reasonable costs of urgent care 
        provided to certain veterans, to establish cost-sharing amounts 
        for veterans receiving care at an emergency room of the 
        Department of Veterans Affairs, and for other purposes.
    This bill would create a new section, 1725A, Payment of reasonable 
costs of urgent care.
    Through American Legion Resolution No. 46: Department of Veterans 
Affairs (VA) non-VA care programs, The American Legion calls on the 
Department of Veterans Affairs (VA) to develop a well-defined and 
consistent non-VA care coordination program, policy and procedure that 
includes a patient-centered care strategy which takes veterans' unique 
medical injuries and illnesses.\13\ Additionally, through American 
Legion Resolution No. 377, Support for Veteran Quality of Life, The 
American Legion urges Congress and the Department of Veterans Affairs 
(VA) to enact legislation and programs within the VA that will enhance, 
promote, restore or preserve benefits for veterans and their 
dependents.\14\ The American Legion believes including urgent care as 
an option in VA's Community Care program will enhance veterans care.
---------------------------------------------------------------------------
    \13\ The American Legion Resolution No. 46 (October 2012): 
Department of Veterans Affairs non-VA care programs
    \14\ The American Legion Resolution No. 377 (August 2016): Support 
for Veteran Quality of Life
---------------------------------------------------------------------------
    The American Legion supports S. 1261.
                  s. 1266: enhancing veteran care act
A bill to authorize the Secretary of Veterans Affairs to enter into 
        contracts with nonprofit organizations to investigate medical 
        centers of the Department of Veterans Affairs.
    Dating as far back as 2003, The American Legion has been involved 
in conducting System Worth Saving (SWS) site visits to VA Health Care 
facilities to better understand the challenges veterans face when 
accessing VA health care. Each year, The American Legion visits 
anywhere between 12 to 15 VA health care facilities. Prior to each site 
visit, a town hall meeting is held so veterans can have an opportunity 
to share firsthand their VA experience. After each visit, a report is 
written identifying best practices and challenges. Challenges are 
followed up with recommendations and the report is shared with the 
medical center to assist them in overcoming their challenges. Prior to 
The American Legion National Convention, the site visit reports are 
compiled into an Executive Summary, which is shared with the House and 
Senate Veterans' Affairs Committees, the VA Secretary, Under Secretary 
of Health and the President of the United States.
    Through American Legion Resolution No. 105, Reiteration of the 
System Worth Saving Program, The American Legion supports visiting and 
investigating VA medical centers for the purpose of identifying gaps in 
services, best practices, and areas that need improvement.\15\ The 
American Legion would also want to ensure that the nonprofit 
organizations selected to investigate are certified, qualified, and 
fair and equitable. They should work closely with VA and Veteran 
Service Organizations to establish a criteria for investigation with a 
responsible metric for evaluation and data collection that highlights 
best practices as well as deficiencies and areas that need improvement.
---------------------------------------------------------------------------
    \15\ The American Legion Resolution No. 105 (Sept. 2015): 
Reiteration of the System Worth Saving Program
---------------------------------------------------------------------------
    The American Legion supports S. 1266.
       s. 1279: veterans health administration reform act of 2017
A bill to amend Title 38, United States Code, to furnish health care 
        from the Department of Veterans Affairs through the use of non-
        Department health care providers, and for other purposes.
            (See below)
             draft discussion: veterans choice act of 2017
A bill to amend title 38, United States Code, to permit all veterans 
        enrolled in the patient enrollment system of the Department of 
        Veterans Affairs to receive health care from non-Department of 
        Veterans Affairs health care providers, and for other purposes.
            (See below)
      draft discussion: improving veterans access to care in the 
                         community act of 2017
A bill to amend Title 38, United States Code, to establish the Veterans 
        Community Care Program of the Department of Veterans Affairs to 
        improve health care provided to veterans by the Department, and 
        for other purposes.
            (See below)
                 choice program-community care options
    Even in the best of circumstances, there are situations where the 
VA health care system cannot keep up with the healthcare needs of the 
growing veteran population requiring VA services, and the veteran must 
seek care in the community. Rather than treating this situation as an 
afterthought, or an add-on to the existing system, The American Legion 
has called for the Veterans Health Administration (VHA) to ``develop a 
well-defined and consistent non-VA care coordination program, policy 
and procedure that includes a patient-centered strategy which takes 
veterans' unique medical injuries and illnesses as well as their travel 
and distance into account.''
    Over the years, VA has implemented a number of non-VA care programs 
to manage veterans' health care when such care is not available at a VA 
facility, could not be provided in a timely manner, or is more cost 
effective through contracting vehicles. Programs such as Fee-Basis, 
Project Access Received Closer to Home (ARCH), Patient-Centered 
Community Care (PC3), and the Veterans Choice Program (VCP) were 
enacted by Congress to ensure eligible veterans could be referred 
outside the VA for needed, and timely, health care services.
    Congress created the VCP after learning in 2014 that VA facilities 
were falsifying appointment logs to disguise delays in patient care. 
However, it quickly became apparent that layering yet another program 
on top of the numerous existing non-VA care programs, each with their 
own unique set of requirements, resulted in a complex and confusing 
landscape for veterans and community providers, as well as the VA 
employees that serve and support them.
    Therefore, Congress passed the Surface Transportation and Veterans 
Health Care Choice Improvement Act of 2015 (VA Budget and Choice 
Improvement Act) in July 2015 after VA sought the opportunity to 
consolidate its multiple care in the community authorities and 
programs. This legislation required VA to develop a plan to consolidate 
existing community care programs.
    On October 30, 2015, VA delivered to Congress the department's Plan 
to Consolidate Community Care Programs, its vision for the future 
outlining improvements for how VA will deliver health care to veterans. 
The plan seeks to consolidate and streamline existing community care 
programs into an integrated care delivery system and enhance the way VA 
partners with other Federal health care providers, academic affiliates 
and community providers. It promises to simplify community care and 
gives more veterans access to the best care anywhere through a high 
performing network that keeps veterans at the center of care.
    Generally, The American Legion supports the plan to consolidate 
VA's multiple and disparate purchased care programs into one New 
Veterans Choice Program (New VCP). We believe it has the potential to 
improve and expand veterans' access to health care.
    The American Legion has carefully reviewed each of the three bills 
and we would like comment on a few provisions of the bills. Under 
Subsection (a) of Senator Tester's bill, the bill would establish 
section 1703A, Veterans Community Care program, which authorizes the 
Secretary to furnish an eligible veteran hospital care and medical 
services through the Veterans Community Care program. To be eligible, a 
veteran must be enrolled in the VA Health Care System, which is 
consistent with the requirments in Senator Crapo's and Senator's 
Isakason's bill. However, The American Legion is concerned that under 
subsection (d) of Senator Tester's bill, it would require the Secretary 
to (Shall) enter into contracts with eligible providers for furnishing 
care and services to eligible veterans. The bill defines the term 
contracts has the meaning given that term in subpart 2.101 of the 
Federal Acquisition Regulation. Under section 201, it would creat a new 
section, 1703C, referred to as Veterans Care Agreements. This section 
would provide the Secretary discretionary (May) authority to establish 
providers agreements. The American Legion believes these two sections 
may create challenges for VA when deciding what type of care should 
fall under the mandatory (Shall) authority and what type of care should 
fall under the discretionary (May) authority.
    Section 2 of Senator Crapo's bill would amend Title 38 U.S.C. 
1703's heading from ``Contracts for Hospital Care and Medical Services 
in Non-Department facilities'' to ``Care in the Community Program'' The 
American Legion believes the current heading gives a false impression 
that this is a contracting authority, and by retitling 38 U.S.C. 1703, 
it would avoid this false impression. Senator Crapo's bill would also 
authorize reimbursement for urgent care provided at a non-Department 
facility in accordance with regulations prescribed by the Secretary and 
would also establish a new section, titled 1703A, which would require 
the Secretary to enter into purchase agreements with non-Department 
health care providers to furnish care and services to enrolled 
veterans. At The American Legion 2016 National Convention, Resolution 
No. 114, Department of Veterans Affairs Provider Agreements with Non-VA 
Providers, was passed which supports legislation that would allow the 
Department of Veterans Affairs (VA) to enter into provider agreements 
with eligible non-VA providers to obtain needed health care services 
for the care and treatment of eligible veterans.\16\
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    \16\ The American Legion Resolution No. 114 (Aug. 2016): Department 
of Veterans Affairs Provider Agreements with Non-VA Providers
---------------------------------------------------------------------------
    All three bills includes provisions for repealing obsolete non-VA 
community care authorities.
    The American Legion along with other Veteran Service Organizations 
have been working diligently with VHA to help with language to 
streamline their Non-VA purchase care program in order to come up with 
a replacement for the Choice program. While each bill is somewhat 
different, when you consider all three bills together, The American 
Legion believes they have what is needed to address the many challenges 
VA face in building a robust community care program.
    The American Legion would like to direct this Committee's attention 
to the Draft Veteran Coordinating Access & Rewarding Experiences (CARE) 
plan, and urges this Committee to develop future legislative proposals 
with this proposal in mind.

    The American Legion wants to thank Senator's Isakson, Tester, and 
Crapo for taking the lead in drafting these three bills and calls on 
them to work together and with The American Legion to deliver a single 
bill that includes all the great work each senator has contributed in 
their sponsored bill to make VA's Community Care program successful.
           s. 1325: better workforce for veterans act of 2017
A bill to amend Title 38, United States Code, to improve the 
        authorities of the Secretary of Veterans Affairs to hire, 
        recruit, and train employees of the Department of Veterans 
        Affairs, and for other purposes.
    This draft bill will direct VA to expand its workforce, leading to 
more timely and efficient healthcare for veterans. The American Legion 
supports legislation that will increase employee capabilities at the 
VA. We feel that recent graduates and veterans bring much needed new 
talent into the VA and increased hiring will lead to improved 
employment opportunities for veterans within the VA. The American 
Legion supports policies that boosts the percentage of veterans hired 
in all agencies, specifically the VA, to 50 percent or above.\17\
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    \17\ The American Legion Resolution No. 346 (Aug. 2016): Support an 
Investigation of Hiring Practices in the Federal Government
---------------------------------------------------------------------------
    The American Legion believes that an increase in VA workforce will 
lead to; reduced patient waiting times, improvement in employee vacancy 
rates, decreased senior VA medical center leadership turnover, helping 
ensure timely claims processing, help to reduce homelessness, minimize 
improper burials at VA cemeteries and; provide better assurance and 
compliance with national policies, rules and laws enacted to assist 
veterans and their families.
    The American Legion has tracked and reported staffing shortages at 
every VA medical facility across the country since the inception of the 
System Worth Saving (SWS) program in 2003. The Veterans Health 
Administration (VHA) is still struggling to achieve the appropriate 
balance of primary care and medical specialists across the country. If 
VA continues to struggle with retention and recruitment, the trend of 
closures (or continued closures) for multiple departments within VA 
health-care systems nationwide will continue.
    Numerous reports cite VA's staffing issues. For example, in 
January 2015, the VA's Office of Inspector General released its 
determination of the ``Veterans Health Administration's Occupational 
Staffing Shortages,'' as required by Section 301 of the ``Veterans 
Access, Choice and Accountability Act of 2014.'' With this report, the 
Inspector General determined the five occupations with the largest 
staffing shortages were medical officers, nurses, physician assistants, 
physical therapists and psychologists.\18\ \19\
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    \18\ The American Legion Legislative Agenda (March 1, 2017)
    \19\ The American Legion Resolution No. 317 (Aug. 2016): Enforcing 
Veterans' Preference Hiring Practices in Federal Civil Service
---------------------------------------------------------------------------
    In another study conducted by Federal H.R. experts AVUE 
Technologies, this legislation seeks to make it easier for the 
Secretary of the VA to manage his workforce, including hiring, 
retention, and overall talent management. There are many elements of 
the legislation that will be helpful to the Secretary however, there 
are elements that, with improvement, would contribute to making a 
difference in a more substantial way, such as the focus on VA first 
responders which is long overdue--in particular the VA Police Officers.
    The VA Police Officers have been targeted by the VA's Chief Human 
Capital Officer (CHCO) and the CHCO's subordinates for downgrade VA-
wide. The VA has taken the position that VA Police Officers should be 
no higher graded than GS-5 (they are currently GS-6) and that they do 
not perform work of law enforcement officers because the VA believes 
they are primarily engaged in patrols and low level security work 
instead of higher graded police officer or law enforcement work. In an 
independent study by Federal H.R. experts, the experts found this to 
completely mischaracterize the day-to-day work of the VA's police 
force. Instead the study found that for Police Officers, the full-
performance level should be GS-7 in all locations where the following 
units are found:

     Medical Centers that provide in-house, inpatient acute 
medical and surgical services and procedures and acute psychiatric 
services in addition to outpatient services.
     Vet Centers that provide readjustment counseling and 
outreach services to all veterans who served in any combat zone.
     Domiciliary that provide a variety of care to veterans who 
suffer from a wide range of medical, psychiatric, vocational, 
educational, or social problems and illnesses.

    The study found no justification to downgrade or cap the grades of 
these positions on a universal basis. While certain locations like 
CBOCs may not exceed GS-5, that grade would misclassify other Police 
Officer positions in other locations. VA police offers were found to 
perform police patrol work and crime and incident investigation. 
Contrary to the VA's assertions, the study found that the police 
officers were engaged in responding to reports of crimes in progress; 
pursuing and apprehending offenders fleeing a crime scene or attempting 
to resist arrest; apprehending offenders and making judgments regarding 
the arrest, citation, or release of suspects/offenders; advising 
persons of their constitutional rights; advising employees of their 
Weingarten rights; conducting frisks and searches; responding to duress 
calls and interceding in physical assaults or other incidents clearly 
requiring police intervention to minimize the possibility of injury to 
all involved parties; subduing unruly individuals who pose a threat to 
the officer and other individuals; and subduing individuals through 
physical force and/or the use of non-lethal and lethal weapons, as the 
situation dictates.
    Additionally, with regard to crime and incident investigations, the 
following duties, among others, were identified:

     Conducts investigations in order to: (1) determine if a 
crime has been committed; (2) identify the perpetrator; (3) apprehend 
the perpetrator; and (4) provide evidence to support a conviction in 
court. Conducts initial discovery and response after being dispatched 
to a crime scene or location of a victim. Completes the initial 
investigation, including the immediate post-crime activities as the 
responding police officer arriving on the crime scene. Secures and 
processes accident, crime, or disaster scenes. Interviews witnesses and 
questions suspects at the scene. Searches the scene for evidence and 
collects, preserves, and documents the chain of custody of evidence. 
Diagrams crime and accident scenes. Estimates values of stolen or 
recovered goods. Recovers and inventories lost or stolen property. 
Transports property or evidence.
     Conducts follow-up investigations, as required, over 
multiple shifts. Investigates accidents, crimes against persons and 
property, and complaints of drug law violations. Collaborates with 
internal and external sources to obtain necessary information to 
further investigations. Reviews information on criminal activity within 
jurisdictional and surrounding areas. Locates and interviews witnesses 
to a crime and interrogates and/or question suspects. Conducts 
surveillance of individuals and/or locations. Checks on status of 
stolen property, criminal histories, and warrants through computer 
network. Records and/or reviews records and pictures to aid in 
investigations.

    Furthermore, there was no basis to lower Leader or Supervisory or 
Managerial positions based on the downgrades of subordinate positions. 
In fact, in many locations the supervisory structure may warrant a 
higher grade based on these new full-performance levels. For VA police 
officers at the locations listed above it was found that the positions 
not only meet all the requirements to sustain their current GS-6 grade 
but also, for at least some, the GS-7 level in addition to meeting all 
of the requirements for 6c coverage. In accordance with OPM regulation 
Cabinet Level Secretaries may make the determination as to which 
positions are eligible for 6c coverage and this is fully within the 
current authorities of the Secretary. Doing so will improve retention 
in a manner that no other action would and recognition that the work 
performed by the VA's police officers warrant a higher grade will 
similarly improve retention.\20\
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    \20\ The American Legion Resolution No. 20 (Oct. 2016): Oppose 
Efforts to Downgrade Low-Level Wage Positions within the Department of 
Veterans Affairs
---------------------------------------------------------------------------
    The bill informs the VA that OPM should be engaged to review the 
police officer positions. This is problematic for two reasons. One, OPM 
is chartered with writing all of the classification and qualification 
standards for the Federal Government. Even Title 38 positions are 
classified using Title 5 classification standards issued by OPM. The 
classification standard for Police Officers was last updated in 1988.
    Through American Legion Resolutions No. 20, Oppose Efforts to 
Downgrade Low-Level Wage Positions within the VA that The American 
Legion vigorously opposes any downgrading of lowest wage positions GS7 
and below, and WG-4 and below, No. 317, Enforcing Veterans' Preference 
Hiring Practices in Federal Civil Service that The American Legion seek 
and support any legislative or administrative proposal that will 
mandate the use of automated recruitment, hiring and retention system 
that safeguard against hiring malpractice in the application and the 
hiring process, and Resolution No. 346, Support an Investigation of 
Hiring Practices in the Federal Government that The American Legion 
supports remedial legislation, as may be needed, to increase the 
percentage of veterans hired in all Federal agencies; specifically, the 
Department of Veterans Affairs to 50 percent or above.
    The American Legion supports S. 1325.
discussion draft: the department of veterans affairs quality employment 
                              act of 2017
To improve the authority of the Secretary of Veterans Affairs to hire 
        and retain physicians and other employees of the Department of 
        Veterans Affairs, and for other purposes.
    This draft bill will direct VA to expand its workforce, leading to 
more timely and efficient healthcare for veterans. The American Legion 
supports legislation that will increase employee capabilities at the 
VA. We feel that recent graduates and veterans bring much needed new 
talent into the VA and increased hiring will lead to improved 
employment opportunities for veterans within the VA. The American 
Legion supports policies that boosts the percentage of veterans hired 
in all agencies, specifically the VA, to 50 percent or above.
    The American Legion believes that an increase in VA workforce will 
lead to; reduced patient waiting times, improvement in employee vacancy 
rates, decreased senior VA medical center leadership turnover, helping 
ensure timely claims processing, help to reduce homelessness, minimize 
improper burials at VA cemeteries and; provide better assurance and 
compliance with national policies, rules and laws enacted to assist 
veterans and their families.
    This draft legislation will create more accountability and 
efficiency within the VA's workforce management, including hiring, 
retention, and overall talent management. There are many elements of 
the legislation that will be helpful to the Secretary.\21\
---------------------------------------------------------------------------
    \21\ The American Legion Testimony (March 16, 2016)
---------------------------------------------------------------------------
    The American Legion has tracked and reported staffing shortages at 
every VA medical facility across the country since the inception of the 
SWS program in 2003. As far back as 1998, The American Legion expressed 
concerns regarding VA physicians and medical specialists staffing 
shortages within the Veterans Health Administration (VHA). This was 
accomplished by monitoring the progress in establishing patient 
centered primary care within each Veterans Integrated Service Network 
(VISN), including both rural and urban localities as well as ensuring 
that the model of care features both the quality and efficient 
combination of medical professionals that are tailored to the needs of 
the local veteran's population.
    As in previous testimony, The American Legion urges the VA to 
develop an aggressive strategy to recruit, train, and retain medical 
professionals to meet the inpatient and outpatient health care needs of 
veterans. The American Legion fully supports such programs, such as the 
VA's education-assistance programs for APNs, RNs, LPNs, and NA's. We 
also urged VA to provide equitable and competitive wages for their 
medical professionals.\22\
---------------------------------------------------------------------------
    \22\ The American Legion Resolution No. 305 (Aug. 2016): Support 
the Development of Veterans On-The-Job Training
---------------------------------------------------------------------------
    VA medical centers in rural areas have often faced challenges 
trying to recruiting and retaining qualified medical and clinical 
providers due to their inability to compete with medical centers in 
large metropolitan areas. In The American Legion's 2012 System Worth 
Savings (SWS) Report on Rural Healthcare, The American Legion found 
that: ``Department of Veteran Affairs Medical Centers (VAMCs) in rural 
America, recruitment and retention of primary and specialty care 
providers has been a constant challenge. Some clinicians prefer to 
practice in more urban settings with more research opportunities and 
quality of life that urban settings provide.'' \23\
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    \23\ The American Legion System Worth Saving Report (2012): Rural 
Healthcare
---------------------------------------------------------------------------
    As an example, at the time of our December 2016 visit to the 
Pacific Island Health Care System, the director, and chief of human 
resource position were both vacant. At the time of our January 2017 
visit to the Greater Los Angeles VA Health Care System, the medical 
center director had been in his position for less than a year, and the 
associate director, chief, and assistant chief, human resource 
positions were ALL vacant. During a follow-up call last month, the VA 
Pacific Island Health Care System told us that all their top management 
positions, except for the Director position have now been filled and 
that the chief of human resources position has been filled with a 
permanent manager who is highly experienced in human resources.
    These staffing shortages are contributing to physician and staff 
burnout which was reinforced during our Saint Cloud, Minnesota visit. 
As The American Legion continues to conduct System Worth Saving Site 
visits across the VA health care system, we see the trend of VA 
staffing shortages declining rather than improving.
    Things that are working well include the significant contribution 
of the VA's Academic Residency Program. As one of the VA's statutory 
missions, the VA conducts an education and training program for health 
profession students and residents to enhance the quality of care 
provided to veterans within the VHA healthcare system. For almost sixty 
years, in accordance with VA's 1946 Policy Memorandum No. 2, the VA has 
worked in partnership with this country's medical and associated health 
profession schools to provide high quality health care to America's 
veterans and to train new health professionals to meet the patient 
health care needs within VA and the Nation. This partnership has grown 
into the most comprehensive academic health system partnership in 
American history.
    While the VA's Academic Residency Program has made significant 
contributions in training VA health care professionals, upon 
graduation, many of these health care professionals choose a career 
outside the VA health care system. With these realities, the VA will 
never be in a position to compete with the private sector as it is 
currently set up. To this end, The American Legion feels strongly that 
VA should begin looking into establishing its own VA Health 
Professional University and begin training their medical health care 
professionals to serve as a supplement to VA's current medical 
residency program. Conceivably, medical students accepted into VA's 
Health Professional University would have their tuition paid in full by 
VA and upon graduation, the graduate would be required to accept an 
appointment at a Federal health facility at a starting salary 
comparable to what a new medical graduate would be paid by VA based on 
their experience and specialty. Similar to a military service academy, 
a VA medical school will be highly selective, competitive, and well 
respected. Applicants can be nominated by their congressional 
representative, teaching staff can be sourced organically as well as 
nationally, and real estate is plentiful. This will help ensure the VA 
will have an adequate number of healthcare professionals to meet the 
growing number of veterans and their healthcare needs.
    In 2014, The American Legion published a SWS report titled ``Past, 
Present, and Future of VA Healthcare,'' which noted several challenges 
VA still faced regarding recruiting and retention such as:

     Several VAMCs continue to struggle to fill critical 
leadership positions across multiple departments.
     These gaps have caused communication breakdowns between 
medical center leadership and staff that work within these departments.

    During our 2013 site visit to the Huntington VA Medical Center in 
Huntington, West Virginia, we recommended that, ``VHA conduct a rural 
analysis for hard to recruit areas and look into different options to 
support VAMCs in getting talent they need to better serve veterans.'' 
VHA needs to ensure that veteran health care is consistent across each 
Veterans Integrated Service Network (VISN).
    In 2015, during our SWS site visit to the VA Medical Center in St. 
Cloud, Minnesota, providers expressed concerns about the number of 
physician vacancies, and how the additional workload is impacting 
morale at the medical centers. During the same visit, one veteran 
expressed concern noting ``every time [I] visit the medical center, [I 
am] assigned a new primary care provider because [my] last provider 
either quit or transfer to another VA.''
    There have been numerous reports citing VA's staffing issues, for 
example in January 2015, the VA's Office of Inspector General (VAOIG) 
released their determination of the ``Veterans Health Administration's 
Occupational Staffing Shortages,'' as required by Section 301, of the 
``Veterans Access, Choice and Accountability Act (VACAA) of 2014.'' 
With this report, VAOIG determined that the five occupations with the 
largest staffing shortages were Medical Officers, Nurses, Physician 
Assistants, Physical Therapists, and Psychologists. The OIG recommended 
that the ``Interim Under Secretary for Health continue to develop and 
implement staffing models for critical need occupations.'' Ultimately, 
if the VA continues to struggle with retention and recruitment, the 
trend of closures (or continued closures) for multiple departments 
within VAMCs nationwide will continue.
    As The American Legion continues to conduct System Worth Saving 
Site visits across the VA health care system, we see VA staffing 
shortages getting worse rather than improving. One reason VA may 
sometimes struggle to provide care within the Veterans Health 
Administration (VHA) is directly related to staffing. One in six 
positions nationally for some critical jobs remain vacant, and critical 
needs like psychiatric workers can see vacancy rates of 40-64 
percent.\24\
---------------------------------------------------------------------------
    \24\ USA Today (Aug. 20, 2015): Half of critical positions open at 
some VA hospitals
---------------------------------------------------------------------------
    Even when VA is hiring an additional 9 percent of their workforce 
they are losing a similar amount to attrition. Some of this could be 
improved with better hiring incentives and more competitive wages, 
particularly in key fields of need such as psychiatric care, 
physician's assistants, nurses and physical therapists.\25\
---------------------------------------------------------------------------
    \25\ VAOIG Report No. 15-03063-511: OIG Determination of Veterans 
Health Administration's Occupational Staffing Shortages (Sept. 2015)
---------------------------------------------------------------------------
    As the Office of the Inspector General recommended, VA also bears 
additional responsibility in the form of the development of better 
staffing models and examining the red tape and bureaucratic burdens 
that stretch hiring out into a process that can take nine months or 
longer. Additional examination of where VA can better incentivize 
prospective applicants to decide on a career serving veterans would be 
helpful. We need to ensure VA has proper funding to get the best and 
brightest team members on their medical and psychological staffs 
serving veterans.
    The VA can further help improve their staffing, especially in 
leadership positions, with better succession planning for VA employees 
to rise to leadership levels within the organization. As an 
organization of advocates that has worked hand in hand with VA for 
decades, The American Legion notes the training programs VA had in 
place during the 1990's were better suited to creating the next 
generation of leadership than the current programs in place. The VHA 
training programs of the 1990's were specifically built to prepare 
administrative employees to assume mid-level management programs at the 
department level. This could include personnel, fiscal, medical 
administration, associate director training and other leadership 
training. The programs were replaced, over time, with VA's current 
Leadership Development Programs, but feedback The American Legion has 
garnered from interacting with VHA personnel during visits from our 
System Worth Saving Task Force has indicated these programs are not 
providing the tools the employees need to be the next generation 
leaders of VA and to lead from within.
    The American Legion understands that filling highly skilled 
vacancies at premiere VA hospitals around the country is challenging. 
We also expect VA to do whatever is legally permissible to ensure that 
veterans have access to the level of quality healthcare they have come 
to expect from VA. VA has a variety of creative solutions available to 
them without the need for additional legislative action. One such idea 
could involve the creation of a medical school, another would be to 
aggressively seek out public private partnerships with all local area 
hospitals. VA could expand both footprint and market penetration by 
renting space in existing hospitals where they would also be able to 
leverage existing resources and foster comprehensive partnerships with 
the community. Finally, VA could research the feasibility of 
incentivizing recruitment at level 3 hospitals by orchestrating a 
skills sharing program that might entice physicians to work at level 3 
facilities if they were eligible to engage in a program where they 
could train at a level 1 facility for a year every 5 years while 
requiring level 1 facility physicians to spend some time at level 3 
facilities to share best practices. Currently, medical staff are 
primarily detailed to temporarily fill vacancies. This practice fails 
to incentivize the detailed professional to share best practices and 
teach, merely hold down the position until it can be filled by a 
permanent hire.
    The American Legion through Resolution No. 317, Enforcing Veterans' 
Preference Hiring Practice in Federal Civil Service believes additional 
consideration to revamping this portion of training, and ensuring this 
training is properly funded, could be a key component to reducing VA's 
reliance on the complicated process of hiring from outside VA and 
ultimately reduce the number of unfilled leadership positions.\26\
---------------------------------------------------------------------------
    \26\ The American Legion Resolution No. 317 (Aug. 2016): Enforcing 
Veterans' Preference Hiring Practices in Federal Civil Service
---------------------------------------------------------------------------
    The American Legion supports the Discussion Draft.
                               Conclusion
    As always, The American Legion thanks the Senate Committee on 
Veterans' Affairs for the opportunity to explain the position of the 
over 2 million veteran members of this organization. For additional 
information regarding this testimony, please contact Mr. Derek 
Fronabarger at The American Legion's Legislative Division.

    Chairman Isakson. Thank you very much, Mr. Celli.
    Ms. Webb?

          STATEMENT OF AMY WEBB, NATIONAL LEGISLATIVE 
                     POLICY ADVISOR, AMVETS

    Ms. Webb. Good afternoon, Chairman Isakson, Ranking Member 
Tester, and Members of the Committee. AMVETS is truly pleased 
to be invited to testify today.
    Of the many bills being considered at this hearing, all of 
which are intended to improve lives of veterans, we support all 
but two. Before discussing those, I would like to mention that 
Senator Flake's Veterans Treatment Court Improvement Act speaks 
loudly to one of our key legislative priorities.
    Many veterans have specific needs and challenges related to 
their military service, and AMVETS has been involved with 
veterans treatment courts since their inception. At that time, 
that was with our then Commander J.P. Brown, who worked with 
Judge Robert T. Russell in Buffalo, NY. Commander Brown took 
that knowledge and helped create a very active veterans 
treatment court in his own homestate of Ohio, and AMVETS 
appreciates that S. 946 would add more Veterans Justice 
Outreach specialists, particularly since there are so many 
solid systems in place to help veterans, but none will properly 
function without adequate staffing.
    The two bills that we are unable to support center around 
Choice, and I think that some of the remarks we have prepared 
have already been said today by a couple of the Senators. But, 
allowing veterans the open-ended ability to seek care in the 
private sector is a concern.
    On the one hand, Choice sounds like a great proposition, 
but on the other, we are concerned that implementing a broader 
Choice Program will either intentionally or unintentionally 
dismantle the VA health care system. This, we oppose.
    As you know, Choice is currently in need of more than $4 
billion in emergency appropriations or in a shift of funds 
between VA accounts in order for the program to continue 
providing the often life-saving health care to our Nation's 
veterans.
    We have recently heard that due to funding shortfalls 
within the Choice Program, that veterans are again being 
stacked in a line each day rather than receiving care in the 
community. The fact that veterans are again being forced to 
wait for health care, even within the program designed 
specifically to alleviate that, is quite a red flag. Something 
is broken here, and Choice is not fixing it.
    Late last month, this Committee received a joint VSO letter 
that included AMVETS, which outlined our collaborative deep 
concerns. While AMVETS supports the funding needed to continue 
Choice through fiscal year 2018, we do not support expanding 
the program. It is imperative that funds are used to invest 
back into the VA system of care in order to remedy capacity 
issues and fill the over 40,000 job vacancies, so the system is 
able to consistently care for enrolled veterans in a timely 
fashion.
    The joint VSO letter also noted that there are at least 27 
VA health care facility leases and dozens of construction 
projects requiring billions of dollars in funding in order to 
sustain and expand VA's capacity for care. Why not invest in a 
system of care that has already been designed to meet the needs 
of veterans? Pushing veterans further and further into the 
private sector is not going to solve anything, whether in cost 
savings or in health outcomes. We have only been able to 
ascertain that the national health care spending is growing at 
quite a fast clip, and the system is rife with quality and 
access-to-care issues.
    We mentioned in our written testimony that currently over 
30 percent of veterans receive their health care through fee 
basis and community care, and the proposed measures to expand 
Choice will potentially break the VA health care system, which 
polls do show is superior to care received in the private 
sector once the veteran can get in.
    While AMVETS absolutely supports the public-private 
partnership where it makes sense, often in the rural and highly 
rural areas, in order to serve the health care needs of 
veterans, what we hear is that veterans want VA health care to 
work for them. Pushing the funding to the private sector 
instead of within this large system of specialized care seems 
more like a bleed-em-dry strategy that concerns us.
    We look forward to working with this Committee to address 
the many issues facing our veterans in today's complex and 
challenging health care environment, and thank you again for 
the opportunity to testify today. I am open to answer any 
questions you may have.
    Thank you.
    [The prepared statement of Ms. Webb follows:]
 Prepared Statement of Amy Webb, National Legislative Policy Advisor, 
                                 AMVETS
















    Chairman Isakson. Thank you, Ms. Webb.
    Mr. Atizado?

   STATEMENT OF ADRIAN ATIZADO, DEPUTY NATIONAL LEGISLATIVE 
              DIRECTOR, DISABLED AMERICAN VETERANS

    Mr. Atizado. Chairman Isakson, Ranking Member Tester, and 
Members of the Committee, I want to thank you for inviting DAV 
to testify on the legislation and draft bills under 
consideration for today's hearing.
    DAV is a non-profit veterans service organization dedicated 
to a single purpose, which is to empower veterans to lead high-
quality lives with respect and dignity.
    Today's hearing is critically important to DAV's 1.3 
million wartime service-disabled veterans. Most of them choose 
and rely heavily or entirely on the VA health care.
    For the sake of brevity, I will limit my comments to a few 
of those bills which DAV supports on the agenda today.
    DAV endorses S. 683, the Keeping our Commitment to Disabled 
Veterans Act of 2017, which would extend until 2018, the 
requirement for VA to provide nursing home care to certain 
service-connected disabled veterans. As Senator Hirono had 
mentioned, over 22,000 severely disabled service-connected 
veterans would benefit from this bill.
    DAV supports S. 833, the Servicemembers and Veterans 
Empowerment and Support Act of 2017, which would expand 
military sexual trauma counseling and treatment and ease some 
of the evidentiary requirements for veterans filing claims for 
service connections, for conditions related to military sexual 
trauma.
    DAV supports S. 946, the Veterans Treatment Court 
Improvement Act, which would require VA to hire additional 
Veterans Justice Outreach Specialists to provide treatment 
court services. As an organization, DAV recognizes the 
importance of veterans treatment courts and are pleased to 
inform you, this Committee, that many of our DAV members across 
the country have and continue to volunteer to serve as mentors 
for justice that involve veterans in these courts.
    DAV supports S. 1261, the Veterans Emergency Room Relief 
Act. This would require VA to include urgent as well as 
emergency care as part of VA's medical benefits package. To 
further strengthen this important measure, we ask the Committee 
to consider inserting language, allowing VA to also enter into 
agreements in addition to contracts with urgent care providers.
    Finally, DAV is pleased to support the draft bill titled 
``Improving Veterans Access to Community Care Act of 2017,'' 
this pursuant to DAV Resolution 238. Mr. Chairman, that 
resolution calls on the Nation to honor the service and 
sacrifices of our Nation's ill and injured veterans by 
strengthening, reforming, and sustaining a modern, high-
quality, accessible, and accountable VA health care system. It 
also asks that in order to provide timely and convenient access 
to enrolled veterans, the VA health care system must evolve. It 
must become and it must create integrated health care networks 
with high-quality community providers where needed. This 
includes DOD and academic affiliates as VA acting as a network 
coordinator and principal provider. This is to ensure 
integrated, high-quality, comprehensive, and veteran-focused 
health care for our Nation's veterans.
    Our members recognize that despite improvements in the VA 
health care system over the years, some veterans are 
experiencing uneven and delayed access to quality veteran-
centered care. Even before the Choice Program was implemented, 
VA's legacy purchased care programs were both cumbersome and 
operated as local endeavors. The problems with these include no 
central support structure to track not only how long it took 
for veterans to get care in the community, but whether the care 
they received in the community is equivalent to the care that 
they receive in VA, that it is a positive impact on veterans' 
health outcomes and whether the veterans are satisfied with 
that care.
    The Improving Veterans Access to Community Care Act of 2017 
contains many provisions and aligns with the overall approach 
proposed by DAV, the Independent Budget, other VSOs, as well as 
the Commission on Care, and the VA. While there are some 
improvements we would recommend and work with the Committee on, 
this bill seeks to preserve those critical components of the VA 
health care system beyond just delivering care. VA has other 
missions such as research, education, and training. Members 
here just talked about the problems with health care staffing 
in the Nation, of which VA plays a critical role in supplying 
that to the Nation's patient population. This bill allows VA to 
modernize, which must happen if it is to be a true partner in 
an integrated, high-performing health care network.
    Mr. Chairman, there is so much more to discuss. We look 
forward to working with you and your staff to address this 
issue as well as improve other VA health care services for our 
Nation's veterans.
    This concludes my statement. I would be happy to answer any 
questions you or other Members of the Committee may have.
    Thank you.
    [The prepared statement of Mr. Atizado follows:]
   Prepared Statement of Adrian Atizado, Deputy National Legislative 
                  Director, Disabled American Veterans
    Chairman Isakson, Ranking Member Tester, distinguished Members of 
the Committee: Thank you for inviting DAV (Disabled American Veterans) 
to present our views on the bills under consideration at today's 
hearing. As you know, DAV is a non-profit veterans service organization 
comprised of nearly 1.3 million wartime service-disabled veterans. DAV 
is dedicated to a single purpose: empowering veterans to lead high-
quality lives with respect and dignity.
              s. 115, the veterans transplant coverage act
    Depending where a veteran resides in relation to a Department of 
Veterans Affairs (VA) Transplant Center, the Department may only cover 
transplant procedures for veterans from deceased donors limiting the 
possibility of finding an organ match from relatives. Additionally, VA 
national policy indicates VA will only cover the transplant-related 
round-trip travel and lodging costs for the living donor and a support 
person. Unless the veteran is the live donor, post-transplant care is 
not provided by VA.\1\
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    \1\ VHA Directive 2012-018, Solid Organ and Bone Marrow 
Transplantation; VHA Handbook 1102.1, National Surgery Office;
---------------------------------------------------------------------------
    This bill authorizes VA to provide veterans coverage for live donor 
transplant operation procedures at any health care facility if the 
veteran qualifies for the VA Choice Program. The VA would be required 
to fully fund all care and services before and after the transplant 
procedure.
    DAV has no resolution from our membership to support this draft 
bill; however, its purpose appears beneficial for veterans in need of 
this specialized care; therefore, we have no objection to its favorable 
consideration by this Committee.
s. 426, the grow our own directive: physician assistant employment and 
                         education act of 2017
    If enacted, this bill would direct VA to carry out a pilot program 
to provide educational assistance to certain veterans with the goal of 
employment as VA physician assistants.
    Under this bill, the pilot program would target veterans with 
experience gained in medical or military health care while serving, and 
who had received a certificate, associate degree, baccalaureate degree, 
master's degree, or post-baccalaureate training in a science related to 
health care, and had participated in the delivery of health care 
services or related medical services.
    The bill would require VA to provide educational assistance, 
including no fewer than 25 scholarships, to participants employed each 
year of the pilot program. VA would be required to reimburse their 
costs of obtaining master's degrees in physician assistant studies or 
similar master's degrees, consistent with VA's existing health 
professions scholarship program authorized in Chapter 76 of title 38, 
United States Code. The bill would require VA to make available mentors 
for participants at each VA facility and would require VA to establish 
partnerships with other government programs and with a specific number 
of educational institutions that offer degrees in physician assistant 
studies. It would also require selectees to agree to an obligated work 
period.
    The bill also would require VA to establish standards to improve 
the education and hiring of VA physician assistants, and implement a 
national plan for the retention and recruitment of VA physician 
assistants.
    The bill would establish a series of new, mandatory positions in 
VA's national Office of Physician Assistant Services in VA Central 
Office, including a Deputy Director for Education and Career 
Development, a Deputy Director for Recruitment and Retention, a 
designated recruiter of physician assistants, and an administrative 
assistant to support these functions. The bill would outline their 
major duties.
    The bill would re-designate not less than $8 million in funds 
appropriated prior to the passage of this bill to carry out its 
purposes. The bill is silent on sources of additional funding that 
might be needed to meet its mandates.
    Finally, the bill would align VA physician assistant pay grades 
equivalent to the pay grades of VA registered nurses.
    DAV does not have a resolution from our membership specific to VA 
recruitment, training or employment of physician assistants as a single 
employment category, but we recognize the value of this bill in 
improving health provider manpower in the VA, and especially in 
addressing shortages being observed today in VA's primary care provider 
workforce. On this basis DAV would not object to enactment of this 
bill.
  s. 683, the keeping our commitment to disabled veterans act of 2017
    DAV endorses S. 683 and calls for swift enactment of this 
legislation based on DAV Resolution 142, which calls for enactment of 
legislation to expand the Department of Veterans Affairs (VA) 
comprehensive program of long-term supports and services (LTSS), 
including nursing home care, for service-connected disabled veterans.
    This bill would extend an expiring requirement under law that the 
VA provide nursing care for certain veterans with service-connected 
disabilities. VA is legislatively mandated by the Veterans Millennium 
Health Care and Benefits Act (Public Law 106-117) to provide continuing 
nursing home care for enrolled veterans who have a 70 percent or 
greater service-connected disability, as well as those who need such 
care for a service-connected disability, or who have a rating of total 
disability based on individual unemployability.
    According to VA, there were around 21,300 veterans nationwide who 
met the legislative mandate for nursing home care in fiscal year (FY) 
2016. VA estimates there will be over 21,800 veterans treated under 
this legislative mandate in 2017 and this number is projected to 
increase to over 22,200 in FY 2018 and over 22,600 in FY 2019. Without 
extension of the current mandate by Congress beyond December 31, 2017, 
VA would no longer be required to provide this critical LTSS coverage 
to service-disabled veterans.
    Unlike other modeled services, reliance on certain LTSS does not 
decline after Medicare eligibility, due to limited Medicare coverage 
for long-stay nursing home services and in-home and community based 
services. Currently, World War II and Korean War era enrollees are in 
the age bands that are the highest users of LTSS. Likewise, Vietnam era 
veterans will be needing and seeking a greater share of LTSS, with most 
having aged beyond 75 over the next ten years.
    S. 833, the Servicemembers and Veterans Empowerment and Support Act 
of 2017
    Section 2 of S. 833, the Servicemembers and Veterans Empowerment 
and Support Act of 2017, would expand eligibility for VA counseling and 
treatment for sexual trauma, to include ``cyber harassment of a sexual 
nature'' to the definition of MST. It also expands the authority of the 
Secretary to provide counseling and care to members of the Armed Forces 
who suffered MST and are currently on ``active duty for training,'' or 
``inactive duty training'' in addition to servicemembers on active 
duty.
    Section 3 of the measure seeks to relax the standard of proof for 
MST-related claims by amending Section 1154 of title 38, United States 
Code (U.S.C.) by adding a new section. Specifically, the bill would 
require that a veteran who claims that a mental health condition began 
in, or was aggravated by MST during active service the VA shall accept 
as sufficient proof for service-connection: 1) a diagnosis of the 
mental health condition by a mental health professional along with 
satisfactory lay evidence or other evidence of such trauma, 2) and an 
opinion by the mental health professional that the mental health 
condition is related to such MST if consistent with the circumstances, 
conditions, or hardships of service even without an official record of 
such incurrence or aggravation in service. Furthermore, the bill would 
require VA to resolve every reasonable doubt in favor of the veteran 
with the reasons for granting or denying service-connection recorded in 
full.
    Under this bill, a covered mental health condition would be defined 
as Post Traumatic Stress Disorder (PTSD), anxiety, depression, or other 
mental health diagnosis described in the current version of the 
Diagnostic and Statistical Manual of Mental Disorders published by the 
American Psychiatric Association, that the Secretary determines to be 
related to MST. MST is defined as a physical assault of a sexual 
nature, battery of a sexual nature, or sexual harassment which occurred 
during active military service.
    S. 833, codifying existing regulations related to the evaluation of 
claims for compensation involving MST and requires the Secretary to 
ensure that non-military sources of evidence that may support the claim 
are specified and used in adjudication of the claim. Examples of such 
evidence include: records from law enforcement authorities; rape crisis 
centers; mental health counseling centers; hospitals and physicians; 
pregnancy tests and tests for sexually transmitted diseases; statements 
from family members, roommates or other members of the Armed Forces or 
veterans and clergy. Evidence of behavioral changes can also be 
considered in support of a claim for service connection to include, a 
request for transfer to another duty assignment; deterioration of work 
performance; substance abuse; episodes of depression; panic attacks or 
anxiety without an identifiable cause; and unexplained economic or 
social behavior changes.
    The bill requires that VA may not deny a claim of a veteran for 
compensation for PTSD that is based on an assault, battery, or 
harassment without first advising the veteran that evidence described 
above may constitute credible corroborating in their claim and allow 
the veteran an opportunity to furnish such evidence or advise the 
Secretary of potential sources of that evidence.
    S. 833 also requires the VA to report to Congress not later than 
March 1, 2018 and once a year afterward to 2027, on claims covered in 
this section submitted during the previous fiscal year. Reports are 
required to identify and track claims decision trends across regional 
offices. Each report shall include: the number of claims submitted; of 
those claims the number and percentage submitted by sex; the number of 
claims denied, to include the number and percentage of those denied 
claims for each sex; the number and percentage of claims that were 
approved, disaggregated by sex, of claims assigned to each rating 
percentage. The bill also requires VA include the three most common 
reasons for denials to include the number of denials that were based on 
failure of a veteran to report for a medical examination.
    Section 4 of the bill directs the VA to ensure that DOD Sexual 
Assault Response Coordinators advise members of the Armed Forces who 
report an incident of MST that counseling services are available at VA 
Vet Centers.
    For decades, VA treated claims for service connection for mental 
health problems resulting from MST in the same way it treated all 
claimed conditions--the burden was on the claimant to prove the 
condition was related to their military service. These types of claims, 
without validation from medical, investigative or police records, were 
routinely denied.
    More than a decade ago, VA relaxed its policy of requiring medical 
or police reports to show that MST occurred. 38 CFR 3.304 (f)(5) 
provides for a liberalization of requirements for establishment of 
service connection due to personal assault, including MST, even when 
documentation of an ``actual stressor'' cannot be found, allowing 
evidence in other records to serve as a ``marker'' indicating that a 
stressor may have occurred instead. Nevertheless, since 2002, VA has 
denied many claims for mental health conditions resulting from MST 
because claimants were unable to produce evidence that an assault or 
harassment occurred. Between 2008 and 2012, VA verified that grant 
rates for PTSD resulting from MST were 17 to 30 percent below grant 
rates for PTSD resulting from other causes.
    Unfortunately, for various reasons including fear of potential 
retaliation, personal shame or embarrassment and impact on career, 
survivors of MST often do not report sexual trauma to medical or law 
enforcement authorities. Lack of reporting results in a 
disproportionate burden placed on veterans to produce evidence of MST. 
Full disclosure of incidents occurring during service tend to be 
reported years after the fact, making proof of service connection for 
PTSD and other mental health conditions even harder to establish. 
Demonstrating a causal relationship between certain injuries and later 
established disability can be daunting due to lack of records or human 
factors that obscure or prevent documentation or even basic 
investigation of such incidents after they occur.
    Sexual trauma during military service is ever more recognized as a 
hazard of service for one percent of men and 20 percent of women who 
have served. It often later manifests in heavy burdens of mental health 
conditions for veterans and the need for complex care and specialized 
treatment required from VHA. An absence of documentation of military 
sexual trauma in the personnel or military unit records of individuals 
often prevents or obstructs adjudication of claims for disabilities of 
this group veterans suffering the devastating after-effects of sexual 
trauma associated with military service.
    Enacting this legislation would expand MST counseling and treatment 
and ease some of the evidentiary requirements for veterans filing 
claims for service-connection for conditions related to the after-
effects of a MST. DAV supports S. 833, the Servicemembers and Veterans 
Empowerment and Support Act of 2017, in accordance with DAV Resolution 
No. 027 to improve the process for determining service connection for 
conditions related to sexual trauma.
          s. 946, the veterans treatment court improvement act
    The bill requires the VA to hire additional Veterans Justice 
Outreach (VJO) specialists to ensure veterans have greater access to 
effective and tailored treatment. VA created the VJO program to provide 
veterans with timely access to VA services and engage justice-involved 
veterans in specialty treatment courts. The veterans' treatment court 
model removes veterans from the regular criminal justice process and 
helps to address symptoms that are unique to veterans, including Post 
Traumatic Stress Disorder and substance abuse disorder. In a veterans' 
treatment court, the presiding judge works alongside the veteran and 
the VJO specialist to establish a structured rehabilitation program 
that is tailored to the specific needs of that veteran.
    The bill would authorize $5.5 million for each fiscal year 
beginning in FY 2017 through 2027 to hire 50 additional VJO 
Specialists. Funding priority would be given to VA facilities that work 
with newly established or exiting but understaffed veterans' treatment 
courts. VA is required to annually report on the implementation of the 
bill and its effect on the VJO program. The Government Accountability 
Office is also required to review and report on the implementation of 
the bill and the overall effectiveness of the VJO program for justice-
involved veterans.
    DAV supports S. 946 based on DAV resolution 124 calling for the 
continued growth of veterans' treatment courts. We recognize the 
importance of this program and are pleased to inform you that DAV 
members across the country have volunteered to serve as mentors in 
veterans' treatment courts.
                    s. 1153, the veterans access act
    DAV supports this legislation that would require the Secretary to 
make ineligible any non-VA health care provider seeking to provide care 
to veterans through any of VA's purchased care authorities if the 
provider had been removed from VA employment or had a VA credential 
revoked because they endangered the health or safety of patients, or if 
they had violated any other medical licensure requirements. The 
legislation would also give the Secretary authority to make ineligible 
any provider under investigation by a medical licensing board, or who 
has entered into a settlement agreement for disciplinary action related 
to their medical practice, if the Secretary deems them a threat to the 
health, safety or welfare of veterans. In addition, the legislation 
requires the Secretary to suspend eligibility of any health care 
provider to provide non-Department health care services to veterans if 
the health care provider has already been suspended from practicing 
within VA.
    DAV Resolution 238 calls for, ``. . . strengthening, reforming and 
sustaining a modern, high-quality, accessible and accountable VA health 
care system; AND . . . creating integrated networks with high-quality 
community providers where needed . . .'' S. 1153 would contribute to 
improving the quality of providers within such integrated networks by 
helping to preclude certain health care providers when VA is aware they 
have a documented record of endangering patient health or safety.
        s. 1261, the veterans emergency room relief act of 2017
    Mr. Chairman, DAV supports S. 1261, the Veterans Emergency Room 
Relief Act of 2017, in accordance with DAV Resolution 240 which calls 
upon Congress to authorize urgent care as part of VA's basic health 
benefits package. VA provides a comprehensive health benefits package, 
yet the availability of urgent care has remained problematic because, 
in many locations, VA health care services are not offered on weekends, 
holidays, evenings and nights. The prudent layperson standard VA has 
used as one of the criteria to establish eligibility for VA 
reimbursemennt for emergency care and the rules for contacting VA to 
ensure veterans are reimbursed for such care are confusing to veterans 
and inconsistently applied by VA staff responsible for completion of 
these claims. These factors frequently result in denial of 
reimbursement for emergency room care and create a significant 
financial hardship for many disabled veterans.
    This bill, authorizing VA to provide reimbursement to veterans who 
receive urgent care services, fills an important coverage gap for 
veterans who rely upon VA for care. It also has the potential to create 
cost savings for VA by allowing veterans to seek care in non-VA urgent 
care centers which are less costly than hospital emergency rooms. The 
National Center of Health Statistics found that almost half of 
emergency room patients (48%) came there because their primary care 
doctors were not available. Urgent care fills the gap between the truly 
emergent care for conditions that may result in the loss of life or 
limb (which require advanced trauma care treatment), and less complex 
acute conditions, such as respiratory and skin infections, sprains, 
back pain or other minor injuries, that require attention and 
treatment, but would normally be addressed by primary care doctors if 
they were available. To further strengthen this important measure, we 
ask the Committee to consider inserting language allowing the VA to 
enter into agreements in addition to contracts with urgent care 
providers.
    This measure requires the Secretary to establish co-payments for 
urgent care services for certain veterans. However, veterans who are 
hospitalized as a result of their urgent care visit and veterans 
seeking care for a service-connected condition in addition to veterans 
meeting criteria for hardship exceptions would be exempt from 
copayments.
    DAV supports this legislation to include urgent and emergency care 
as part of VA's medical benefits package, consistent with DAV 
Resolution No. 240.
                s. 1266, the enhancing veteran care act
    S. 1266, the Enhancing Veteran Care Act, would authorize the 
Secretary of Veterans Affairs to enter into contracts with qualified 
nonprofit organizations to investigate VA medical centers for the 
purposes of assessing and reporting any deficiencies identified.
    This measure requires the Secretary to delegate the authority to 
contract for an investigation to the director of the Veterans 
Integrated Service Network (VISN) in which the medical center is 
located or the director of the medical center. Before entering into a 
contract the VISN or medical center director would be required to 
notify the VA Secretary, the VA Inspector General and the Comptroller 
General of the United States to ensure there is coordination of any 
ongoing investigations.
    DAV has no resolution from our membership regarding the specific 
topic of this legislative proposal and takes no formal position on the 
bill.
     s. 1279, the veterans health administration reform act of 2017
    The Veterans Health Administration Reform Act of 2017 would rewrite 
VA's existing purchased care authority by establishing a new ``Care in 
the Community'' program with streamlined eligibility when VA determines 
it is in the veteran's clinical best interest, including consideration 
of timeliness, or when the veteran faces undue access burdens, such as 
excessive driving distance, or when VA determines it is not economical 
to directly provide the care. The bill requires VA to reach agreements 
with the Department of Defense, Indian Health Services and other 
federally qualified health centers for the provision of care to 
eligible veterans. It also authorizes provider agreements for VA to 
engage community health care providers. Administration of the program 
and coordination of veterans health care would remain within VA.
    S. 1279 also seeks to improve timely access to care by authorizing 
reimbursement for emergency and urgent care services, improving 
coordination of care for veterans eligible to use Medicare and 
Medicaid, and making other changes to educate veterans and VA about 
access options for enrolled veterans.
    Although DAV does not have resolutions regarding some of the 
innovative ideas in the legislation, we support the overall intent of 
the legislation to strengthen and expand options for veterans to 
receive care from community providers when VA is unable to directly 
provide timely, high quality care, as called for in DAV Resolution 238.
         s. 1325, the better workforce for veterans act of 2017
    S. 1325, the Better Workforce for Veterans Act of 2017, a 
comprehensive measure to streamline and strengthen hiring practices at 
the Department of Veterans Affairs (VA) includes provisions to address 
chronic workforce shortages by improving recruitment efforts, hiring 
practices, and training and retention of quality employees.
    The bill would allow direct hiring of students and recent graduates 
into competitive and excepted services and would provide authority for 
VA to hire former Federal employees for certain high demand positions. 
It would authorize VA to hire senior executives using resume-based 
hiring techniques and require VA to determine the effectiveness of 
recruiting and hiring activities as well as the creation of a 
standardized exit survey for VA employees. We do note that in creating 
new flexibilities, caution must be taken to ensure that VA still 
adheres to existing merit review principles including veteran, 
minority, and disability status of job candidates and new hires.
    S. 1325 would require that reductions in force consider performance 
and the establishment of a process for public-private talent exchange. 
The bill also requires a report on workforce vacancies within the 
Veterans Health Administration (VHA); evaluation of pay for medical 
center directors and VISN directors; and the establishment of a human 
resources academy within VHA. We note that experts and panels, such as 
the congressionally established Commission on Care, recommended VA 
further review and amend its own policies to streamline and reduce 
redundancies and inefficiencies in its recruitment and hiring 
processes. We are pleased to see the emphasis on the development of the 
VA's human capital management talent in this bill and we encourage the 
Committee to hold VA accountable for reform from within the agency.
    DAV Resolution No. 244, in part, calls for modernization of VA's 
human resources management system to enable VA to compete for, recruit 
and retain qualified employees needed to provide comprehensive quality 
health care services to our Nation's sick and disabled veterans. While 
we do not have a resolution from our membership related to all of the 
specific provisions in this bill, we support the overarching goal of 
S. 1325, aimed at helping VA to fill important health professional 
staff vacancies, including key leadership positions within VHA, which 
is integral and essential for providing veterans timely access to 
quality care.
 draft bill, department of veterans affairs quality employment act of 
                                  2017
    This draft bill, the Department of Veterans Affairs Quality 
Employment Act of 2017, contains provisions that are aimed at improving 
the Department of Veterans Affairs' (VA) authority to hire and retain 
physicians and other employees. The bill would establish an executive 
management fellowship program, require a process for assessing the 
performance of political appointees, allow VA to directly hire 
physicians who have satisfactorily completed residency training in the 
Veterans Health Administration (VHA); establish mechanisms to improve 
human resources activities including, recruitment, hiring and retention 
of quality employees and require that the Government Accountability 
Office review succession and workforce planning within the Department.
    As we noted with regard to S. 1325 above, DAV supports the goal of 
this bill in accord with DAV Resolution No. 244, which, in part, calls 
for modernization of VA's human resources management system to enable 
VA to compete for, recruit and retain qualified employees needed to 
provide comprehensive quality health care services to our Nation's sick 
and disabled veterans. While we do not have a resolution from our 
membership related to all of the specific provisions in this bill, we 
support the overarching goal of this draft bill.
           discussion draft, the veterans choice act of 2017
    DAV Resolution 238 calls on the Nation to:

        ``. . . honor the service and sacrifices of our Nation's ill 
        and injured veterans by strengthening, reforming and sustaining 
        a modern, high-quality, accessible and accountable VA health 
        care system; AND . . . in order to provide timely and 
        convenient access to enrolled veterans, the VA health care 
        system must evolve by creating integrated networks with high-
        quality community providers where needed, including the 
        Department of Defense and academic affiliates, with VA acting 
        as the network coordinator and principal provider to ensure 
        integrated, high-quality, comprehensive and veteran-focused 
        health care.''

    As currently drafted, the Veterans Choice Act of 2017 is not in 
alignment with the goals contained in DAV Resolution 238. Although 
there are some provisions within the measure that DAV could support, 
DAV opposes the draft bill because the overall effect would lead to 
fragmented and uncoordinated care for millions of enrolled veterans, 
leading to worse health outcomes. Further, the enormous cost of 
unfettered choice proposed by the bill, as well as the resultant impact 
on VA's ability to maintain the critical mass necessary to provide a 
full continuum of care to enrolled veterans, particularly disabled 
veterans, would endanger the long term viability of the VA health care 
system.
    The draft bill would require VA to pay for private sector care for 
every enrolled veteran seeking any health care service from any 
qualified health care provider without any authorization or even 
consultation required from any clinical entity responsible for 
coordinating their care. The congressionally-mandated Commission on 
Care (Commission) considered and debated similar unfettered choice 
proposals during the last Congress, but ultimately rejected them 
because they concluded such proposals were both clinically unsound for 
veterans and financially unfeasible for VA or the Federal Government.
    Our main objection to the draft bill is that it would create a 
separate and operationally-distinct community care network in which VA 
is simply a payer of care, a concept we strongly disagree with because 
it would lead to uncoordinated and fragmented care for millions of 
veterans. The final report by the Commission on Care concluded that, 
``veterans who receive health care exclusively through VHA generally 
receive well-coordinated care, yet care is often highly fragmented 
among those combining VHA care with care secured through private health 
plans, Medicare, and TRICARE. This fragmentation often results in lower 
quality, threatens patient safety, and shifts cost among payers.'' \2\ 
Furthermore, VA's primary care (medical home) model with integrated 
mental health care has proven more likely to prevent and treat 
conditions unique to or more prevalent among veterans, particularly 
those with disabilities or chronic conditions. For these reasons, DAV, 
our partners in the Independent Budget, other VSOs, the Commission on 
Care and Secretary Shulkin all favor the approach of building 
integrated networks with a modernized VA health care system acting as 
the coordinator and primary provider of care, along with other Federal 
and community providers offering high quality health care options for 
veterans, whenever and wherever necessary.
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    \2\ Commission on Care. (2016). Commission on Care: Final Report. 
Page 28. Accessed July 5, 2017 from https://s3.amazonaws.com/sitesusa/
wp-content/uploads/sites/912/2016/07/Commission-on-Care_Final-
Report_063016_FOR-WEB.pdf
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    Although no cost estimates for the draft bill were made available 
to us, economists working for the Commission did analyze a number of 
similar proposals that offered varying levels of choice, including 
unfettered choice, and their projections provide benchmarks. The 
Commission recommended an option in which enrolled veterans could 
choose their primary care providers from within an integrated network, 
but limited their choices for specialty care. The Commission noted that 
in establishing integrated networks, VA ``. . . must make critical 
tradeoffs regarding their size and scope. For example, establishing 
broad networks would expand veterans' choice, yet would also consume 
far more financial resources . . .'' By contrast, the draft measure 
does not appear to contemplate any such tradeoffs in terms of network 
size or veteran choice.
    The Commission's economists estimated that the recommended limited 
choice option would increase VA spending by at least $5 billion in the 
first full year, though they cautioned that it could be as high as $35 
billion without strong management control of the network. The 
Commission's economists also analyzed an unfettered choice option to 
allow veterans the ability to choose any VA or non-VA provider--without 
requiring them to be part of any defined network. The economists 
estimated such a plan could cost up to $2 trillion more than current 
projections for VA expenditures over the first ten years. Based on the 
premise that the draft bill would provide unfettered choice for all 
enrolled veterans, create an extremely broad--almost universal--
network, and lacks any effective coordination mechanisms, it seems 
likely the costs to implement such a proposal would be significant, 
somewhere between the estimates for the two Commission options 
discussed above. In today's fiscal environment, it seems unrealistic 
such dramatic spending increases would be appropriated or sustained, 
and even if approved, the cost shift and patient migration to private 
care would ultimately endanger the viability of the VA health care 
system.
    It is imperative that any veterans health care reform measure must 
improve the overall delivery of high-quality care to enrolled veterans, 
both directly by VA and by community partners. To accomplish this goal, 
as Secretary Shulkin has repeatedly testified, it is essential to 
modernize the VA health care system in numerous ways, including, but 
not limited to addressing: challenges in recruiting, hiring and 
retaining the best and brightest; deficiencies in capital 
infrastructure--beginning with VA leases which have not been authorized 
since 2012; critical gaps in VA's medical care benefits package, 
particularly access to urgent care in the community; the need to change 
VA's authority to provide veterans greater access to telemedicine; 
inadequate clinical grievance and appeals processes available to 
veterans when there is a difference of opinion between the patient and 
provider; and budget, appropriations and internal accounting processes 
that impede fully funding and efficiently utilizing resources provided 
to VA health care.
    These are but some areas identified in the sweeping 4,000-page 
Independent Assessment Report issued in 2014 and the subsequent 
Commission on Care report of 2016, both of which recommended taking an 
integrated systems approach to addressing challenges hindering VA's 
consistent delivery of timely, high-quality health care to our Nation's 
veterans. These reports and other independent experts agree that care 
delivered by VA is in many ways comparable or better in clinical 
quality to that generally available in the private sector, however it 
is inconsistent from facility to facility, and can be substantially 
compromised by problems with access, service, and poorly functioning 
operational systems and processes. If left unaddressed, problems with 
staffing, facilities, capital needs, information systems, procurement 
and health disparities threaten the long-term viability of VA care and 
the health and well-being of millions of veterans who choose VA to meet 
their health care needs.
    The Commission, VA and the VSO community all agree that building an 
integrated, high performing VA health care network should focus on the 
most cost-effective, compatible, and highest quality community 
partners, specifically the Department of Defense (DOD), the Indian 
Health Service (IHS), and other Federal health systems, as well as 
university hospitals that have existing academic affiliations with VA, 
followed by the best of private providers. Utilizing these providers 
first would capitalize on the cultural and military competence 
inculcated in VA health and offered by Federal partners and academic 
medical centers affiliated with VA. It is important to note that VA's 
relationship with U.S. medical schools and teaching hospitals has 
benefited our Nation's ill and injured veterans and serves this 
Nation's medical education system by helping train more than 20,000 
individual medical students and more than 40,000 individual medical 
residents within VA facilities. In fact, the VA health care system 
represents the largest training site for physicians, and funds 
approximately 10 percent of national graduate medical education costs 
annually. Strengthening VA's relationships with academically-affiliated 
medical centers supports this critical pipeline of clinicians that 
serves not just veteran patients but the U.S. patient population in 
general.
    To ensure the overall quality of health care provided to enrolled 
veterans, VA must retain responsibility as the coordinator and 
principal provider of veterans care. Decisions about veterans' access 
to community network providers should be based on clinical 
determinations and veteran preferences. Such shared decisionmaking 
would involve veteran patients as active partners with the clinician in 
treatment decisions, to clarify acceptable medical options and choose 
appropriate treatments. While not all patients want to play an active 
role in choosing a treatment, most want clinicians to inform them and 
take their preferences into account. The draft bill, however, would 
result in a system in which veterans who choose to use community care 
are often left on their own to make critical decisions about health 
care treatment options, without clinical guidance.
    The draft bill also lacks mechanisms to assess the value of care VA 
purchases from non-Department providers, to review the quality of 
community care veterans receive, how it impacts veterans' health 
outcomes, and veterans' satisfaction in the same manner as the care VA 
directly provides veterans. Without such metrics it is difficult, if 
not impossible, to ensure the highest levels of quality and safety for 
veterans. Moreover, because the draft bill lacks strong coordination 
between VA and community providers, the quality of care could be 
adversely affected if important clinical information is not promptly 
and clearly communicated between VA, Federal and community providers.
    Mr. Chairman, although DAV opposes the draft bill in its current 
form, we remain committed to working with you and the Committee to 
develop long-term health care solutions so that ill and injured 
veterans have increased access to timely, high quality, cost-effective 
care in a high performing, integrated VA health care network.
 discussion draft, improving veterans access to community care act of 
                                  2017
    Pursuant to DAV Resolution 238 calling for strengthening, reforming 
and sustaining the VA health care system, DAV is pleased support this 
measure which would improve access to care in the community, while 
preserving and enhancing the unique benefits and vital services VA 
provides to DAV members and all eligible veterans. The draft bill 
includes many of the recommendations put forward by DAV, other VSOs, VA 
and the Commission on Care, and embodies the shared approach of 
building integrated networks with a modernized VA health care system 
acting as the coordinator and primary provider of care, along with 
other Federal and community providers offering high quality health care 
options for veterans, whenever and wherever necessary.
    DAV and our Independent Budget (IB) partners have proposed a 
comprehensive framework to reform VA health care based on the principle 
that it is the responsibility of the Federal Government to ensure that 
disabled veterans have proper access to the full array of benefits, 
services and supports promised to them by a grateful Nation. In order 
to achieve this goal, our comprehensive framework has four pillars--
Restructure, Redesign, Realign, and Reform. We offer our views on 
specific provisions of this draft bill, the Improving Veterans Access 
to Community Care Act of 2017, which we believe fit within this 
framework and recommend it be part of the final legislation this 
Committee passes to reform VA health care.
            I. Restructure our Nation's system for delivering health 
                    care to veterans, relying not just on a Federal VA 
                    and a separate private sector, but instead creating 
                    local Veterans-Centered Integrated Health Care 
                    Networks that optimize the strengths of all health 
                    care resources to seamlessly integrate community 
                    care into the VA system to provide a full continuum 
                    of care for veterans.
Veterans-Centered Integrated Health Care Networks
    To this end, we believe the health care network contemplated in 
this draft measure would most likely yield the local Veterans-Centered 
Integrated Health Care Networks. Like private sector health care plans 
and larger provider systems that offer health coverage, the proposed 
section 1730A(c)(4) of this measure will allow VA to create a tiered 
network that would best meet the expectations of veteran patients at 
the local level.
    This kind of integrated network should provide veterans information 
they would need to make informed decisions. For example, information 
about the quality of the community providers in this network will give 
veterans the ability to discern between those community providers that 
are more knowledgeable about the veteran experience and unique needs, 
information about the satisfaction rating from other veterans who have 
seen that provider, and whether there is a good working relationship 
with the VA that facilitates care coordination.
    This integrated network would create and preserve the kind of 
community-VA provider partnership that mirrors the care our members 
value most in the VA health care system. We also support the provision 
that would prohibit VA from limiting veterans to receiving care or 
services from an entity in a specific tier.
    To that the formation of local Veterans-Centered Integrated Health 
Care Networks leads to an overall high performing network, our 
framework places VA as the coordinator and principal provider of care, 
which is discussed in detail below. The development of VA's current 
primary care (medical home) model with integrated mental health care 
has proven more likely to prevent and treat conditions unique to or 
more prevalent among veterans, particularly those with disabilities or 
chronic conditions.
            II. Redesign the systems and procedures by which veterans 
                    access their health care with the goal of expanding 
                    actual, high-quality, timely options; rather than 
                    just giving them hollow choices:
Care Coordination
    We strongly urge the Committee to preserve the organizational model 
required in Section 106 of the Veterans Access, Choice, and 
Accountability Act of 2014 (Public Law 113-146; title 38, United States 
Code, 1701 note) in any future consolidation of VA's purchased care 
authorities. Section 106 effectively created a ``wall'' that separated 
the financial and clinical operations of the current Choice program, 
which better insulated front-line clinicians, such as VA Community 
Health Nurse Coordinators, social workers, or other VA health care 
professionals against the fiscal pressures that have been known to sway 
clinical decisions and delay or deny community care to veterans.
    DAV also strongly urges the Committee to discontinue the current 
arrangement under the Choice program that has effectively removed a 
critical part of the care coordination responsibility away from VA 
front-line clinicians. VA Community Health Nurse Coordinators are the 
veteran's case manager and coordinators of care who work with the 
veteran's health care team to provide for the veteran patient's 
medical, nursing, emotional, social and rehabilitative needs as close 
to and/or in the veteran's home.
    While VA Community Health Nurse Coordinators are now better able to 
exercise their clinical authority due to the Section 106 
reorganization, they are frustrated having lost their ability under the 
current Choice program to act as a liaison between community providers 
and VA and as an advocate for their veteran patients--who themselves 
have unsuccessfully tried to exercise their Choice option and asked for 
assistance from their VA nurse coordinator--to get the care they need 
in the community.
    We strongly support the proposed section 1730A(a)(2) in this bill 
that requires VA coordinate veterans care especially if that care is 
provided in the community and paid for by the Department.
Community Care Eligibility
    For veteran patients, waiting for a health service begins when the 
veteran and the appropriate clinician agree to a service, and when the 
veteran is ready and available to receive it. We believe it is time to 
move toward a health care delivery system that keeps clinical decisions 
about when and where to receive care between a veteran and his or her 
doctor--without bureaucrats, regulations or legislation getting in the 
way. We urge the Committee to consider that as the new local Veterans-
Centered Integrated Health Care Networks are fully phased in, decisions 
about providing veterans access to community network providers should 
be based on clinical determinations and veteran preferences, rather 
than arbitrary time or distance standards that exist in the current 
Choice program.
    While this measure proposes a standardize eligibility criteria for 
veterans to receive clinically necessary care in the community, we 
stand ready to work with the Committee to ensure veterans, and 
especially service-connected veterans are not any more encumbered in 
receiving care in a reformed VA health care system. For example, if 
clinical access to a primary care provider is to be used, we recommend 
language employing a full-time primary care ``provider'' rather than 
``physician.'' \3\ This would ensure uniformity with the private sector 
practice of using non-physician providers in primary care settings. We 
also support the provision making eligible to receive care in the 
community those veterans enrolled in Project ARCH so they do not 
experience a disruption in the care they have been receiving when the 
authority for the program is consolidated.
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    \3\ Proposed section 1730A(b)(1)(B)(ii)
---------------------------------------------------------------------------
    DAV is supportive of VA's approach in determining when veterans 
should be given the option to receive care in the community through 
shared decisionmaking leveraging the relationship between a veteran and 
their doctor, and using business intelligence about clinical 
performance and quality of care. This new focus will strike a better 
balance in using community care to fill gaps in service than unfettered 
choice. This approach is more likely to be sustainable, a hallmark of 
good governance, as well as garner higher patient satisfaction.
Veterans Care Agreements
    Section 201 of this draft measure would authorize the establishment 
of ``Veterans Care Agreements,'' and would prescribe the types of 
providers eligible for participation. We support the establishment of 
such agreements, but we are concerned that VA would be required to 
first exhaust other acquisition strategies before being allowed to 
pursue such agreements. In addition, different terms are used for 
paragraph (4) in both bills. We appreciate the use of the term 
``provider'' be used rather than ``health care provider'' for 
consistency and ease of implementation of this section by the 
Department. We agree with VA's assessment regarding the need for this 
authority to be enacted into law without further delay and applaud the 
inclusion of this provision.
Emergency and Urgent Care
    DAV recommends this measure includes provisions to make urgent care 
part of VA's medical benefits package and to better integrate emergency 
and urgent care with the overall health care delivery system. DAV 
believes a health care benefit package is incomplete without provision 
for both urgent and emergency care. We note S. 1261, the Veterans 
Emergency Room Relief Act of 2017, is on today's agenda and refer to 
our comments on that bill as it pertains to these critical health care 
services.
Emergency Care Defined
    Carrying out the multiple and complex authorities\4\ for VA to pay 
or reimburse emergency care under title 38 are a source of continuous 
complaints and can drive ill and injured veterans and their families to 
financial ruin.
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    \4\ 38 U.S.C. Sec. Sec. 1703, 1725 and 1728
---------------------------------------------------------------------------
    According to VA, ``in FY 2014, approximately 30 percent of the 2.9 
million emergency treatment claims filed with VA were denied, amounting 
to $2.6 billion in billed charges that reverted to Veterans and their 
[Other Health Insurance]. Many of these denials are the result of 
inconsistent application of the ``prudent layperson'' standard from 
claim to claim and confusion among Veterans about when they are 
eligible to receive emergency treatment through community care.''
    One of the by-products of Emergency Medical Treatment and Labor Act 
(EMTALA) was the prudent layperson standard in response to a critical 
payer issue of the day--payment denials for the lack of prior 
authorization. To address the inconsistent application of the prudent 
layperson standard, DAV recommended the ``emergency condition'' be 
defined using EMTALA, with a minor amendment to include behavioral 
conditions, so that the definition of an emergency condition for VA 
purposes would be:

        ``A medical [or behavioral] condition manifesting itself by 
        acute symptoms of sufficient severity (including severe pain) 
        such that the absence of immediate medical attention could 
        reasonably be expected to result in placing the individual's 
        health [or the health of an unborn child] in serious jeopardy, 
        serious impairment to bodily functions, or serious dysfunction 
        of bodily organs. With respect to a pregnant woman who is 
        having contractions that there is inadequate time to effect a 
        safe transfer to another hospital before delivery, or that 
        transfer may pose a threat to the health or safety of the woman 
        or the unborn child.''
Claims Processing and VA as Primary Payer
    In addition, VA's processing of claims has been a significant 
weakness to the Department's community care programs resulting in 
costlier care, inappropriate billing of veterans and strained 
partnerships with community providers. Government Accountability Office 
reports throughout the years have consistently highlighted disturbing 
limitations in the Department's claims processing system as having 
unnecessary manual operations rather than automatically applying 
relevant information and criteria to determine whether claims are 
eligible for payment and notifying veterans and community providers 
about the results of the determination, payment, and appeal procedures.
    Many veterans worry about claims that are not paid promptly or are 
left unpaid, and they are left in a difficult position of trying to get 
claims paid or be put into collections. These delays or denials create 
an environment where community providers are hesitant to partner with 
VA for fear they will not be paid for services provided. Hospitals and 
community providers have also expressed concern that prompt payment 
laws do not apply to care that is provided to veterans if they do not 
have a contract with VA.
    Having heard complaints from veterans regarding section 101(e) of 
the current Choice program, which places on them greater financial 
burden and emotional stress while trying to recover from injuries and 
illnesses. Congress passed Public Law 115-26 reverting back the 
responsibility of the government as first-payer and prompt payer for 
care and services. We appreciate this measure reaffirming this policy.
    Thus, DAV supports the required claims processing in Section 102 of 
this draft measure, which would apply the prompt payment act to all 
services under the new Veterans Community Care Program and would allow 
VA to continue accepting paper claims. Ostensibly, the quicker 
processing of electronic claims could act as an incentive for community 
providers to submit claims electronically. This section would mandate 
the establishment of an electronic interface to enable private 
providers to submit electronic claims as required by the section. We 
appreciate the provision in this draft measure requiring an eligible 
provider to submit claims to VA within 180 days of furnishing care or 
services. These factors are critical elements in high performing 
Veterans-Centered Integrated Health Care Networks particularly with 
community providers who do not have the resources to dedicate solely to 
electronic claims processing.
First and Third-Party Collections
    We urge this Committee to include language statutorily requiring VA 
to offset a veteran's copayment debt with monies VA receives from 
billing the veteran's health insurance plan. Under current law, 
service-connected veterans are required to pay their share of costs 
created as a result of medical treatment rendered as inpatient, 
outpatient, extended care, or medication for a nonservice-connected 
disability or condition. VA is also authorized by law to recover the 
reasonable cost of medical care furnished to a veteran for the 
treatment of a nonservice-connected disability or condition when the 
veteran or VA is eligible to receive payment for such treatment from a 
third-party.
    While the law allows VA to recover reasonable costs, the Department 
has had a long-standing practice of applying all third-party payments 
first to the corresponding co-payment to extinguish the veteran's share 
of costs before the government's. The veteran is billed for the portion 
of the co-payment not covered by the insurance reimbursement and the 
portion of the co-payment.
    Recently however, VHA issued a memo (VHA Notice 2017-40) rescinding 
this long-standing practice. It is unconscionable that VA is placing 
its interest before that of service-connected veterans by requiring 
them to pay copayments in addition to collecting reimbursements from 
their health plan without offsetting the veteran's copayment debt.
            III. Realign the provision and allocation of VA's resources 
                    so that they fully meet our national and sacred 
                    obligation to make whole those who have served.
    Section 203 is in line with our recommendation to maintain the 
financial and clinical reorganization under Section 106 of the Veterans 
Access, Choice, and Accountability Act of 2014 (Public Law 113-146; 
title 38, United States Code, 1701 note). We believe it is beneficial 
to require, rather than make discretionary, the transfer of funds and 
payment of services to the Chief Business Office of the VHA. This would 
help ensure transparency and accountability to a single entity when 
conducting oversight. Moreover, we believe Section 204 is beneficial in 
addressing known issues with VA purchasing care in the community and 
allowing the Department to better manage its resources.
    In conclusion Mr. Chairman, DAV supports this draft measure, the 
Improving Veterans Access to Community Care Act of 2017, which contains 
many provisions and aligns with the overall approach proposed by DAV, 
the IB, other VSOs, the Commission on Care and VA. Further, it embodies 
the goals of DAV Resolution 238, which calls for strengthening, 
reforming and sustaining a modern, high-quality, accessible and 
accountable VA health care system, while expanding access to care by 
creating integrated networks, with VA acting as the coordinator and 
principal provider of care, and community partners providing access 
whenever and wherever necessary.

    This concludes my testimony, Mr. Chairman. I would be pleased to 
respond to any questions from you or the Committee Members concerning 
our views on these bills.

    Chairman Isakson. Thank you very much.
    Mr. Stultz?

  STATEMENT OF GABRIEL STULTZ, LEGISLATIVE COUNSEL, PARALYZED 
                      VETERANS OF AMERICA

    Mr. Stultz. Chairman Isakson, Ranking Member Tester, and 
Members of the Committee, on behalf of Paralyzed Veterans of 
America, thanks for the opportunity to offer our views on 
legislation affecting the delivery of veteran health care.
    I recognize that there are numerous bills on the agenda 
today, but I am going to focus my comments on the Choice 
Program.
    Should veterans have unfettered choice in when and where 
they receive health care? Three bills being considered dealing 
with the Choice Program diverge primarily on this question.
    About a week ago, I heard Senator Cruz comment during a 
town hall with Concerned Veterans for America that nobody 
understands your health care needs better and cares more about 
you and your family than you do. You are in the best position 
to make the decision about where to get the best health care.
    Any veteran sitting in a hospital waiting room would 
naturally feel this way. It feels right, it makes sense, and it 
is hard to argue with. But, what he is really trying to say is 
that veterans know better and care more than the rigid 
bureaucracy, the red tape, incomprehensible rules that fail to 
take into account a particular veteran's circumstances when 
determining how that veteran can access care.
    He cannot seriously be suggesting that doctors, clinicians, 
social workers, and other aspects of a care team do not play a 
critical role in educating veterans and ensuring that they 
fully understand the specific health care services that they 
actually need. For some reason, this part is always left out of 
the talking points.
    We and our VSO partners have constantly stressed the 
importance of coordinated care, regardless of who provides it, 
because it has proven to lead to better health care outcomes 
for patients. That is why we have long called for moving away 
from arbitrary wait time and distance standards toward a 
clinically based determination that takes a full look at each 
individual veteran's unique circumstances.
    We support the Secretary's attempt to move the VA in this 
direction. As he said in a recent budget hearing, his hope is 
to provide care when veterans need it and where they need it, 
which includes the community. Developing an integrated, high-
performing network is the fiscally responsible way to achieve 
this. It will get us to a place where veterans have meaningful 
choices while maintaining an apparatus that facilitates access 
and prevents fragmented care that can result in disastrous 
consequences.
    For some of our members, Choice works well. One of our 
veterans who normally uses VA for comprehensive care in his 
annual evals used Choice to treat a recent bout of pneumonia 
close to home, a condition that can easily be fatal for someone 
with a spinal cord injury. His care was excellent, but not 
everyone can easily navigate the system.
    We recently represented a paralyzed Army veteran who also 
suffered from an opioid addiction and Traumatic Brain Injury. 
After VA cut back his access to opioids, he made a conscious 
but ill-fated decision to seek care elsewhere through the 
Choice Program. After years of patchwork-style care in the 
private sector, he reached back out to VA. Days before his 
appointment, he was found dead outside of his apartment, 
bleeding from his feet. With his specific comorbidities, ones 
commonly associated with combat veterans, VA was uniquely 
suited to treat him in a holistic manner. In hindsight, Choice 
was not the answer for him.
    While that situation illustrates an uninformed choice, we 
cannot forget that in some areas, there simply is not a choice 
for catastrophically-disabled veterans. When comparable care 
does not exist in the community, our members are simply stuck 
waiting. This is why it is essential that as we expand 
available options, we give VA the tools it needs to strengthen 
its specialized services and compete with the private sector.
    We are seeing early signs of VA taking steps to invest in 
its foundational services, such as spinal cord injury and 
blinded rehab, while expanding care in the community. The 
Secretary authorized the hiring of 800 to 1,000 more nurses in 
these areas, and he is going to do it by eliminating 
redundancies at VA Central Office to free up resources. These 
are the kinds of actions that show VA is serious about getting 
its own house in order and building a system that cares for all 
veterans, including those who may not be best served through 
care in the community.
    So, as we debate expanding choices for veterans and 
reforming the way VA delivers health care, what do we owe our 
veterans? I think we owe them the support to make an educated 
choice. We owe them a coordinated choice that ensures 
appropriate follow-up care is delivered, a choice that ensures 
each doctor you see has the full picture of your medical 
history, not just a snapshot, and we owe them a choice that 
does not bankrupt us with a price tag that clears over a 
trillion dollars in the first 10 years.
    I am borrowing words when I say this, but it is an 
important point. Congress owes our veterans a system that is 
optimized for those who need it most, not those who want it 
least. Let us not forget that.
    Mr. Chairman, this concludes my statement. I would be happy 
to answer any questions that you have.
    [The prepared statement of Mr. Stultz follows:]
      Prepared Statement of Gabriel Stultz, Legislative Counsel, 
                     Paralyzed Veterans of America
    Chairman Isakson, Ranking Member Tester and Members of the 
Committee, On behalf of Paralyzed Veterans of America (PVA), I would 
like to thank you for the opportunity to testify today on the 
legislation being considered by the Committee. There is no doubt that 
the bills addressing the Choice program could have a significant impact 
on the delivery of health care services to veterans going forward. 
Additionally, many of the bills on the agenda can improve access to 
critical services needed by veterans.
                      the ``veterans choice act''
        the ``improving veterans access to community care act''
       s. 1279, the ``veterans health administration reform act''
    There are three bills that directly address the next iteration of 
the Choice Program. We appreciate the Committee's significant efforts 
in this matter and the Senators for sponsoring the legislation being 
considered during today's hearing. To better construct a debate on 
their merits, we will address the bills together in one discussion.
    PVA strongly supports the concept of developing an integrated, 
high-performing network that would seamlessly combine the capabilities 
of the Department of Veterans Affairs (VA) health care system with both 
public and private health care providers in the community. This 
approach has gained consensus among stakeholders, including the most 
recent and current VA Secretaries, the Independent Budget (IB), most 
major Veteran Service Organizations (VSO), the Commission on Care, and 
congressional leadership. As stakeholders continue to coalesce around 
this concept, though, the dynamics that govern the boundaries of this 
network need to be thoroughly explored.
    These three bills collectively demonstrate the need for scrutiny--
how the network is developed and governed is limited only to the 
imagination. The devil is in the details; they are critical and will 
have a dramatic impact on VA's future health care landscape. Our 
philosophy is that the development of VA's network of providers should 
be locally driven, contemplating demographics, demand and availability 
of resources within that particular area. It is more, though, than just 
filling access gaps. Quality, both within VA and in the community, is 
inextricable from this analysis. It should be a critical factor in 
determining whether VA should continue to offer a service or if it 
should capitalize on segments of the community that are already 
delivering that service with excellent results. Similarly, just because 
VA is offering poor quality in a particular service line does not 
automatically mean there is a second choice available in the community. 
VA is obligated to raise the quality in its own house in those 
circumstances.
    A well-balanced network that supplements service gaps in VA's 
system sets a natural boundary for the network. It is efficient and 
preserves VA core competencies and specialized services such as spinal 
cord injury and disorder care.
    Establishing appropriate eligibility standards will be an integral 
part of a sustainable network. This is the most significant point on 
which these three proposals diverge. Chairman Isakson's draft proposal, 
the ``Veterans Choice Act,'' provides unfettered choice to all veterans 
enrolled in the VA health care system. However, it remains unclear how 
this proposal would be funded. The cost is staggering, and the impact 
on VA and its ability to serve veterans who most need care is 
predictable. The Commission on Care's economists found that the cost of 
unmitigated choice throughout a loosely-managed network, a concept most 
closely reflected by the ``Veterans Choice Act,'' would yield a price 
tag of well over $1 trillion over a decade. In a case such as this 
proposal, it will not be enough to simply say that VA has enough 
resources to manage this option. That is an absolutely false 
assumption.
    In recent months, proposals such as billing veterans' other health 
insurance for service-connected care, Medicare subvention, and 
elimination of Individual Unemployability payments to service-connected 
disabled veterans over the age of 62 have been floated to potentially 
offset the $3 billion price tag of the Choice Program. If the 
administration had to consider taking from the most vulnerable groups 
of veterans to meet this projected cost, where can we expect to find 
the money for this expansion? What money would be left to sustain VA's 
foundational services, let alone general health care services for the 
veterans who choose VA as their provider?
    Alternatively, Ranking Member Tester's draft proposal, the 
``Improving Veterans Access to Community Care Act,'' and Senator 
Crapo's bill, the ``Veterans Health Administration Reform Act'' 
(S. 1279), structure eligibility standards in line with PVA's vision of 
employing a clinically-based determination. This is also the path the 
Secretary wishes to take. This approach requires us to confront the 
difficult question of how a decision is reached in the absence of 
arbitrary, but clear, delineations for eligibility. As we mentioned, 
variations in how liberally access is granted to community care 
providers can have a drastic impact on cost.
    These two proposals call for case-by-case determinations and 
include a variety of parameters for VA practitioners to consider when 
consulting with the veteran. Providers should be able to sit down with 
a veteran and consider circumstances such as access and availability of 
services and the urgency of that veteran's situation. The veteran 
should also have the opportunity to voice concerns over how a certain 
care plan will adversely or inadvertently impact him or her. Access to 
transportation, geographic distance and travel time can often present 
unreasonable obstacles to care for veterans. For example, a 30-mile 
trip to a VA facility might seem reasonable on paper, but a doctor 
administering a treatment plan that requires the veteran to commute 
three times per week may have good grounds to object to that 
determination.
    Providers should have the ability to help educate veterans and make 
decisions in the context of the patient's specific circumstances. They 
should be able to take action when it is clear that VA offers a needed 
service, but a particular veteran's situation requires a higher level 
of expertise than what that doctor or facility can offer. Arbitrary 
standards should not prevent a doctor from sending a veteran out to the 
community when the need is urgent and VA is not prepared to administer 
the care in a timely fashion.
    Some veterans might have reservations about their provider, i.e. 
VA, having the final say in whether they are eligible to utilize the 
Choice Program, but it is a marked improvement over the current process 
where bean-counting bureaucrats make decisions behind closed doors for 
veterans who appear to be just another number in the queue. A more 
pointed concern is the past institutional bias exhibited by VA 
employees for administering care directly in VA at all costs. VA has 
long had authority to contract for care, but in prior years employees 
demonstrated a reluctance to utilize this tool to the point that it 
eventually prevented timely access to care for many veterans. This 
behavior, though, was largely attributed to mid-level bureaucrats 
making decisions driven by how the funding was administered. The 
current funding arrangement under the Choice Program produced a welcome 
side-effect of removing the incentive to avoid contracting care out to 
the community. Over the last two years, VA's institutional behavior has 
been modified to a degree, and it has become more comfortable with 
contracting for care when the need exists.
    Once the clinical parameters are determined, eligible veterans will 
have meaningful choices among the options developed within the high-
performing network and the ability to schedule appointments that are 
most convenient for them. When you pair this decisionmaking process 
with a well-managed, integrated network and the structural 
flexibilities discussed above, it becomes possible for VA to be a 
competitive and sustainable enterprise.
    We applaud Senator Tester's explicit provision extending medical 
malpractice protections under 38 U.S.C. Sec. 1151. This is an 
especially important signal to veterans that Congress and VA are not 
abandoning oversight and responsibility for the quality of care 
delivered in the community. When veterans receive treatment at a VA 
medical center, they are protected in the event that some additional 
disability or health problem is incurred. Under Sec. 1151, veterans can 
file claims for disability as a result of medical malpractice that 
occurs in a VA facility or as a result of care delivered by a VA 
provider. This protection currently does not attach to a veteran during 
outsourced care. The veteran must pursue standard legal remedies 
instead of VA's non-adversarial process. Adding insult to literal 
injury, veterans who prevail in a private action are limited to 
monetary damages instead of enjoying the other ancillary benefits 
available under Title 38 intended to make them whole again. These 
include treating the resulting injuries as service-connected 
conditions, such as a botched spinal surgery resulting in paralysis. It 
also includes access to adaptive housing and adaptive automobile 
equipment benefits should the veteran require these features. 
Furthermore, the limits on these monetary damages vary from state to 
state leading to disparate results for similarly-situated veterans. To 
keep all veterans on equal footing, we insist that this provision be 
incorporated in any legislation that moves forward. We recognize that 
there will be questions on the mechanics of this protection and to what 
extent this provision would expand VA's liability exposure. We stand 
ready to have that conversation and to assist the Committee in sorting 
through these issues.
    S. 1279 offers a unique idea for expanding choices for veterans by 
allowing VA practitioners to refer Medicare-eligible veterans to 
Medicare providers. It also encourages greater information sharing 
efforts between the two systems. In addition to capitalizing on an 
already-existing network of providers, this adjustment to the law could 
reduce instances of fragmented care for veterans who normally use VA 
for primary care but take advantage of Medicare to receive specialty 
care for a non-service-connected condition close to home. We certainly 
recognize the value in shifting some of the financial burden that would 
otherwise be absorbed by VA on to the Medicare rolls, but we are 
concerned that a turf war between these two financially-stressed 
systems will likely result. An additional concern is also the potential 
for Congress to simply reduce funding for VA in an amount that 
corresponds to any cost savings realized instead of allowing VA to 
reinvest that money in its own medical services.
    These three proposals contain the tools necessary to achieve an 
end-state at VA where veterans have meaningful choices and quick access 
to quality care. As the Committee moves toward a final bill, we will 
continue to support measures that encourage VA to retain ownership and 
responsibility for care provided to veterans, no matter where it is 
received. VA's role in care coordination, no matter how expansive the 
network, must be clear. It is one of the most important features that 
makes VA care not only competitive with the private sector, but in many 
segments better. Simply listing in statute that a third-party 
administrator is responsible for ``managing the network'' is not enough 
to identify where that responsibility lies.
    We will yet again raise the most important questions for our 
members: What are Congress and VA doing to ensure that as the Choice 
Program expands, VA's foundational services remain competitive? What 
steps are being taken to deal with scenarios where access to care in 
specialized services is dismal, but there are no comparable services 
offered in the community to fill the void? Is VA focused on ensuring 
that VA specialized services are staffed appropriately based on demand, 
or is it more focused on providing ever-greater convenience to veterans 
who already have options? We have stated on multiple occasions before 
this Committee that care delivered in the community is an essential 
component of VA's health care system. But it is simply that, a 
component. This Committee needs to demand comprehensive answers to 
these questions, on the record, instead of settling for platitudes and 
vague promises to ``take care of that later.'' A member of the 
Commission on Care warned against designing a health care system that 
is ``optimized for people who do not rely on veteran-specific health 
care.'' \1\ The Commissioner captured our perspective, as 
representatives of the highest per-capita users of VA and its 
specialized services, when he stated, ``[w]e must design our veteran 
health care system for those who need it most, not for those who want 
it least.'' \2\
---------------------------------------------------------------------------
    \1\ Blecker, Michael. ``Explaining decision not to sign the Report 
of the Commission on Care.'' Letter to Commission on Care. 
29 June 2016. Available at https://s3.amazonaws.com/sitesusa/wp-
content/uploads/sites/912/2016/07/Commissioner-Alternative-Viewpoints-
06302016.pdf. (Last accessed July 7, 2017).
    \2\ Id. (Emphasis added).
---------------------------------------------------------------------------
            s. 115, the ``veterans transplant coverage act''
    PVA supports S. 115, the ``Veterans Transplant Coverage Act.'' This 
legislation gives VA the authority to provide organ transplants to 
veterans from a live donor regardless of veteran status of the donor or 
the facility they are in. Under the current Choice program, veterans in 
need of organ transplants are denied due to the program's eligibility 
requirement. If a living donor is not a veteran, the transplant 
coverage is denied if the surgery is not performed at a VA facility. 
However, due to the very access problems that prompted the Choice 
program--long distance travel, inaccessible transportation, etc.--these 
veterans are unable to receive the care they so desperately need. 
Whether or not a veteran receives a necessary organ transplant should 
not depend on who or where the donor is.
 s. 426, the ``grow our own directive: physician assistance employment 
                      and education act of 2017''
    PVA supports S. 426, the ``Grow Our Own Directive: Physician 
Assistance Employment and Education Act of 2017.'' This bill would set 
up a five year pilot program to provide education assistance to 
veterans training as physician assistants (PAs) in VA. The goal is to 
train veterans with medical or military health experience to be readily 
employable physician assistants at VA. Section 2 of the bill explains 
the prioritization of veteran participants who are in the Intermediate 
Care Technician Program and those individuals who plan to work in 
medically underserved states with a high population of veterans. To 
meet these goals the bill provides funding and support staff to the 
Office of Physician Assistance Services. It would also require VA to 
establish a strategic plan to recruit and retain PAs and adopt the 
standards leading to competitive pay for PAs employed by VA. Currently 
the vacancy rate of PAs at VA is 25 percent, the third largest shortage 
throughout the health care system. Recruiting and retaining PAs at VA 
is critical to improving access to high quality care. Further, this 
bill will provide job opportunities for veterans with medical work 
histories that are hard to translate to the civilian sector.
s. 683, the ``keeping our commitment to disabled veterans act of 2017''
    PVA supports S. 683, the ``Keeping Our Commitment to Disabled 
Veterans Act of 2017.'' This legislation would extend the requirement 
to provide nursing home care to certain veterans with service-connected 
disabilities to December 31, 2018. Without an extension, VA 
reimbursement of nursing home care will end December 31, 2017.
 s. 833, the ``servicemembers and veterans empowerment and support act 
                               of 2017''
    PVA strongly supports S. 833, the ``Servicemembers and Veterans 
Empowerment and Support Act of 2017.'' This legislation would expand VA 
coverage of counseling and treatment for military sexual trauma (MST). 
This bill would codify the idea that MST does in fact include the 
experience of ``cyber harassment of a sexual nature.'' Currently, these 
victims are ineligible for VA counseling and benefits. The experience 
of cyber harassment is varied for its victims and distressingly unclear 
in our laws. But the intent of a perpetrator, as in any sex crime, is 
the assertion of power over someone and the degradation of their 
humanity. Most often the harassment takes the form of ``revenge porn,'' 
nude or sexual photos or videos, taken with or without consent, and 
used to harm its subject. The possessor of the material may blackmail, 
control and/or threaten the victim. Often it is used for humiliation by 
sending the material to the victim's family or coworkers, or, like 
`Marines United,' to buildup a culture of male camaraderie by degrading 
and threatening the safety of their female peers.
    The goal of cyber harassment is to cause maximum distress. While 
someone may not be interpersonally exploitable, that effort can be 
exacted through social media, to greater and longer lasting effect. To 
be the victim of cyber harassment of a sexual nature is to be exploited 
by thousands of people, forever unknowable. Such an experience denies 
any hope of accountability or acknowledgement of injustice.
    Recent qualitative analyses of mental health effects on the 
civilian victims of cyber harassment of a sexual nature consistently 
reveal very serious effects; high prevalence of PTSD, anxiety, 
depression, suicidal ideation and increased likelihood of physical 
assault. Only 34 states and the District of Columbia have laws 
criminalizing the practice of cyber harassment. The Uniform Code of 
Military Justice does not directly address this issue. Veterans who are 
victims of this kind of sex crime will often have no recourse. This 
bill is a greatly needed step to ensure VA is able to meet the needs of 
those who served honorably and came home carrying wounds ignored for 
too long.
    s. 946, the ``veterans treatment court improvement act of 2017''
    PVA firmly believes in the rule of law and that anyone convicted of 
a crime should be held accountable. Our criminal justice system, 
though, has long recognized the existence of aggravating and mitigating 
circumstances that play an important role in influencing the 
administration of penalties. While advocacy before a sentencing judge 
following conviction is critical, prosecutorial discretion is also 
vast. Veterans Justice Outreach Specialists can help veterans use their 
honorable service, as well as mitigating circumstances arising from 
that service, to ensure both the prosecutor and judge see more than 
just a rap sheet when making decisions.
    If the specialist demonstrates that the veteran is entitled to 
health care or disability benefits, the judge or prosecutor might be 
able to fashion a sentence or plea offer that incorporates utilization 
of these services in lieu of imposing solely punitive sanctions. It 
could also lead to an outright deferment of prosecution conditioned on 
the veteran exploring and obtaining all services available to him or 
her. This scenario is especially enticing to the judicial system given 
the constant struggle to find resources, particularly for in-patient 
substance abuse rehabilitation programs and mental health care.
    For some veterans, this path might help them avoid being 
permanently stigmatized with a criminal conviction. For others, it 
might be the ticket that lifts them out of homelessness and the 
corresponding criminal recidivism, specifically with petty and/or 
vagrancy crimes. It is no secret that some veterans go years before 
realizing they were entitled to certain benefits that might have helped 
them avoid poverty and dejection. A court order pointing the veteran to 
the Department of Veterans Affairs can sometimes turn into a life-
changing event. At the least, more veterans touched by this program 
will re-engage productively with society. That is a goal worth 
pursuing.
 s. 1153, the ``veterans acquiring community care expect safe services 
                             act of 2017''
    PVA generally supports S. 1153, the ``Veterans Acquiring Community 
Care Expect Safe Services Act of 2017,'' or ``Veterans ACCESS Act.'' 
This legislation would deny or revoke the eligibility of a health care 
provider to be a community care provider if they have been fired from 
VA, violated their medical license, had a department credential 
revoked, or were imprisoned for one year or more.
      s. 1261, the ``veterans emergency room relief act of 2017''
    PVA supports S. 1261, the ``Veterans Emergency Room Relief Act of 
2017.'' This legislation would require VA to contract with urgent care 
providers and pay reasonable costs for care provided to veterans who 
are enrolled at VA and have received care there within the preceding 
two years. It would also establish cost-sharing amounts for certain 
veterans receiving care at a VA emergency room. We have consistently 
advocated for adding urgent care services to the standard medical 
benefits package to help fill the gap between routine primary care and 
emergency care. This is consistent with current health care trends, and 
greater utilization could provide a relief valve to VA emergency 
services, the Choice Program, and the system as a whole. It would help 
address issues of long distance travel for veterans needing immediate 
attention, and mitigate long term costs for VA by providing quick 
attention to medical needs that would otherwise compound in both cost 
and severity if the veteran were to wait to be seen at VA. 
Additionally, this has the potential to decrease the current burden at 
VA emergency rooms, freeing up capacity to properly address their 
patient loads.
    We do, however, continue our opposition to any requirement that a 
veteran have received VA care within the preceding 24 months in order 
to qualify for emergency and urgent care benefits. The strict 24-month 
requirement is problematic for newly enrolled veterans, many of whom 
have not been afforded the opportunity to receive a VA appointment due 
to appointment wait times, despite their timely, good-faith efforts to 
procure one. This barrier has caused undue hardship on veterans and has 
resulted in some receiving unnecessarily large medical bills through no 
fault of their own. Additionally, this provision discriminates against 
healthier veterans who otherwise do not need as much health care as 
other veterans and may go more than two years without being seen. This 
bill's authorization to impose cost-sharing should be enough to 
compensate for dropping the 24-month requirement as a cost control 
mechanism.
              s. 1266, the ``enhancing veteran care act''
    PVA generally supports S. 1266, the ``Enhancing Veteran Care Act.'' 
This legislation would authorize the Secretary of Veterans Affairs to 
enter into contracts with nonprofit organizations to investigate 
medical centers and report deficiencies. This legislation allows the 
Secretary to delegate the contracting authority for an investigation to 
the VISN director or the director of the medical center to be 
investigated. The Office of Inspector General has at times demonstrated 
a bureaucratic rigidity too cumbersome to address localized needs for 
investigation. This bill ostensibly aims to meet that need. While the 
Secretary is already able to contract with third party investigators, 
this bill extends that ability to lower leadership positions. We also 
believe it is an appropriate step to require the Secretary, Inspector 
General and Comptroller General of the United States be notified of an 
investigation for the purposes of coordination.
       s. 1325, the ``better workforce for veterans act of 2017''
    PVA supports S. 1325, the ``Better Workforce for Veterans Act of 
2017.'' This legislation would improve the authorities of the Secretary 
to hire, recruit, and train employees at VA. In order to transform the 
culture and timeliness of care, Congress must enable VA to quickly hire 
a competent workforce with competitive compensation that ensures VA is 
a first-choice employer among providers.
    The access to care issues plaguing Department of Veterans Affairs 
(VA) can almost always be traced back to staff shortages, and the 
systemic consequences of those shortages, within the health care 
system. The current 45,000 vacancies are a result of improper staffing 
decisions, a lack of sufficient resources, and the misallocation of 
existing resources. No reformation of staffing or capital 
infrastructure processes will increase access without appropriate 
resources.
    No one is more affected by provider shortages than those veterans 
with complex injuries who rely on VA to treat their specialized needs. 
Unfortunately, VA has not maintained its capacity to provide for the 
unique health care needs of severely disabled veterans--veterans with 
spinal cord injury/disorder, blindness, amputations, and mental 
illness--as mandated by Public Law 104-262, the ``Veterans' Health Care 
Eligibility Reform Act of 1996.'' As a result of this law, VA developed 
policy that required the baseline of capacity for Spinal Cord Injury/
Disease System of Care to be measured by the number of available beds 
and the number of full-time equivalent employees assigned to provide 
care.VA was also required to provide Congress with an annual 
``capacity'' report to be reviewed by the Office of the Inspector 
General. This reporting requirement expired in 2008, and was reinstated 
in last year's ``Continuing Appropriations and Military Construction 
and Veterans Affairs Appropriations Act for FY 2017.'' This report, a 
critical tool of oversight, should be made available to Congress by 
September 30 of this year. We suspect this report will verify the 
willful disregard for staffing shortages that exist in our most 
critical specialties.
    It is worth noting that the SCI/D System of Care is the only 
specialty service line with its own staffing mandate, implemented in 
2000, as a standardized method of determining the number of nursing 
staff needed to fulfill all points of patient care. VA has not met this 
statutory mandate. For years, PVA has identified chronic staff 
shortages, resulting bed closures, and denied admissions. Since 2010, 
VA has operated at only 60% of the capacity mandate. Further still, the 
mandate itself is 17 years old, and in need of an update to reflect the 
aging population of veterans. Such an update would provide a starker 
picture of unmet need for the most vulnerable population of veterans.
    A modernized and effective human resources operation is vital to 
any organization, especially one as large as VA. The multiple 
authorities governing the VHA personnel system are incompatible with a 
high-performing health care system. Hiring managers and their employees 
must attempt to understand the end-to-end hiring process under four 
separate rules systems. This unnecessarily adds complexity to the 
hiring system which is difficult for both the potential employee and 
the human resources staff to navigate. The unnaturally slow hiring 
process also ensures VA loses talented applicants. It is not reasonable 
to expect a quality provider to wait up to six months for VA to process 
an application. Similarly, when an employee announces his or her 
forthcoming retirement or departure from VA, H.R. is unable to begin 
the recruiting or hiring process for that position until it is actually 
vacated. This not only causes an unnecessary vacancy, exacerbated by 
the lengthy hiring time, but it also prevents a warm handoff between 
employees and any chance for training or shadowing.
    Mid-level management at the VISN level seems to have obfuscated all 
responsibility for clinical staff shortages, while maintaining 
themselves handsomely. The 21 VISNs, managed by directors and senior 
managers control the funding for all 1,233 VA health facilities, and 
are required to oversee the performance for their VA facilities and 
providers. Currently a nominal appointment, this structure was intended 
to decentralize decisionmaking authority and integrate the facilities 
to develop an interdependent system of care.
    In 1995 the total number of VISN staff was 220. In fiscal year 
2011, the total number of VISN employees had climbed to 1,340, a 509% 
increase, while bedside clinician and nurse staffing in specialized VA 
services plateaued, then fell behind demand. Meanwhile, the VA failed 
to request from Congress the resources to meet health care demand, 
particularly in specialized services such as spinal cord injury and 
disorder care and inpatient mental health.
    PVA believes that veterans have suffered from VA's inability to be 
competitive with its private sector health care counterparts who do not 
face the same restrictions on pay and benefits. In the face of a 
nationwide provider shortage, and an aging generation of baby boomers, 
VA must be competitive now in order to have any chance of meeting the 
needs of veterans.
    While the personnel challenges facing VA, are numerous, and often 
frustrating, it is important to remember these staffing issues and how 
they are resolved will have an immediate impact on the life and well-
being of catastrophically injured veterans. For the thousands with 
complex needs, there is no private sector alternative where they can 
seek care until VA's access problems are solved.
  draft bill, the ``department of veterans affairs quality employment 
                             act of 2017''
    PVA supports the proposed draft legislation the ``Department of 
Veterans Affairs Quality Employment Act of 2017.'' This legislation 
would improve the authority of the Secretary of VA to hire and retain 
physicians and employees at VA. PVA is particularly interested in a 
couple sections included in the bill. Section 3, which would require 
the Secretary to select at least 18, but no more than 30, employees to 
participate in a one year fellowship with a private sector company or 
entity that administers or delivers health care or other services 
similar to those provided within VBA and VHA. PVA generally supports 
this idea. In the current environment there could be a benefit to 
sending VA senior executives into the private sector to better 
understand best practices from both sides. At the same time, sending 
already limited resources and talent outside of VA could further 
undermine the existing training programs within the Department.
    Section 4 would require the Secretary to conduct an annual 
performance plan of VA's political appointees. The plan would be 
similar to those employees who are members of the Senior Executive 
Service and would assess recruitment and retention of qualified 
employees, engagement and motivation, and performance and 
accountability. While surprised there is not already a performance plan 
for VA political appointees, PVA considers this a reasonable provision.
    Section 5 would allow the Secretary to noncompetitively reappoint a 
former VA employee to any position within the Department as long as the 
position is not more than one grade higher than their former position 
and as long as the employee left the Department voluntarily within the 
prior two years and maintained necessary licensures and credentials. 
PVA has concerns about bringing back a former employee to a higher 
grade through a noncompetitive process. While PVA supports the intent 
to easily fill critical vacancies, we are not convinced hiring former 
employees through a noncompetitive process is the most appropriate path 
to filling those vacancies.
    Section 6 would require the Secretary to create a single recruiting 
database to list any vacant positions the Secretary determines are 
critical to the mission of VA, or difficult to fill, or both. It would 
keep information on applicants not selected for initial positions but 
who are qualified for other positions in the department. The Secretary 
would be required to use the database to fill any vacant positions. PVA 
questions whether such a recruiting database is necessary. Presumably, 
the `mission critical' positions the proposed database would house are 
currently residing in USAJobs.gov.
    Section 7 would improve training for Human Resources professionals 
and include virtual training. The development and implementation of 
defined goals for recruitment and retention (to include promotions, 
continuing education, etc.) should be components of H.R. staff's 
performance plans. VA H.R. management staff are not accountable to 
direct service providers. PVA believes they should be held accountable. 
H.R. performance is not measured by the degree to which they meet 
hiring and recruitment goals. As a consequence, failure to fill a 
critical vacancy in a timely manner carries no adverse effect on the 
involved H.R. staff.
    VA must be able to recruit and retain qualified staff by providing 
competitive compensation and opportunities for professional and 
technical development. The Association of American Medical Colleges 
estimates the United States will have a shortage of 130,600 physicians 
by 2025. Today, the most vulnerable populations, including rural 
communities and veterans with specialty needs, are the first to feel 
the effects. While VA recruitment efforts are improving, the 
inexcusably long process it takes to bring an employee onboard continue 
to turn away highly qualified candidates. VA must provide its human 
resources management staff with the resources and training necessary to 
correct these issues.

    Mr. Chairman, thank you for the opportunity to offer our 
organizations views on these bills. We would be happy to answer any 
questions you or your colleagues may have.

    Chairman Isakson. Well, thank you very much for your 
testimony, and to all of you, thank you very much for your 
patience and for your input, which was absolutely phenomenal, 
as we move toward dealing with the issue of choice.
    You have all raised some points that I want to refer to 
real quickly, if I can.
    Mr. Stultz, let me just thank you for mentioning 
coordinated care. You talked about the Secretary's desire to 
give the veterans the care they need where they need it. You 
need a coordinated care system where the veteran who needs the 
care and the doctor who is providing it are responsible and the 
VA cooperate together to see to it they get the very best 
possible care that they can.
    I think Dr. Yehia, in some of his conversations before, 
that is exactly what he was referring to. The patient or the 
veteran and the doctor are a team, and their goal together is 
the best health care possible for the veteran that they serve. 
That is exactly what all of us on this Committee want to see 
happen too, whether it is a rural or urban veteran or whatever 
it might be.
    Ms. Webb, you made a number of outstanding points. One, the 
letter from the VSOs, which we received some time ago, thank 
you very much for that joint letter. We paid a lot of attention 
to that.
    We do recognize that some people are suspicious that there 
is an attempt to bleed the system dry. I think that is the 
terminology you used. There is no game plan on this Committee 
whatsoever to bleed any system dry, but there is one to make 
sure we have a realistic and highly visible funding system.
    You referred to the--you did not call it seven; it is 
seven--different funding baskets out of which VA pays for the 
benefits and how we have these constant crises with that. We 
run out of money in one; we have money in others, but we are 
running out of money. So, everybody ends up in panic mode.
    I am committed, as I indicated in my question to Dr. Yehia 
earlier in the testimony, to get all that money in one pot, to 
have one central source that will be accessible, and see to it 
if we are running out of money, we are really running out of 
money. It is not just some fake crisis that somebody put up.
    One of the biggest problems we have had is in that area, 
and one of the biggest things I want to try and address is to 
see to it that that is corrected. I really appreciate your 
testimony and your input and what you had to say.
    In terms of the 2.2 million dues-paying American Legion 
members, of which I am, as I told you earlier today, still one 
of them because I paid my dues again, thank you for the input 
that you all made. But, I have a question that I want to ask of 
you.
    Do you poll or in any other way survey, on an annual basis 
or on an issue basis, your veterans with regard to the veteran 
health services?
    Mr. Celli. We do. As a matter of fact, we conduct several 
visits a year, somewhere between 10 and 13 at different VA 
medical centers around the country. We hold town halls. We 
speak to the patients who are actually in the VA hospitals, and 
we speak to the providers to figure out what challenges that 
they are having. We use that information in a best practices 
report that we issue not only to the VA, but we also send it up 
here to Congress and to the President of the United States.
    So, we do speak to them on a regular basis through our town 
hall meetings. Of course, we get calls, just like all the other 
VSOs do, every single day, but our System Worth Saving Program 
is our boots-on-the-ground access to our veteran's voice.
    Chairman Isakson. How responsive is the VA health system to 
you when you give them input from these polls?
    Mr. Celli. They are extremely responsive. As a matter of 
fact, whenever we--I mean, we deal directly with Dr. Yehia. We 
deal directly with Dr. Alaigh. We deal directly with the 
Secretary. Our access is pretty much unfettered. We enjoy a 
great partnership with the Department of Veterans Affairs and a 
great partnership with our veterans. When there is a problem, 
we bring that to their attention and they work tirelessly to 
ensure that that problem is satisfied.
    Sometimes it is a perceived problem by the veteran, in 
which case we just have to recognize that the veteran may or 
may not have access to what it is that they want, but more 
times than not, it is a payment problem like with Choice or it 
is an access-to-care problem because they have been waiting too 
long, and we are able to get those satisfied.
    Chairman Isakson. How long have you been doing the job you 
do at The American Legion?
    Mr. Celli. About 5 years now.
    Chairman Isakson. Have you seen any trend line in terms of 
that responsiveness over the last 5 years?
    Mr. Celli. I think it has gotten extremely better over the 
past 2 years. The access and the transparency has gotten 
extremely better over the past couple years.
    Chairman Isakson. We did not talk before this hearing, did 
we?
    Mr. Celli. Not at all. [Laughter.]
    Chairman Isakson. The reason I made that comment, as I was 
listening to you talk--and I think this should go back to the 
Secretary, Doctor, as well--there is a visible improvement in 
the VA's responsiveness--as a Committee Member, I think Senator 
Tester would agree with the same thing--to us as well as I 
sense to the VSOs. As we move forward to fix Choice and fix 
veterans' health care and ensure veterans get the health care 
they need, where they need it, and when they need it, which is 
the goal of the Secretary, that we would be responsive to the 
problems that are brought to us by the VSOs and be responsible 
to the veterans who come to us with those. If we do that, we 
will have a 21st century health care system for the 21st 
century veterans of the United States of America.
    Thank you, all of you, for your testimony.
    Senator Tester.
    Senator Tester. Thank you, Mr. Chairman.
    I would just add that I think the VA has been very 
responsive, except in one area, and that is funding for the 
Choice Program, because we have ping-ponged all over the place, 
and I think that I need to bring that up because, as a 
Committee, we need more time than what we received on this.
    We were supposed to be funded through November or October, 
and then it was June, and then it was August. You get my drift. 
Other than that, good job.
    I want to go off of a script for a second from these bills 
that are on the agenda today. I want to talk about a different 
bill, and so I would just ask for your attention just for a 
minute--it is not that complicated--because I want to get your 
opinion on it.
    Earlier today--first of all, you guys all know that Choice 
needs additional funding for fiscal year 2017 and 2018. Right? 
[No response.]
    Earlier today, I dropped a bill that would get the 
Department the money that it needs for the Choice Program. It 
would bolster VA's internal capacity to provide care. It would 
make it easier for VA to provide care to vets closer to home by 
authorizing leases and getting pre-9/11 caregivers the help 
that they have needed for decades.
    So, I would like to have your reaction to this legislation, 
because there are some folks that do not believe that we should 
be tackling internal VA care and caregivers in the same 
legislation as providing funds for private care on an emergency 
basis. Remember what I just said. They do not believe we should 
be tackling internal VA care and caregivers in the same 
legislation as providing funds for private sector care on an 
emergency basis, that is.
    I am going to start with you, Mr. Celli. Could you give me 
your perspective on that bill, whether you think it is good, 
bad, or----
    Mr. Celli. Well, thank you, Senator. The challenges that 
you face are administrative on your end. We absolutely support 
your bill. We support the caregiver portion of the bill. We 
support paying for it and whatever means is necessary.
    Senator Tester. OK.
    Mr. Celli. We support pre-9/11 caregivers getting the same 
services and the same benefits and the same access to resources 
that post-9/11----
    Senator Tester. OK. Ms. Webb?
    Ms. Webb. I was able to glance over that this morning and 
have not had a chance to read the entire bill, but all the 
provisions that you lay out sound----
    Senator Tester. OK.
    Ms. Webb [continuing]. Acceptable and like AMVETS, we would 
support.
    Senator Tester. I guess the big question is, would you guys 
support building VA capacity on an emergency basis? That is 
really the question.
    Ms. Webb. Yes.
    Senator Tester. OK.
    Mr. Atizado. Senator Tester, thank you for that question.
    You know, Ms. Webb had mentioned the letter that the VSOs 
had sent over----
    Senator Tester. Yes.
    Mr. Atizado [continuing]. To the Senate, and I think that 
covers a little bit of your question about what our opinion as 
a reaction is to----
    Senator Tester. Yep.
    Mr. Atizado [continuing]. Some of this perspective, and I 
think it is an emergency.
    Senator Tester. Thank you.
    Mr. Atizado. You know, for many years now, we have been 
talking about how veterans are not getting access to care from 
VA, and it is not because VA does not want to give them care. 
They do not have the people. They do not have the capacity, and 
frankly, sometimes they do not have the authority. I think this 
has constituted an emergency, such as the Congress' response to 
the access crisis in Arizona. I think this comes to that level 
as well.
    Senator Tester. Got you.
    Mr. Stultz?
    Mr. Stultz. I would really want to know who they are 
because I think it says a lot about priorities, and for us, I 
represent veterans with the most catastrophic disabilities. As 
I have said repeatedly, whether in written statements or here 
in front of the Committee, there are no comparable services 
everywhere.
    Senator Tester. Yeah.
    Mr. Stultz. The Choice Program is not the fix for 
everybody. For us, internal capacity has to get better----
    Senator Tester. Yep.
    Mr. Stultz [continuing]. With the Choice Program.
    Senator Tester. Yep. Especially with the population that 
you represent, absolutely critical.
    I just got to ask something--this is off script--but it 
goes to your statement, Ms. Webb. When I was in Missoula, MT, 
having a veterans listening session, one of the people that I 
had on my panel--and I did not pre-read anything that they had 
to say--stood up and said, ``The best thing you guys on the VA 
Committee could do would be to disband Choice and put every 
dollar into the VA and focus on the VA.'' How many of your 
members would have that same feeling? Could you tell me that 
without putting you too much on the spot?
    Ms. Webb. Well, I think that there is a lot of nuance that 
we try to communicate with our members, and I think there is 
room and there is a need for a public-private partnership.
    The point for us is the expansion of Choice. We do not 
support that because I think any of that extra money should be 
invested back into VA.
    Senator Tester. OK.
    Ms. Webb. But, there is some need for some of the funding 
to go elsewhere.
    Senator Tester. Yeah. I have got several other questions, 
but we have got other Members present, so, I yield Mr. 
Chairman.
    Chairman Isakson. Senator Tillis.
    Senator Tillis. Thank you, Mr. Chairman, and, Mr. Chairman, 
I meant to mention in the first round that The New York Times 
article we talked about briefly today at lunch. I want to thank 
you and the Ranking Member for creating a distinctive 
environment on this Committee that is producing some really 
consequential legislation on a bipartisan basis. I thank you 
both for that.
    Mr. Stultz, I have a question for you, which relates to 
that situation about the veteran who passed away after he opted 
out. Have you done much work in looking at the electronic 
medical record implementation that we are working on? How we 
would ultimately extend that to the broader caregiver community 
and implement intervention strategies to make sure that at the 
end of the day, the VA will still continue to own, I think, the 
responsibility for a good health care outcome? Has your 
organization given any thought to how we could do that by 
having that holistic model of care that veteran may be 
receiving if they choose to go outside of the VA?
    Mr. Stultz. Are you asking for specific implementation or 
the ramifications of tighter integration between the community 
and VA?
    Senator Tillis. Well, I am saying if we have that tighter 
integration, we may know what is occurring once they go out----
    Mr. Stultz. Right.
    Senator Tillis [continuing]. Of the VA to either a non-VA 
provider or to a Choice option. I am assuming that a part of 
the--and I am looking forward to seeing the details of the 
electronic medical record strategy, but it is then fully 
exploiting that 360 view of the medical activities that that 
veteran may be going through. I was just curious if your 
organization has thought that through, because in your 
particular case, that is where having the absolute latest 
information may actually require an outreach to a veteran to 
say, ``We know you made this decision at some point, but 
perhaps there is a better option now.'' I would think that has 
got to be key to some of the things we are doing for longer-
term managed care and better access to medical information.
    Mr. Stultz. I think that is a great point, sir, and if you 
look back at VA's Choice Consolidation Plan from, I think, over 
a year ago now at least, one of the pieces that they discussed 
was care coordination. They had an idea that they would--if 
care went out into the community, based on the acuity level of 
your care and the needs that you had--this gentleman, for 
example--they would stay involved, even though they were not 
administering the actual care. So, tools like this can really 
make those ideas go a long way to prevent things like this.
    Senator Tillis. Well, I hope as we get information back 
from the VA that that does become--you have got to get the 
baseline in place, which has to become a priority, because I 
think that will help make the Choice Program work, and also 
make them aware of options and service levels where either non-
provider care or VA-centered care will work.
    Mr. Celli, you made a comment that I want to come back to. 
I do not want to parse your words, but it is something that I 
think is important. I have said it. I know you have been in the 
Committee hearing when I have said it before, and it was with 
respect to one of Senator Tester's comments about the 
caregivers bill, I think. You said we need to fund it by all 
means necessary. I do not think you meant at the expense of 
something else that you think needs to be funded by all means 
necessary.
    Mr. Celli. Senator Tillis, thank you for pointing that out. 
That is true. I do not mean by cannibalizing existing programs 
within the VA. I mean that there are funds available through 
emergency means that as to Gabe's point would be appropriate to 
fund this program.
    Senator Tillis. I think the key here is so that when we 
move forward on things that I happen to agree with as a matter 
of policy, that we provide sustainable, predictable funding, so 
that a crisis does not emerge, which causes us to make some 
sort of knee-jerk reaction for other programs that we think are 
equally important.
    I have said before to the VSOs, you may hear me be cool to 
a net new idea, not because I oppose the idea, but I want to 
make absolutely certain we were talking about that with the 
veterans treatment court that we are doing it in a way that 
pays for itself, not at the expense of something else that you 
all have fundamentally supported.
    Ms. Webb, I wanted to go back. The Chair brought it up, but 
in North Carolina it is really interesting because I hear the 
States that are urban States talk about what their priorities 
are and I hear the rural States talk about what their 
priorities are. In North Carolina, we are literally 51 percent 
urban, 49 percent rural. When we get rural in North Carolina, 
we get really rural. I know it is hard to imagine, but if you 
go in western North Carolina or eastern North Carolina, there 
are all kinds of challenges there.
    I, for one, just want to give you some assurance that 
someone like me who believes that there are things that we can 
do to really make Choice a key piece of the puzzle. I see the 
whole outside of that puzzle always continuing to be the VA, 
whether it is brick-and-mortar presence, where men and women 
who have the sorts of profound injuries that Mr. Stultz's 
organization would represent have that environment that is 
unique to the situation that they have experienced. There are 
very few people who have not served that could possibly 
understand or comprehend. They congregate with caregivers; they 
congregate with other soldiers or veterans. I think that is 
critically important. The therapeutic value of that alone means 
that we have to maintain that full circle of care and 
visibility, and I think most of the Members here get it.
    So, as we move forward with the discussion on getting the 
Choice Program right, I think that you have a consensus among 
these Members that we have got to get that right too. Thank you 
all for your time here today.
    Ms. Webb. Thank you.
    Chairman Isakson. Thank you, Senator Tillis.
    Senator Blumenthal?

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

    Senator Blumenthal. Thank you, Mr. Chairman, and thank you 
all for being here today. You are here constantly at our 
hearings, and we are grateful to you for your presence, your 
insightful testimony, and your service to our Nation.
    I want to focus on the criteria and decisionmaking process 
for Choice, because I think we are all in agreement that we 
want the Choice Program to provide the best possible care. 
There should be alternatives outside the VA system where 
necessary, and necessary should be defined as being in the best 
interest of the veteran; that is, where the veteran can receive 
care that is the most timely and expert. Obviously, timeliness 
depends on difficulty of access, geographic distance, as well 
as waiting times, and quality depends on the expertise; for 
example, criteria of professional qualifications at federally 
qualified health centers or Medicare providers or the VA 
facilities themselves that may approve certain providers.
    Should these decisions be made by the VA in setting 
criteria and choosing outside providers, or should there be 
some independent means of doing so?
    Mr. Celli. So, Senator Blumenthal, time and time again, we 
focus on the smaller picture like Choice rather than the bigger 
holistic picture of where VA health care is going.
    You have asked the Secretary to sit down and come up with a 
comprehensive plan on where the future of VA health care should 
go, and he has done that. He has got together with his team. He 
has run it past the veterans service organizations, and he has 
come up with a comprehensive program. CARE is probably not the 
acronym we would have used, but the program itself is solid. 
The recommendations in there look at exactly what it is that 
you just touched on, which is how do we come to these 
decisions, how has VA grown over the past several years, what 
lessons have we learned from the Phoenix scandal? The outcome 
of that has been a more coordinated and comprehensive care 
model that we all support.
    So, to continue to throw up the word ``Choice'' I think 
just misses the bigger picture, and I think we are all ready to 
move on.
    Mr. Atizado. Senator Blumenthal, thank you for that 
question.
    To your point and question about where VA should be in 
regards to when a veteran will be able to access a community, I 
think VA needs to be exactly where it has been but empowered 
more.
    VA providers tend to be--tend to spend a lot more time with 
veteran patients as a whole. Part of the recruitment tool for 
clinicians is that they tell these budding and new doctors that 
we want our providers to spend more time, 30 minutes on average 
as opposed to 20 minutes, in the private sector. That extra 10 
minutes actually allows that doctor to sit down and know their 
patients, because VA as an organization firmly believes in a 
lifelong relationship with veterans.
    In that relationship, the VA has to be, I guess, a force 
multiplier. They need to help guide the veteran to inform them, 
to educate them, to be the best consumer of health care they 
can be, to not only be healthy, but to lead a better life.
    I think they have to play a role, sometimes more active 
depending on the situation and sometimes a little bit more 
passive, but certainly not far from the side of the veteran 
when they make that decision.
    Senator Blumenthal. Let me ask you on a related topic. You 
mentioned the Phoenix scandal. Have you been satisfied with the 
results of the Inspector General investigation?
    Mr. Celli. It is a complicated question; there are a lot of 
things that went wrong that caused Phoenix to happen. A lot of 
those things have not yet been fixed. The scheduling program, 
the IT, the software that runs that--what we have done is taken 
the focus away from incentivizing no wait times, and we have 
encouraged the employees to be more forthright and honest. 
While I do not want to take anything away from what happened 
and the depravity of veterans not being seen when they need to 
be seen, we also need to recognize that the secret wait list, 
if you will, was the scheduler's ways of trying to take care of 
a veteran when their supervisors told them that they cannot. 
So, there is a lot that went wrong, a lot that went right, and 
a lot that we have learned from that.
    Am I satisfied with where we are today? I think it is still 
a work in progress.
    Senator Blumenthal. Thank you very much.
    Thank you, Mr. Chairman.
    Chairman Isakson. Senator Tester.
    Senator Tester. Thank you, Mr. Chairman.
    Adrian, I am going to go to you because I am going to read 
from your testimony, and I want you to comment on this. Talking 
about the commission that the Choice Act made happen:

        The Commission's economists estimated that the 
        recommended limited choice option would increase VA 
        spending by at least $5 billion in the first full year, 
        though they cautioned that it could be as high as $35 
        billion without strong management control of the 
        network. The Commission's economists also analyzed an 
        unfettered choice option to allow veterans the ability 
        to choose any VA or non-VA provider--without requiring 
        them to be part of any defined network. The economists 
        estimated such a plan could cost up to $2 trillion more 
        than current projections for VA expenditures over the 
        first ten years. Based on the premise that the draft 
        bill would provide unfettered choice for all enrolled 
        veterans, create an extremely broad--almost universal--
        network, and lacks any effective coordination 
        mechanisms, it seems likely the costs to implement such 
        a proposal would be significant, somewhere between the 
        estimates for the two Commission options discussed 
        above. In today's fiscal environment, it seems 
        unrealistic such dramatic spending increases would be 
        appropriated or sustained, and even if approved, the 
        cost shift and patient migration to private care would 
        ultimately endanger the viability of the VA health care 
        system.

    Those are your words. Talk to me about them.
    Mr. Atizado. Senator, thank you for pointing out that 
section of our testimony.
    I think what we are trying to do here is find a reasonable 
and sustainable solution for VA care, and it really stems from 
the idea that as Congress, this Committee considers legislation 
to expand access--more access points for veterans to receive 
care in the community--costs will go up. We have seen that in 
the Choice Program.
    Depending on how that structure is set up from unfettered, 
which is literally give a veteran a card to go forth and be on 
your own and find your own way, that has not only tremendous 
cost implications, but it has some human costs as well. Private 
sector--the long debate in Congress about U.S. health care and 
the delivery of care tells us that when providers do not work 
together with patients as a team, that can be quite disastrous, 
not only costly for the patient in terms of money and life, but 
on the economy of the U.S. health care system.
    So, when you have a system where you have unfettered choice 
and veterans can go anywhere, the costs will go up, which is 
clearly not sustainable. It does not serve us well, when we 
know there are better ways to construct a way for VA to allow 
veterans to get care in the community.
    Senator Tester. Thank you.
    Mr. Stultz, I want to talk about VA accountability. I just 
want to go with you very briefly, and then if anybody has 
something to add--I pointed this out to Dr. Yehia in the 
questions to the previous panel that if we are going to have 
community care programs, I think the VA can transfer that care. 
However, I do not think they can ultimately transfer the 
responsibility for the veteran's well-being.
    You are dealing with paralyzed veterans. You talked about 
an instance where the pneumonia treatment was successful. You 
talked about another one where the veteran ended up dying.
    Could you tell me what happens in the VA when something 
goes wrong? Then tell me what happens in the private sector 
when something goes wrong for a veteran.
    Mr. Stultz. In the VA, you have a non-adversarial process. 
You submit it like a disability claim. They adjudicate it. They 
are not working against you. In the private sector, you are 
going through standard litigation and subject to all those 
rules in the adversarial process. VA also comes with the added 
package of service-connected treatment for that and things like 
adaptive equipment for your car, adaptive equipment for your 
house. For the rest of your life, they take care of the fact 
that you have become more disabled based on whatever care you 
got.
    Senator Tester. Right. How long does the process through VA 
normally take versus how long it would take in the private 
sector----
    Mr. Stultz. That is a----
    Senator Tester [continuing]. To get your----
    Mr. Stultz [continuing]. A very interesting question 
because I like to talk about appeals reform. [Laughter.]
    It can range for a number of years, but at the same time, 
collecting a judgment in the civilian world can take a number 
of years as well. So, the tradeoff is there. I am not sure on 
time or really what we are after.
    Senator Tester. OK, OK.
    Anybody else like to comment on that? Mr. Celli? Amy?
    Mr. Celli. So, I mean, real quick, I mean, to your 
question, Senator----
    Senator Tester. Yep.
    Mr. Celli [continuing]. It could happen in a matter of 
weeks if you had a fully-developed claim.
    Senator Tester. Yep.
    Mr. Celli. The VA would be on the hook to make sure that 
they cared for that veteran and those with increased 
disabilities for the rest of their life. That does not exist in 
the private sector, so it could happen quickly, or it could 
take years.
    The one thing that I just wanted to touch on when you were 
talking to Mr. Atizado is----
    Senator Tester. Sure.
    Mr. Celli [continuing]. Including the increased cost, the 
risk of increased cost to privatization, something would have 
to give. We cannot continue to just pay more and more. What 
would ultimately happen is we would start restricting 
availability and veterans would not be able to have the same 
access to care that they have today.
    Senator Tester. That is a solid point, and I am glad you 
said that, because I think, ultimately, in the end, what 
everybody on this Committee wants to have is we live up to the 
promises made when you signed the dotted line. I think there 
will come a time, if we are not smart today, where tomorrow, 
veterans may not be able to be on the list that are fully 
deserving of the benefits.
    I want to thank you all for being here today. Thank you 
very much.
    Chairman Isakson. Thank you, Jon.
    Let me say, Mr. Stultz, I want to--you prompted me to think 
of something for a minute. Are you familiar with Project SHARE 
in Atlanta?
    Mr. Stultz. I am not.
    Chairman Isakson. At the Shepherd Spinal Center?
    Mr. Stultz. Yes. I am sorry.
    Chairman Isakson. I just was going to say we were talking 
about VA care and private care and Choice and things of that 
nature, and in your self-introduction, you said you represented 
the most profoundly injured veterans that we have who have the 
most unique special circumstances.
    One thing I want to be sure to mention is, we just 
dedicated in Atlanta, thanks to the gift of Bernie Marcus, the 
founder of Home Depot, the largest center dedicated to veterans 
that I know of anywhere in the country that is taking veterans 
that VA can no longer help and were really falling between the 
cracks and not getting the best care possible.
    So, if you ever get a chance to come to Atlanta to visit 
Project SHARE at the Shepherd Spinal Center, it will warm your 
heart and also show you what a combination of private-sector 
and public money can do to help our veterans.
    Thank you for what you do. We appreciate it.
    Mr. Stultz. Thank you, sir.
    Chairman Isakson. It is a pleasure to serve with Jon 
Tester, the Ranking Member. We are going to find common ground 
in the next few months and get a Choice bill that works for 
everybody, which ensures the longevity and the future of the VA 
health services with the expansion of access to care that is 
needed to bring about the Secretary's dream, and that is better 
care for veterans who have care accessible to them.
    Thank you all for being here. We will leave the record open 
for a week for any additional submissions.
    We stand adjourned.
    [Whereupon, at 4:40 p.m., the Committee was adjourned.]

                            A P P E N D I X

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[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
           Prepared Statement of the American Academy of PAs

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                                 ______
                                 
Prepared Statement of American Federation of Government Employees, AFL-
                                  CIO
    The American Federation of Government Employees, AFL-CIO and its 
National VA Council (AFGE) appreciates the opportunity to submit a 
statement for the record on the bills under consideration today. AFGE 
represents nearly 700,000 employees in the Federal and D.C. government 
including 250,000 rank and file employees at the Department of Veterans 
Affairs who provide vital care and services for our veterans.
                      s. 1153--veterans access act
    S. 1153 would bar providers from participating in VA purchased care 
programs if they have been fired from the VA for certain misconduct, 
violated requirements of their medical license, lost a VA credential, 
or committed certain crimes.
    AFGE supports S. 1153. When VA privatizes care, the standards must 
be as high as they are inside the VA.
              s. 1261--veterans emergency room relief act
    AFGE opposes S. 1261 as currently written. Absent specific 
guidelines for when veterans can use non-VA urgent care centers, this 
bill could lead to more fragmented and uncoordinated care, and lead the 
VA further down the road of privatization. In addition, too many 
veterans are already subjected to harsh collection practices through 
Choice and through VA third party collection processes.
    AFGE urges the Committee to first conduct an inventory of emergency 
departments and urgent care centers within VA medical centers; a number 
of facilities have closed emergency departments over the years without 
adequate justification. This study should also examine the feasibility 
of expanded urgent care centers within VA medical centers. Urgent care 
provided directly by the VA will be far more veteran-centric than 
urgent care provided in the private sector.
                  s. 1266--enhancing veteran care act
    This bill would give the VA authority to contract with non-VA 
entitles to investigate deficiencies at VA medical centers.
    AFGE opposes S. 1266. The VA has adequate internal capacity to 
investigate its medical centers, alone or in conjunction with other 
independent governmental entities. Contracting out this responsibility 
is likely to be used to lay the groundwork for further privatization.
       s. 1279--veterans health administration reform act of 2017
    AFGE opposes S. 1279 because the criteria that would be used to 
determine if a veteran can seek care outside the VA are too vague (e.g. 
clinical best interest, undue burden, not economical). VA medical 
centers across the Nation continue to be deprived of adequate staff and 
resources to provide all veterans with the timely, veteran-centric care 
they have earned and that they prefer. The conditions resulting from 
chronic underfunding and short staffing need to be addressed by 
strengthening the VA rather than further depleting resources away from 
the VA to provide more fragmented, nonspecialized care to veterans.
           s. 1325--better workforce for veterans act of 2017
    AFGE concurs that it is critical to fill the reportedly 49,000 
vacancies at the VA. However, in AFGE's view, some of the provisions in 
the underlying bill--as currently written--fall short of improving 
hiring, recruiting, and training efforts within the VA and may have 
unintended consequences
    Sections 101 and 102 of the bill gives the Secretary more direct-
hire authority to fill current staff level vacancies. AFGE has serious 
concerns about how this increase in direct-hire authority will impact 
current Federal employees. If this bill were to become law, AFGE fears 
that an unintended consequence could be preferential treatment given to 
outside candidates, thereby bypassing current VA employees who seek a 
promotion. Without adequate protections in place for current Federal 
workers who have worked diligently to move up the VA ladder, the bill 
could have a negative impact on efforts to strengthen the VA workforce.
    Section 106 of the underlying bill directs the VA to collect data 
on hiring effectiveness and Section 107 calls for the VA to design a 
standardized exit survey that would be voluntarily administered to 
outgoing employees. AFGE wants to stress the importance of having 
stakeholder input throughout the process of developing these 
mechanisms. It is critical that the VA consult with labor organizations 
who represent their employees as well as the many Veterans Service 
Organizations (VSOs) whose members rely on the VA for vital care and 
services when developing these survey tools. By incorporating input 
from both labor and the VSO community, the VA will be able to develop 
tools that adequately address issues at the worker, manager, and 
patient level.
    One goal that appears throughout the underlying bill is the notion 
of transparency. AFGE appreciates the inclusion of this provision in 
the bill and the acknowledgment that the VA should be more transparent 
as it relates to staffing levels and vacant positions. With that in 
mind, AFGE would like to see the bill go further by posting not just 
nurse staffing levels, but all staffing levels at every VA facility. In 
addition to the VA being transparent with its current workforce, AFGE 
would like to see the VA be transparent with posting job openings. AFGE 
highlighted its concern with new direct-hire authority above, and in 
that vein, wants to express its desire that necessary oversight is 
exercised so that the Secretary does not use this new direct-hire 
authority to fill positions without those jobs being publicly posted 
with an open announcement.
    Another area where AFGE has significant concern with the underlying 
bill relates to the proposed use of non-Federal employees to provide 
care and services to our Nation's veterans. As it's currently written, 
Section 202 of the bill would allow the VA and private sector companies 
to essentially swap employees for a period that can range from three 
months to four years. AFGE has long opposed allowing the private sector 
to enter the Federal Government and then return to their original job 
outside of the government. This is an unnecessary step down the path to 
privatization, and AFGE opposes the section in its entirety.
    AFGE opposes Section 204 as currently written. Section 204 
establishes a two-tier payment system of base pay and market pay for 
directors of medical centers and Veterans Integrated Service Networks 
(VISN). The bill would set market pay for directors on a case-by-case 
basis through a process that requires the Secretary to consult at least 
two national surveys and takes into account managerial experience, 
complexity of the facility, and labor market conditions among other 
considerations.
    Under Section 204, medical center and VISN directors--who would no 
longer have to be physicians themselves (as a result of Section 203)--
would gain a significant right that was taken away from every VA 
physician and dentist last year. Public Law 114-315 repealed the 
requirement enacted in 2004 that ``the Secretary shall consult two or 
more national surveys of pay'' (Public Law 108-445).
    In addition, Public Law 114-315 eliminated the requirement to set 
market pay through peer-based compensation panels, a valuable system 
for ensuring pay fairness, that protected providers from abuse of 
discretion by managers. According to reports from our physician 
members, the Secretary has not established any new policies to replace 
the compensation panels.
    AFGE is ready and willing to work with the Committee to amend 
Section 204 to ensure that VA physicians and dentists reacquire 
adequate market pay protections, which in turn will strengthen 
recruitment and retention and enable the VA to provide medical care to 
more veterans on a timely basis.
    AFGE also opposes Section 207 of the bill that would allow the 
Secretary to enter into a Memorandum of Understanding (MOU) with the 
Surgeon General to allow not less than 500 Public Health Service (PHS) 
commissioned officers to enter the VA. Allowing PHS to come into the VA 
would erode frontline workers collective bargaining rights and move the 
VA one step closer to privatization. PHS does not appear to have any 
significant expertise in treating veterans. In addition, Congress has 
provided VA with ample tools over the last two decades to recruit and 
retain nurses within the Federal workforce. The VA should be focused on 
recruiting, hiring, and retaining high quality medical professionals 
who will make a career out of serving veterans, not finding creative 
stop-gap measures. The United State Government must keep the promise it 
made to our veterans by rewarding their dedication and sacrifice with 
the best care and services imaginable, and the only way to do that is 
through hiring staff at every level who will be there long-term to care 
and provide for our veterans. AFGE opposes this section of S. 1325 in 
its entirety.
    AFGE opposes Section 212 as currently written. Section 212 would 
require a review of the job descriptions, position classifications and 
grades for all VA police officers and firefighters to ensure compliance 
with Office of Personnel Management (OPM) classification standards. 
This section also mandates the development of staffing models and an 
audit of recruitment and retention efforts for both positions, and a 
report to Congress regarding the Department's use of special pay to 
address its critical shortage of police officers.
    AFGE shares the concerns of lawmakers and veterans' groups that the 
outdated police officer job duties increase safety risks to the VA 
community. However, after consultation with classification experts, 
AFGE strongly urges the Committee to adopt a more comprehensive and 
aggressive approach to modernizing the VA police officer position, i.e. 
mandating that the Secretary exercise his existing statutory authority 
to convey law enforcement officer (LEO) status to all VA police 
officers. Only this major overhaul of VA police officer positions will 
ensure that VA has the capacity to adequately respond to the wide range 
of violent and non-violent incidents that arise on a regular basis at 
its facilities.
    A recent expert analysis of VA police officer duties indicates that 
VA police officers already meet the statutory definition of law 
enforcement officer based on their primary duties and training 
requirements (5 CFR 831.902; 5 CFR 842.802).
    AFGE previously requested that former VA Secretary Robert McDonald 
exercise this authority. AFGE stands ready to work with bill sponsors 
and other Members of the Committee to develop a stronger statutory 
solution to this significant VA safety issue.
      s. _____--discussion draft, the veterans choice act of 2017
    AFGE strongly opposes the Veterans Choice Act of 2017. This bill 
would vastly increase the use of non-VA care through a massive 
expansion of the Choice Program. Like the Concerned Veterans of America 
plan that was soundly rejected by the Commission on Care, this bill 
would erode the critical core of the VA health care system and put such 
an enormous financial strain on the VA so as to threaten its very 
survival.
    The bulk of veterans' care, and all primary care and mental health 
care must continue to be provided within the VA system, to ensure that 
veterans continue to receive the world-class integrated care they have 
earned and prefer. Only the VA, as the coordinator of care, can ensure 
that non-VA care is used in a smart way to ensure that veterans can 
receive the most appropriate care for their circumstances.
    In contrast, this bill would not result in a smart use of non-VA 
care but rather an unlimited use of non-VA care that would likely lead 
to worse care for veterans in both the short and long term, and the 
severe weakening of our Nation's leader in health care training and 
research.
    AFGE also opposes this bill because it would not ensure the VA is 
the primary coordinator and arranger of non-VA care.
s. _____--discussion draft, improving veterans access to community care 
                              act of 2017
    AFGE generally supports the Improving Veterans Access to Community 
Care Act of 2017. This bill enables the VA to modernize its services, 
which will both allow the VA to better integrate a truly smart use of 
non-VA care with VA's own world class services, but also allow the VA 
to meet increased demand from higher functioning and consolidated non-
VA care programs.
    AFGE also supports this bill's provisions for ensuring that the VA 
is the primary coordinator of non-VA care. The integrated networks 
created by this bill would allow veterans to more seamlessly move 
between the VA and non-VA providers when the use of non-VA care to 
supplement VA's own care is warranted.
    The VA has made great progress in making needed improvements to its 
health care system and other operations over the past three years. This 
bill ensures that veterans will continue to be well served by the VA 
and integrated networks providing non-VA care when the VA cannot meet 
the need itself. This bill also is the far better option for protecting 
the critical resources that the VA must retain in order to keep its 
promise to veterans.
s. _____--the department of veterans affairs quality employment act of 
                                  2017
    AFGE does not support this bill as a whole, though it includes 
several positive management improvement provisions included in previous 
legislation.
    Like some of the provisions that raised concerns from AFGE in 
S. 1325, as already discussed, this bill relies too heavily on the 
private sector to improve the Department. For example, Section 3 would 
provide management training to VBA and VHA employees in a private 
sector setting. VA managers need to learn the best practices of other 
VA managers and when applicable, exemplary managers from other 
agencies. That is why AFGE supports management improvement provisions 
that strengthen VA's own managers through better training and 
performance evaluation.
    AFGE supports a public database on vacancies, but the database in 
Section 6 of this bill has too narrow a scope. Veterans, the public, 
employee representatives, and all stakeholders need access to complete 
data about vacancies throughout the Department, not just vacancies that 
are determined to be critical by the Secretary.
    The human resources training proposed by Section 7 is greatly 
needed, but to ensure that it is truly effective, labor 
representatives, and other stakeholders must have regular input in the 
design and delivery of training curriculum. Without the perspective of 
front line employees, any H.R. training will continue to fall short.
    AFGE has similar concerns in this bill regarding provisions for 
exit surveys and succession planning studies as we have for S. 1325, 
i.e. it is essential that these workforce improvement efforts reflect 
the regular input of representatives of front line employees.
    Thank you for the opportunity to share the views of AFGE.
                                 ______
                                 
Letter from Col. James T. Currie, USA (Ret.) Ph.D., Executive Director, 
  Commissioned Officers Association of the U.S. Public Health Service
  
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                                 ______
                                 
   Prepared Statement Developed by Fighting for Veterans Healthcare, 
   Association of VA Psychologist Leaders,* Association of VA Social 
         Workers,* and Nurses Organization of Veterans Affairs*
    * An independent organization, not representing the Department of 
Veterans Affairs
     Proposals for the Veterans Choice Program Redesign and their 
                    Impact on Veterans' Health Care
                               background
    Over the last decade, as the rising demand for veterans' healthcare 
services outpaced the Veterans Health Administration (VA)'s capacity to 
meet it, excessive delays developed at some VA facilities. In 2014, 
Congress enacted the temporary Veterans Choice Program whose goal was 
to reduce delays by offering non-VA options to veterans who had to wait 
long or travel far for care. To date, over 1.6 million veterans have 
utilized the program.\1\
---------------------------------------------------------------------------
    \1\ Budget Request for Fiscal Year 2018: Presentation before the 
House Committee on Veterans' Affairs, House, 114th Cong. 1 (May 24, 
2017) (Testimony of David Shulkin).
---------------------------------------------------------------------------
    The demand for veterans' healthcare services is predicted to 
continue to climb during the next several years.\2\ There are two basic 
ways to address VA's lack of capacity to meet this demand--bolster the 
VA by augmenting its number of clinicians and support staff, or 
purchase more services in the private sector. Those two options offset 
each other, since increases in Choice would be carved out of the VA.
---------------------------------------------------------------------------
    \2\ Eibner, C., Krull, H., Brown, K., Cefalu, M., Mulcahy, A. W., 
Pollard, M., . . . Farmer, C.M. (2015). Current and Projected 
Characteristics and Unique Health Care Needs of the Patient Population 
Served by the Department of Veterans Affairs [Product Page]. Retrieved 
June 8, 2017, from https://www.rand.org/pubs/research_reports/
RR1165z1.html
---------------------------------------------------------------------------
    As Congress deliberates Choice program redesign, policymakers 
should consider not only the plan's ability to remedy access problems, 
but also its broad impact. Congress must ensure that the next Choice 
program does not compromise VA's overall quality of health care--care 
that has been demonstrated, with geographic variations, to be at least 
equal to and often superior to non-VA care. Congress must ensure that 
the VA's innovative, integrated care model is preserved. It must assure 
that the system for clinically training the majority of U.S. healthcare 
professionals is maintained. It must make sure that the VA is able to 
sustain its research mission that benefits not only veterans, but also 
every American. It must ensure that the private sector has the capacity 
to absorb an influx of veterans in a timely manner, and delivers 
excellent care. Given that non-VA care is more expensive than VA care, 
Congress must ensure that Choice is used judiciously so that there is 
no reduction in the level of services available to veterans. Finally, 
it must ensure that the VA is improved, not dismantled, because that's 
what veterans overwhelmingly prefer, and have been promised by 
administration and Congressional officials. Our analysis of major 
policy ideas for the next version of Choice concludes that only one 
proposal does all this.
             proposals for veterans choice program renewal
    At least four ideas for modifying Choice have been proposed by 
policymakers and veterans' stakeholders. One--which we endorse--would 
fortify VA-delivered care and its management of the network of Choice 
providers. The other three concepts, although structured differently 
and still lacking specific details, would eliminate distance and wait 
time requirements, purchase far more care in the private sector, cut VA 
services and incrementally privatize veterans' healthcare.
    The following are the four ideas, and their potential impact on 
veterans' healthcare if enacted:

1. Strengthen VA Delivered Care
The VA eliminates third party administrators and assumes direct 
        management of high performing, integrated networks. Disparities 
        between supply and demand are addressed first by resourcing 
        VAs. External providers are used only to fill in gaps that 
        local VAs cannot provide. Eligibility for Choice is based on 
        distance and wait time criteria that are convenient for the 
        veteran.
Impact:
     Builds and strengthens the VA system for the long term.
        - Hires VA front line and support staff in locations where 
        demand outstrips supply.
        - Increases VA appointment capacity.
        - Maintains quality assurance.
     Supplements care when needed.
        - Ensures that when timely, nearby VA care is not available, 
        care is outsourced to the community.
     Is fiscally efficient.
        - Eliminating 3rd party administrative middlemen saves money 
        and streamlines initiation of Choice care, when needed.
        - Hiring VA staff rather than purchasing more expensive private 
        sector care reduces costs.
        - Gives VAs the ability to manage utilization and control 
        expenses.
     Supports the comprehensive integrated care approach.
        - VA generalists treat veterans in primary care clinics and 
        then walk them down the hall to meet with a behavioral health 
        professional, pharmacist, social worker, nutritionist or other 
        specialist.
        - The VA's coordinated, integrated care is not only more 
        effective than the private sector's, it's far more convenient 
        to veterans because everything is handled in one location.

2. Make Choice Cards Universal
Allow eligible veterans to seek unrestricted care from any outside, 
        certified provider, without needing to obtain pre-
        authorization.
Impact:
     Fragments, diminishes and delays quality care.
        - Relies on community providers who are not vetted for quality 
        and/or are less knowledgeable about veteran specific healthcare 
        issues.
        - Increases wait times in the private sector for veterans as 
        well as non-veterans. There aren't enough primary care, 
        specialist, or mental health services in the community. By 
        2030, the U.S. will face a shortage of between 40,800 to 
        104,900 physicians.\3\
---------------------------------------------------------------------------
    \3\ IHS Markit, The Complexities of Physician Supply and Demand 
2017 Update: Projections from 2015 to 2030. Prepared for the 
Association of American Medical Colleges. Washington, DC: Association 
of American Medical Colleges. February 28, 2017
---------------------------------------------------------------------------
        - Because many physicians are unwilling to accept Choice 
        payment rates,\4\ veterans may have difficulty finding a 
        qualified provider.
---------------------------------------------------------------------------
    \4\ Bishop, T, Press, M.J., Keyhani, S. & Pincus, H.A. (2014). 
Acceptance of Insurance by Psychiatrists and the Implications for 
Access to Mental Health Care. JAMA Psychiatry, 71(2), 176-181.
---------------------------------------------------------------------------
        - Creates uncoordinated administrative structures in which 
        accountability is diminished.
        - Spreads treatment across the private sector, thereby reducing 
        care coordination and integration. The Commission on Care Final 
        Report \5\ (page 28) recognized: ``Veterans who receive health 
        care exclusively through VHA generally receive well-coordinated 
        care, yet care is often highly fragmented among those combining 
        VHA care with care secured through private health plans, 
        Medicare, and TRICARE. This fragmentation often results in 
        lower quality, threatens patient safety, and shifts cost among 
        payers.''
---------------------------------------------------------------------------
    \5\ Commission on Care. (2016). Commission on Care: Final Report. 
Retrieved from https://s3.amazonaws.com/sitesusa/wp-content/uploads/
sites/912/2016/07/Commission-on-Care_Final- Report_063016_FOR-WEB.pdf
---------------------------------------------------------------------------
        - The private sector virtually never screens for PTSD, MST or 
        many other veteran problems, so many cases will be missed and 
        untreated.
        - Suicide prevention programs in the community are generally 
        far less comprehensive than in the VA.
     Leads to downsizing of VA delivered care.
        - Allows veterans to bypass the VA for services and send the 
        bill to the VA for payment, even if the VA can provide prompt 
        care that is closer and of higher quality. VA would cover the 
        expenses of outsourced care by reducing their staff, programs, 
        and services.
        - Allows eligible veterans who previously have been receiving 
        care outside the VA using their own health insurance to send 
        their bills directly to the VA for payment. That will further 
        drain the VA budget.
        - Impairs VA's ability to continue to outperform the public 
        sector, since funds are diverted to pay for Choice.
        - Secretary Shulkin's testimony at the June 7, 2017 Senate 
        Committee on Veterans Affairs hearing affirmed: ``Just giving 
        veterans a card, a voucher, and let them go wherever they want 
        to go . . .  is appealing to some but it would lead to 
        essentially the elimination of the VA system altogether. It 
        would put veterans with very difficult problems out into the 
        community with nobody to stand up for them and to coordinate 
        their care, and the expense of that system is estimated to be 
        at the minimum $20 billion dollars more a year than we 
        currently spend on VA healthcare.'' \6\
---------------------------------------------------------------------------
    \6\ Examining the Veterans Choice Program and the Future of Care in 
the Community. Presentation before the Senate Committee on Veterans' 
Affairs, 114th Cong. 1 (June 7, 2017) (Testimony of David Shulkin).

3. Limit the VA's Core Mission To Foundational Conditions
Redefine the VA's core mission as focusing on the treatment of 
        foundational conditions, such as PTSD, Traumatic Brain Injury, 
        polytrauma, blindness, spinal cord injury, pain, limb loss and 
        mental health. Outsource most of the remaining care to 
        providers in the private sector.
Impact:
     Diminishes the quality and comprehensiveness of veterans' 
healthcare.
        - Outsourcing services to the private sector could mean many 
        veterans may not receive high quality care. In study after 
        study that contrasts private sector services to those of the 
        VA, (including again in Definitive Healthcare's 2017 summary 
        \7\), the quality of government-run VA care has been shown to 
        be as good as and often better than private sector care. That's 
        true across the spectrum, including for diabetes, heart 
        disease, geriatric care, serious mental illness, PTSD, 
        depression, safety practices, preventive care, surgical 
        complications, infection control, hospital readmissions, 
        hospital mortality and medication 
        compliance.\8\-\14\
---------------------------------------------------------------------------
    \7\ Foltz, W. (2017, April 24). The VA Healthcare System--
Definitive Healthcare. Retrieved June 8, 2017, from https://
www.definitivehc.com/hospital-data/the-va-healthcare-system-a-broken-
system-with-superior-quality
    \8\ Farmer, C. M., Hosek, S. D., & Adamson, D. M. (2016). Balancing 
Demand and Supply for Veterans' Health Care [Product Page]. Retrieved 
February 14, 2017, from http://www.rand.org/ pubs/research_reports/
RR1165z4.html
    \9\ Association of VA Psychologist Leaders. (2016, March 23). 
Comparison of VA to community healthcare: Summary of research 2000-
2016. Retrieved from http://avapl.org/advocacy/pubs/ 
FACT%20sheet%20literature%20review%20of%20VA%20vs%20Community%20Heath%20
Care% 2003%2023-16.pdf
    \10\ O'Hanlon, C., Huang, C., Sloss, E., Price, R., Hussey, P., 
Farmer, C., & Gidengil, C. (2017). Comparing VA and Non-VA Quality of 
Care: A Systematic Review. Journal of General Internal Medicine, 32(1), 
105-121. https://doi.org/10.1007/s11606-016-3775-2
    \11\ Ho, P.M., Lambert-Kerzner, A., Carey, E.P., Fahdi, I.E., 
Bryson, C.L., Melnyk, S.D., . . . Del Giacco, E. J. (2014). 
Multifaceted intervention to improve medication adherence and secondary 
prevention measures after acute coronary syndrome hospital discharge: a 
randomized clinical trial. JAMA Internal Medicine, 174(2), 186-193. 
https://doi.org/10.1001/jamainternmed.2013 .12944
    \12\ Tanielian, T., Farris, C., Batka, C., Farmer, C.M., Robinson, 
E., Engel, C.C., . . . Jaycox, L.H. (2014). Ready to Serve: Community-
Based Provider Capacity to Deliver Culturally Competent, Quality Mental 
Health Care to Veterans and Their Families. Santa Monica, CA: RAND 
Corporation. Retrieved from http://www.rand.org/pubs/research_reports/
RR806.html
    \13\ Kavanagh, K.T., Abusalem S., & Calderon, L.E. (2017). The 
incidence of MRSA infections in the United States: Is a more 
comprehensive tracking system needed? Antimicrobial Resistance & 
Infection Control, 6(34)DOI: 10.1186/s13756-017-0193-0
    \14\ Nuti, S.V., Qin, L., Rumsfeld, J.S., Ross, J.S., Masoudi, 
F.A., Normand, S.-L.T., . . .  Krumholz, H.M. (2016). Association of 
Admission to Veterans Affairs Hospitals vs. Non-Veterans Affairs 
Hospitals With Mortality and Readmission Rates Among Older Men 
Hospitalized With Acute Myocardial Infarction, Heart Failure, or 
Pneumonia. JAMA, 315(6), 582-592. https://doi.org/10.1001/
jama.2016.0278
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        - Private sector providers have less expertise in detecting and 
        treating underlying conditions to which veterans are highly 
        vulnerable. For example, a general practitioner is less likely 
        to explore PTSD as the reason for chronic insomnia, the impact 
        of Traumatic Brain Injury on mood and decisionmaking, or that a 
        particular condition--asthma induced by burn-pits or diabetes 
        produced by Agent Orange exposure--is related to military 
        service.
        - Many veterans have comorbid physical and mental health 
        problems, which require integrated care. This is especially 
        true of the large number of aging veterans.
     Increases wait times for veterans and non-veterans in the 
private sector.
        - As in #2, this plan leads to longer wait times in the private 
        sector, which is already is struggling to keep up with demand. 
        There aren't enough private sector doctors available to treat 
        veterans or willing to accept Choice payment.
     Severely impacts poor, mentally ill and homeless veterans.
        - The VA has substantial programs that have had a significant 
        impact on veteran homelessness. VA actively attempts to locate 
        homeless veterans and ensure they are housed and cared for. The 
        VA employs peer specialists who routinely reach out to veterans 
        diagnosed with schizophrenia and other serious mental illness 
        who have stopped showing up to appointments. Few private sector 
        facilities offer the level of robust wrap-around psychosocial 
        services that are standard in the VA.
     Reduces VA clinics and access for veterans who value and 
choose VA.
        - Major segments of VA healthcare would be outsourced to the 
        private sector.
4. Allow Choice Eligibility Based On A Composite Community Standard 
        Metric
Bases eligibility for Choice on a community standard metric, which will 
        be a composite of patient satisfaction, wait time and quality 
        measures. Where the composite score for a local VAMC non-
        foundational service line falls below that number, all veterans 
        in that local clinic will automatically be eligible for Choice. 
        Independent of whether VAMC service lines exceed that number, 
        individual veterans can be granted Choice once they discuss VA 
        and Choice options with their VA provider. Uses high-performing 
        integrated networks for outsourced care.
Impact:
     Changes Choice eligibility to be based on a composite 
measure (comprised of wait time + patient satisfaction + quality 
metrics).
          Individual veteran level eligibility: Once veterans and their 
        providers discuss and compare VA and community alternatives, 
        veterans may be granted Choice. However:

        - Neither the VA's Access and Quality Tool website http://
        www.accesstocare.va.gov/ nor Medicare's Hospital Compare 
        website https://www.Medicare.gov/hospitalcompare/search.html 
        have the data that veterans need to make informed decisions. In 
        most cases, comparative metrics don't exist.
        - There is no available data on a facility's effectiveness in 
        reducing symptoms or functional deficits.
        - There is no data on outpatient care.
        - Many diagnoses aren't included.
        - There is no data on use of evidence-based psychotherapies.
        - There is no data about private practitioners.
        - Although wait times at VA facilities are published, community 
        wait times are unknown.

          Clinic level eligibility: When a VA non-foundational service 
        line's composite score falls below their community's score, all 
        veterans in that clinic will automatically be eligible for 
        Choice for that service. However:
        - The algorithm to compute this composite metric has not been 
        developed.
        - Including patient satisfaction in this metric is inherently 
        problematic, since patient satisfaction scores have not been 
        found to relate to the provision of good health care.\15\ \16\
---------------------------------------------------------------------------
    \15\ Fenton, J.J., Jerant, A.F., Bertakis, K.D., & Franks, P. 
(2012). The cost of satisfaction: a national study of patient 
satisfaction, health care utilization, expenditures, and mortality. 
Archives of Internal Medicine, 172(5), 405-411. https://doi.org/
10.1001/archinternmed.2011.1662
    \16\ Brookes, L. (Interviewer) & Fenton, J. J. (Interviewee). 
(2014). Patient Satisfaction and Quality of Care: Are They Linked 
[Interview Transcript]. Retrieved from Medscape News and Perspectives 
site: http://www.medscape.com/viewarticle/826280_5
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        - Comparing VA with community composite scores is misleading, 
        since they are not apples-to-apples comparisons. Private sector 
        statistics are based on non-veteran patients who, on average, 
        are younger and have fewer medical and mental health conditions 
        than do veterans.\17\ \18\
---------------------------------------------------------------------------
    \17\ Klein, S. (2011, September). The Veterans Health 
Administration: Implementing patient-centered medical homes in the 
Nation's largest integrated delivery system. The Commonwealth Fund. 
Retrieved from http://www.commonwealthfund.org//media/files/
publications/case-study/ 2011/sep/1537_klein_veterans_hlt_admin_case-
study.pdf
    \18\ U.S. Department of Veteran Affairs. (2016). Restoring trust in 
Veterans health care: Fiscal year 2016 annual report. Retrieved from: 
https://www.va.gov/HEALTH/docs/VHA_AR16.pdf
---------------------------------------------------------------------------
        - Metrics can confuse mathematical differences with meaningful 
        clinical differences. A difference between a 14-day and a 16-
        day wait may not be justification for more expensive private 
        care.
     Increases costs and decreases productivity.
        - Reduces VA's ability to control costs if veterans have the 
        prerogative to opt for private sector care even when the local 
        VA is able to provide treatment that is less expensive, 
        clinically superior, quicker and/or closer.
        - Requires VA providers to devote extra time mastering 
        knowledge of private sector scores and going over those with 
        patients. This decreases clinician productivity and increases 
        wait times.
        - Is more expensive overall than the current VA system.
     Incrementally removes option of the VA for veterans 
seeking VA as their home.
        - There will be a steady flow of funds out of the VA and into 
        private sector care. If funds that could have been used to make 
        improvements are diverted to pay for Choice, VA facilities that 
        lag behind will never be able to catch up. Even high performing 
        VA's will falter when funds diminish.
        - Dozens of VA service lines are already identified as falling 
        below the metric, qualifying all of the clinic veterans to be 
        automatically eligible for Choice.
     Fragments care.
        - Encourages the VA to provide foundational services and 
        outsource other services to the private sector.
        - Bi-directional, interoperable sharing of VA and private 
        sector electronic medical records does not exist.
     Expands provider network where needed.
        - Aims to develop high-performing networks that link the 
        private sector to the VA over time, although they are not yet 
        available.
                                analysis
    Making significant, lasting improvements in the VA's ability to 
provide high quality care without serious delays is unquestionably the 
right thing to do. It honors the sacred obligation we owe to veterans, 
to care for those who have borne the battle. In our analysis, idea #1 
optimally achieves what Choice was intended to do--remedy wait time 
delays by outsourcing care when the VA doesn't have prompt or existing 
services--without collateral damage to the unique advantages, superior 
quality, cost-effectiveness and integration within the VA healthcare 
system. It observes the guiding principle for healthcare systems and 
doctors, ``first, do no harm.''
    In a fixed pot, every dollar spent on Choice would be subtracted 
from local VA budgets. Choice care is paid first and the VA makes do 
with what's left. Expansion of Choice inherent in ideas #2, 3 and 4 
sets in motion a hollowing out, in which over time, local VAs will have 
less money, vacant positions won't be filled, medical services will be 
cut back and clinics closed. As the availability of VA's services 
diminish, more veterans will opt for or be placed into Choice, leading 
to more VA cuts in a vicious cycle. These models degrade the quality of 
options that already exist. They inexorably privatize veterans' 
healthcare, with the conversion occurring quickly in ideas #2 and 3, 
and gradually in idea #4. Idea #1 impedes privatization.
    Idea #1 best supports the VA's integrated care model. The VA's one-
stop approach facilitates the immediate identification and referral of 
a variety of problems, for example, when a veteran hints at feeling 
suicidal during an optometry appointment and is walked down the hall to 
a mental health clinician. It best supports the VA's holistic approach 
that incorporates the physical, psychological, social, and economic 
aspects of health and the impact these factors have on treatment 
compliance. Care provided in ideas #2 and 3, and to some degree in #4, 
is more fragmented, and limited to just the patient's chief complaint. 
Further, there is no ability at present to bi-directionally coordinate 
VA-community care via electronic medical records.
    Idea #1 is the only one that assures continuity of the VA's 71-
year-old statutory education mission. More than two-thirds of all U.S. 
doctors, not just VA doctors, receive their training at VA facilities. 
So do 40 other healthcare professions. Ideas #2, 3 and 4 lead to 
reductions in the number of VA attending supervisors, case volume, 
resident rotations and specialty training programs. A decline in VA 
training opportunities will be calamitous, given the shortages that 
already exist. There is no large-scale capacity in the private sector 
to train knowledge and skills of practitioners.
    Idea #1 most effectively fosters groundbreaking research that has 
been the hallmark of the VA. More than 60% of VA researchers are 
clinicians, and their studies originate from daily interactions with 
veterans.\19\ The VA has the largest integrated electronic medical 
record system in the world, uniquely enabling research questions to be 
pursued. Studies aimed at better understanding and treating veterans' 
conditions will be nearly impossible if care is scattered across the 
community.
---------------------------------------------------------------------------
    \19\ U.S. Department of Veteran Affairs. (2016). Restoring trust in 
Veterans health care: Fiscal year 2016 annual report. Retrieved from: 
https://www.va.gov/HEALTH/docs/VHA_AR16.pdf
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    Although ideas #1 and #4 are similar in some respects, there are 
key differences between them.
     #1 grants Choice options on a case-by-case circumstance. 
#4 does this too, but also grants Choice to large groups of veterans in 
identified clinics.
     #1 upholds the VA as a system treating a full complement 
of conditions. In #4, the VA emphasizes the provision of foundational 
services.
     While there have been important concerns raised about the 
use of distance and wait times to determine Choice eligibility in #1, 
these criteria allow the VA to manage Choice utilization and costs. The 
substitute composite metric in #4 is still unformed and untested.

    The best information to date shows that community care is likely 
more expensive than VA's.\20\ To offset added systemic costs for Choice 
care in plans #2, 3 and 4, it's likely that some current or future 
veterans would no longer be served, and/or charged higher deductibles 
and out of pocket expenses. Cutting benefits to disabled unemployable 
veterans to pay for Choice expansion was proposed in the original FY 
2018 VA budget, although policymakers scrapped that idea recently and 
are now searching for a substitute.\21\
---------------------------------------------------------------------------
    \20\ Congressional Budget Office. (2014, December). Comparing the 
costs of Veterans' health care system with private-sector costs. 
Retrieved from https://www.cbo.gov/sites/default/files/113th-congress-
2013-2014/ reports/49763-VA_Healthcare_Costs.pdf
    \21\ https://www.stripes.com/news/va-backs-off-budget-proposal-to-
cut-benefits-for-disabled- unemployable-vets-1.473551#.WUKEHnXysdV
---------------------------------------------------------------------------
    There is a myth that the only way the VA will be motivated to excel 
is if it is forced to compete with the private sector for its 
customers. This in spite of the reams of studies that show the VA--
without relying on market-based incentives--already delivers care that 
is equal or superior to that provided in the private sector. The sense 
of mission to serve veterans is what motivates VA employees, and with 
convincing effect.
    Ideas #2, 3 and 4 contradict what veterans overwhelmingly want--
that the VA's clinical care and breadth of services be fixed and 
strengthened, not dismantled.\22\ That's especially true for those 
veterans who use the VA.
---------------------------------------------------------------------------
    \22\ VFW. (2017). Our Care 2017: A report evaluating Veterans 
health care. Washington D.C.: VFW. Retrieved June 7, 2017, from https:/
/www.vfw.org/news-and-publications/press-room/ archives/2017/3/vfw-
survey-veterans-want-va-fixed-not-dismantled

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    We recommend other considerations for Choice redesign:

     Build VA capacity first.
        - Sustain budgets that assure all VA facilities have sufficient 
        capability to provide comprehensive, high performing care. Such 
        resources include staff, space and IT support. It would be a 
        mistake to expand the Choice Program without first increasing 
        the capacity for care at VA facilities where demand for 
        services exceeds supply.
        - Enhance telehealth resources (in VA's FY 2018 budget request) 
        so that veterans have expanded access to VA providers without 
        needing to go outside the VA.
     Guarantee a high level of coordinated, integrated care.
        - Mandate that Choice providers/facilities be able to bi-
        directionally exchange electronic VA medical records before 
        they are accepted into the Choice program.
        - Mandate that Choice providers engage in the same treatment 
        recommendation process expected of VA providers, i.e. for them 
        to understand what medical and mental health services are 
        available at their local VAs and refer their veteran patients 
        to the VA when the VA renders higher quality care.
     Strengthen the VA brand.
        - Include only high quality providers in the network. Choice 
        should not mean that VA relies on partners simply because they 
        are willing to accept payment, without adhering to the same 
        high quality standards. Stipulate in Choice contracts that 
        providers meet VA's elevated standards, use evidence-based 
        treatments, have knowledge of military culture and competence 
        in veteran-specific problems, engage in ongoing measurement of 
        progress, and perform screenings, such as for PTSD, Military 
        Sexual Trauma and Suicide Prevention.
        - Expand opportunities for the VA to publicize and advertise 
        what it does well. The public remains grossly uninformed about 
        its successes, innovations and overall superior quality.
                                 ______
                                 
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
        Prepared Statement of Urgent Care Association of America

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
 Prepared Statement of Rubina DaSilva, MBA, PA-C, President, Veterans 
                Affairs Physician Assistant Association
    Chairman Isakson, Ranking member; Senator Tester and other members 
of the Senate Veterans' Affairs Committee, On behalf of the entire 
membership of the Veterans Affairs Physician Assistant Association 
(VAPAA) we appreciate the invitation to submit this testimony for the 
record. We thank bipartisan Members of this Committee for critical 
legislation for Physician Assistant (PA) Workforce issues before you 
today in the VA System with sponsoring ``Grow Our Own Directive: 
Physician Assistant Employment and Education Act of 2017.'' (S. 426) 
and we thank Senator Tester for his leadership on this bill.
    The Physician Assistant (PA) profession has a special unique 
relationship with veterans. The very first classes of physician 
assistants to graduate from PA educational programs were all former 
Navy corpsmen and Army medics who served in the Vietnam War and wanted 
to apply their knowledge and experience in a civilian role in 1967. 
Today, there are approximately 2,178 PAs employed by the Department of 
Veterans Affairs (VA), making the VA the largest single Federal 
employer of PAs. These PAs provide high quality, cost effective quality 
health care working in hundreds of VA medical centers and outpatient 
clinics, providing medical care to thousands of veterans each year in 
their clinics. Physician Assistants work in Primary Care and Lead PACT 
teams of nursing, pharmacist, social workers, dieticians, and 
rehabilitation services.
    The Veterans Affairs Physician Assistant Association (VAPAA) 
maintains that Physician Assistants are a critical component of 
improving VA health-care delivery, and have consistently recommended 
that VHA include them in all health-care national strategy staffing 
policy plans. PAs have remained on the OIG Top Ten critical occupation 
2015 and 2016 tied at number 3 and have remained a top ten critical 
occupation on the Workforce Succession Planning from 2010 -2016. The 
occupation 0603 Physician Assistant--there were 640 vacancies, 
representing a 23% vacancy rate.
    In 1990, VA turnover for registered nurses was 20%, because of 
continued problems, Congress enacted the Nurse Pay Act of 1990 (Public 
Law 101-366) requiring VA to establish a locality pay system for nurse. 
The acts primary intent was to make VA salary rate competitive with 
those in the private sector health care facilities in the same 
communities. VA implemented the locality pay system on April 7, 1991, 
about 8 months later after the passage of the act.
    Workforce Management Consultant (WMC) in 2016 stated that 
Converting Physician Assistant (PA) pay structure to the Nurse Locality 
Pay System (LPS): ``it is unknown if converting Physician Assistants to 
the Nurse Locality Pay System will improve recruitment and retention at 
those facilities.'' This, despite acknowledging that Congress and VA 
enacted the Nurse Pay Act of 1990 (Public Law 101-366) for a vacancy 
rate of 20% for nurses.
    VA WMC acknowledge the recommendation to convert PAs to the nurse 
Locality Pay System (LPS) was incorporated in VHA's 2015 Strategic 
Workforce Plan and that the Secretary has the authority to place PAs on 
the LPS--but USH and Secretary have not done so, thus continuing the 
problems with recruitment and retention of PAs which directly impacts 
access to veteran care.
    On April 20, 2016, Dr. McCarthy Assistant Deputy under Secretary 
for Health for Patient Care Services Veterans Health Administration 
testified:

          The PA occupation has been a difficult to recruit and retain 
        occupation for several years. A major barrier to recruitment 
        and retention of physician assistants is the significant pay 
        disparity between private sector market pay and VA pay 
        schedules for PAs. Although Special Pay rate authority exists 
        at the medical center level to address these disparities, it is 
        antiquated and vastly underutilized. Salary surveys performed 
        during FY 2015 by several VA medical facilities has resulted in 
        establishment or adjustment in local special salary rates for 
        the PA occupation resulting in significant increases in 
        salaries. This is an indication of the existing salary 
        disparity overall. Including the PA occupation as a covered 
        occupation under the Locality Pay System in VA would be an 
        important element in addressing recruitment and retention 
        difficulties.

    Not including PAs in the LPS is an unsuccessful business and 
medical model for the VA as is it eliminating one third of its 
applicant pool that can provide care to veterans; it is creating an 
artificial and sustaining staffing shortage which is limiting Veteran 
access to care.
    Costs such as recruitment, retention, relocation, bonuses, 
scholarships, employing locum tenens, and locality pay are 
substantially increased with higher overhead for two profession vs 
three self-sustaining professions--Physicians, PAs and NPs.
    WMC (Workforce Management) rebuts that giving nurse locality to 
PAs, then VA is obligated to give LPS to every profession. If Congress 
or VA gives podiatry locality it only helps the recruitment of 
podiatrist. If locality is given to PA's it will improve recruitment 
and retention of PA while increasing access to veterans in all VHA 
facilities and CBOCs within VHA as PAs carry their own veteran panels 
and practice in all areas of medicine. They work in both ambulatory 
care clinics, emergency medicine, CBOC's in rural health, and in a wide 
variety of other medical and surgical subspecialties including mental 
health, Women's Health, Compensation and Pension, Rehabilitation 
Services, Medical Home, Cardiology, Gastroenterology, Orthopedics, 
Dermatology, Rheumatology, Endocrinology, Emergency Services, 
Hospitalists, Intensivist, ENT, Radiology, Nuclear Medicine, Urology, 
Occupational Medicine, Renal, General Surgery, Cardiothoracic Surgery, 
Home Based Primary Care (HBPC), Community Living Centers, VHA Nursing 
Home
    In the VA system about a quarter of all primary care patients 
treated are seen by a PA1. Approximately 33% of PAs today employed by 
VHA are veterans, retired military, or currently serving in the 
National Guard and Reserves.
    Not one profession; Physician, PA or NP can sustain a local 
workforce as the VHA must compete with the private sector as the local 
demand recruits each profession which creates a delay in veteran 
access.
    It is only within the VA that you see the disparity of VHA PA pay 
and the private sector pay. Large health care systems such as Kaiser 
Permanente, Mayo, and Cleveland clinic have competitive salary.
    The 2015 Workforce Succession Planning Report showed that 12 out of 
the 22 VISN (85 main facilities not including respective CBOCs) stated 
that the reason they could not hire PAs was because they could not 
compete with the private sector. These VISNs had in their plan to 
conduct salary surveys to seek parity with private sector. However, 
upon recent review from 1/2014-2/2015 of submissions for PA special 
salary rates to VA Compensation Office, less than 8% submitted such 
requests.
    July 2017 review of facilities submitting Special Salary 
Adjustments (SSA) have shown that the pay disparity between VHA PA pay 
was an average of 18% below local market pay with the highest being 
34%. The data further supported facilities that sought out special pay 
rates were then able to immediately fill all positions which resolved 
the difficulty recruiting PAs. This demonstrates the strong correlation 
between seeking parity with the private sector and hiring hard to 
recruit PA positions within VHA.
    The PA workforce has grown far less than other medical provider 
positions within the VHA, very little is being done about it; 
therefore, what should be a warning signal of serious retention and 
recruiting problems is being left to local VAMCs to manage. Despite 
increasing discrepancy in salary levels, benefits, and education debt 
reduction programs between the civilian sector and the VAMCs often 
tells our members there is no problem. Inclusion of Physician 
Assistants into the Nurse LPS within Grow Our Own Directive S. 426 will 
allow for salary adjustments so that the VHA can be competitive.
    VAPAA is also concerned that the use of recruitment incentives 
within the VA is at the discretion of the hiring facility and is not 
standardized across the VA system. During 2012-2013 only 44 Physician 
Assistants have received $319,074 in funding to further their education 
in comparison to Seven hundred five registered nurses seeking to become 
Nurse Practitioners receiving scholarship awards totaling over 
$11,842,919 in support of NPs and NP programs. VA should implement 
recruitment and retention tools targeting Employee Incentive 
Scholarship Program by including PA as a hard to recruit occupation at 
the facility level to reflect WSP and OIG findings. Include Employee 
Debt Reduction Program funding to include PAs and make it available to 
all advertised PA vacancy announcements as EDRP cannot be issued unless 
it is advertised in the initial vacancy announcement. VISN and VA 
medical center directors must be held accountable for the failure to 
utilize these recruiting tools.
    S. 426 also provides another solution for meeting the healthcare 
workforce challenges while providing support to unemployed Post-9/11 
combat veterans and a career path for returning veterans who had served 
as medics and corpsmen with combat medical skills; like those of 
returning Vietnam War veterans with these skills. This legislation 
takes veterans with medical and military experience and provides them 
with educational assistance to become certified PAs for employment at 
the VA, where they can continue to serve their fellow veterans.
    By serving where the VA needs are the greatest, the veteran PAs can 
increase access to care by serving in rural and underserved areas.
    Recommendations: We ask that the Committee recognize the advantages 
to the Recruitment and Retention of Physician Assistant (PA) Workforce 
in the VA System by supporting enactment and supported by the veteran 
service organizations at the November 18, 2015 hearing on S. 2134 and 
call attention the VHA witness Dr. Carolyn McCarthy testified in favor 
of this legislation ``Grow Our Own Directive: Physician Assistant 
Employment and Education Act of 2015.'' (S. 2134) and (H.R. 3974).
    A. Restructure VHA Handbook 1020--Employee Incentive Scholarship 
Program (EISP).
    B. Include PAs at all facility level to reflect Workforce 
Succession Planning and the OIG Top 5 as a hard to recruit occupation 
as this is the qualifying factor for EISP funding.
    C. Include Education Debt Reduction Plan in all PA job postings.
    D. Include targeted scholarships for the ICT program OIF OEF Grow 
Our Own returning veterans, and mandate VHA shall appoint PA ICT 
National director to coordinate the educational assistance necessary 
and be liaison with PA university programs.
    E. S. 426 would direct new Physician Assistant director position to 
work within the National Healthcare Recruiter, Workforce Management & 
Consulting VHA Healthcare Recruitment & Marketing Office.
          a. This position then can develop targeted recruiting plans 
        with 187 PA programs, working in a way that the local Human 
        Resource Officer (HRO) often will not; due to lack of staffing.
    F. The VA employed PA national Healthcare Recruiter would develop 
improvements in finding qualified candidate in a matter of days not 
months.
    G. VHA must incorporate new PA consultant manager into this 
National Healthcare Workforce program office.
    H. Health Professional Scholarship Program.--The Health 
Professional Scholarship Program (HPSP) provides scholarships to 
students receiving education or training in a direct or indirect health 
care services discipline. Awards are offered on a competitive basis and 
are exempt from Federal taxation. In exchange for the award, 
scholarship program participants agree to a service obligation in a VA 
health care facility. The Committee believes strongly that ample 
resources exist within the Department to ensure that hard to fill Top 5 
OIG occupations are not excluded from participation.
    I. Establish PA Pay Grades I-V, to continue be competitive with the 
civilian job market
                               conclusion
    Chairman Isakson and Ranking Member Senator Tester, and other 
Members of SVAC, as you strive to ensure that all veterans receive 
timely access to quality healthcare and as you build increased capacity 
for delivery of accessible high-quality health care, and demand more 
accountability into the VA health care system, I strongly urge the full 
Committee to review the important critical role of the PA profession 
and ensure legislatively that VHA takes immediate steps to address 
these longstanding problems and continue to work with VAPAA in 
supporting our Nation's veterans.
                                 ______
                                 
 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, I would like to 
thank you for the opportunity to testify on today's pending 
legislation.
                s. 115, veterans transplant coverage act
    This legislation would authorize the Department of Veterans Affairs 
(VA) to provide live donor transplants to veterans eligible for VA 
health care regardless of the live donor's eligibility for care at VA. 
Currently, VA provides care to non-veterans who fall under one or more 
of the eight categories in which they are authorized to provide medical 
coverage. These categories range from survivors and dependents of 
certain veterans, newborn children of women veterans and in cases of 
humanitarian care.
    By authorizing VA to perform medical care on non-veteran live 
donors in situations of medically necessary transplants for veterans, 
more veterans will be able to obtain lifesaving surgery in a timelier 
manner. The VFW strongly supports this legislation.
  s. 426, grow our own directive: physician assistant employment and 
                         education act of 2017
    This legislation would build on the success of the Intermediate 
Care Technician (ICT) pilot program. Launched in December 2012, the ICT 
pilot program recruited transitioning veterans who served as medics or 
corpsmen in the military to work in VA emergency departments as 
intermediate care technicians. The ICT program offered transitioning 
medics and corpsmen, who have extensive combat medicine experience and 
training, the opportunity to provide clinical support for VA health 
care providers without requiring them to undergo additional academic 
preparation.
    This legislation would go a step further by affording transitioning 
medics and corpsmen the opportunity to become physician assistants. 
With the continued drawdown of military personnel, more medics and 
corpsmen will be leaving military service and transitioning into the 
civilian workforce. The VFW strongly supports efforts to leverage their 
medical knowledge and experience to meet the health care needs of our 
Nation's veterans.
    s. 683, keeping our commitment to disabled veterans act of 2017
    This legislation would extend, for one year, the requirement for VA 
to provide nursing home care to certain veterans with service-connected 
disabilities.
    As the veteran population continues to age, the need for nursing 
home care continues to rise. Nursing home care within VA is considered 
the ``safety net'' for their outpatient services such as residential 
care, respite care, hospital-based home care, adult day health care, 
homemaker/home health aide services and other extended care programs. 
Yet the eligibility requirements for nursing home care and inpatient 
hospital care are inconsistent with standard medical practice and do 
not support continuity of care for veterans.
    The VFW supports the intent of this legislation, but believes a 
standard for VA nursing home entitlement must be established for all 
veterans--not just veterans with a disability rating of 70 percent or 
higher.
s. 833, servicemembers and veterans empowerment and support act of 2017
    This legislation would expand health care and benefits from VA for 
veteran survivors of sexual trauma. While the VFW agrees with the 
intent of this legislation, there are concerns as well. The VFW 
strongly supports the expansion of coverage to include survivors of 
cyber harassment. As technological capabilities have continued 
expanding and becoming more accessible, many have fallen victim to 
sexual harassment and assaults of a sexual nature on the Internet and 
by other technological means. Survivors of cyber harassment should not 
fall victim again by being pushed to the wayside due to legal 
definitions not being inclusive of them. Regardless if an individual is 
sexually harassed or assaulted in a physical nature, or by means of 
technology, they deserve the right to seek counseling and treatment.
    Section 2 would also expand the population who can use VA for 
counseling and treatment beyond the current restriction of only those 
who were assaulted while serving on active duty. It is the duty of 
Congress and VA to take care of every veteran who served, regardless of 
their duty status.
    The VFW supports codifying the standard of proof for sexual trauma, 
as current law only regulates combat veterans. Yet, there are concerns 
with some portions of this section. Some inconsistencies can be found 
throughout section 3, which begins by saying it is covering all 
veterans making a claim of ``a covered mental health condition'' either 
due to, or aggravated by, military sexual trauma (MST). While this term 
is later defined, further into section 3 there are inconsistencies 
where only Post Traumatic Stress Disorder is referenced for the 
nonmilitary sources of evidence, as well as under the notice and 
opportunity to supply evidence portion.
    The VFW has long advocated for nonmilitary sources of evidence to 
be able to be used by veterans filing disability claims with VA. 
Particularly for MST claims, as survivors may not have felt comfortable 
talking with military law enforcement, medical personnel or their 
commands. By expanding what veterans can submit as evidence for MST 
claims, to include records for non-military law enforcement, rape 
crisis centers, physicians and statements from others, this would 
greatly reduce the barriers of proof for survivors seeking treatment 
through VA. Yet, the VFW is concerned that by saying the Secretary 
shall accept nonmilitary evidence, but also saying the Secretary may 
seek a credible opinion during the review of evidence, will contradict 
and further complicate the benefits of allowing outside evidence.
    This legislation would also expand notifications of opportunity to 
supply evidence for disability claims. The VFW is concerned that by 
providing veterans submitting MST claims the opportunity to submit more 
evidence after a claim is submitted, and before the Secretary is able 
to deny the claim, will create a double standard. While the VFW 
supports improving the disability claims process for veterans claiming 
MST, providing them a benefit others do not have in their claims 
process would be unfair to other veterans. There should be equity for 
all veterans in not just health care, but in benefits and applications 
as well.
    This legislation would also require reports on claims for 
disabilities incurred or aggravated by military sexual trauma. One of 
the reporting requirements would be a description of training that the 
Secretary provides to employees of the Veterans Benefits 
Administration. The VFW believes this reporting requirement should not 
be limited to strictly employees, but should also include contractors 
and affiliates of the Veterans Benefits Administration. This would 
include contract physicians' compensation and pension exams, as well as 
Veteran Service Organizations assisting in benefit claims.
    The VFW supports section 4, which would ensure Sexual Assault 
Response Coordinators (SARCs) from the Department of Defense advise 
members of the Armed Forces reporting instances of sexual assault or 
harassment that they are eligible for services at Vet Centers. The VFW 
would like to see this section expand to ensure this information is 
provided during sexual assault awareness training as well as 
incorporated into training for the Sexual Assault Prevention Response 
Office.
        s. 946, veterans treatment court improvement act of 2017
    The VFW supports this legislation, which would require VA to hire 
50 additional Veterans Justice Outreach (VJO) Specialists to provide 
treatment court services to justice-involved veterans. These 
specialists serve as an invaluable asset in ensuring the VJO program 
helps veterans avoid unnecessary criminalization of mental illness and 
receive treatment in lieu of incarceration.
    Outreach specialists for VJO make sure veterans within the program 
have access to VA services, provide outreach, and handle case 
management for justice-involved veterans. By requiring VA to not allow 
their number of employed VJO Specialists to go lower than the number 
currently within the system the day this legislation would go into 
effect, as well as increasing that number by 50, more veterans in need 
of assistance and guidance through this unique and live-saving program 
will have access to Veteran Treatment Courts.
                      s. 1153, veterans access act
    This legislation would suspend or prohibit certain non-VA providers 
from providing community care health services to veterans. The VFW 
supports the intent of this legislation, but has concerns that must be 
addressed before passing.
    The Veterans ACCESS Act has four factors which would result in the 
denial or revocation of eligibility of a health care provider to 
provide non-VA health care services to veterans. One of those factors 
categorized under section 2 of this legislation would authorize the 
Secretary to revoke eligibility of a medical provider who violated a 
law for which a term of imprisonment of more than one year may be 
imposed. This particular part of the legislation has nothing 
specifically to do with medical licensing and is incredibly vague. The 
VFW agrees if a crime results in a medical provider losing their 
license that they should not be able to practice medicine, but that is 
already covered in this legislation.
    The VFW also has concerns with language stating that the Secretary 
may deny, revoke, or suspend the eligibility of health care providers 
under investigation by the medical licensing board of a state in which 
the provider is licensed or practices. This denies the providers their 
right to due process, as they are only under investigation and no 
verdict has been reached.
    Last, this legislation provides no means for health care providers 
who may have their eligibility revoked, but want to come back as a 
community care provider for VA patients. Particularly in rural areas, 
these community providers are crucial in allowing veterans timely 
access to care. If health care providers are not able to provide care 
to veterans using VA, the department should be required to explain to 
them how long they are revoked or suspended. In instances where 
providers are revoked, they must be informed of what they may do to 
provide community care again, as well as when they may reapply.
              s. 1261, veterans emergency room relief act
    The VFW strongly supports expansion of emergency treatment and 
urgent care in the community. However, we oppose the requirement to 
have VA establish copayments for community urgent and emergent care 
that is different from copayments charged for VA care. This proposal 
also makes no exception for veterans with service-connected 
disabilities or who are currently exempted from co-payments. Veterans 
currently exempted from co-payments should not be required to bear a 
cost-share for emergency and urgent care services.
    As an alternative, VA should consider establishing a national nurse 
advice line to help reduce overreliance on emergency room care. The 
Defense Health Agency (DHA) has reported that the TRICARE Nurse Advice 
Line has helped triage the care TRICARE beneficiaries receive. 
Beneficiaries who are uncertain if they are experiencing a medical 
emergency and would otherwise visit an emergency room, call the nurse 
advice line and are given clinical recommendations for the type of care 
they should receive. As a result, the number of beneficiaries who turn 
to an emergency room for their care is much lower than those who 
intended to use emergency room care before they called the nurse advice 
line. By consolidating the nurse advice lines and medical advice lines 
many VA medical facilities already operate, VA would be able to emulate 
DHA's success in reducing overreliance on emergency room care without 
having to increase cost-shares for veterans.
       s. 1279, veterans health administration reform act of 2017
    This legislation would, among other things, consolidate VA's 
community care authorities, expand VA's authority to provide emergency 
room and urgent care, and improve VA community care. The VFW supports 
this legislation and would like to offer suggestions to strengthen it.
    The VFW strongly believes that veterans have earned and deserve 
timely access to high quality, comprehensive, and veteran-centric 
health care. In most instances, VA care is the best and preferred 
option, but we acknowledge that VA cannot provide timely access to all 
services to all veterans in all locations at all times; that is why VA 
must leverage private sector providers and other public health care 
systems to expand viable health care options for veterans.
    The VFW supports section 2, but would like to offer recommendations 
to strengthen it. This section would build on lessons learned from the 
Veterans Choice Program to reform the way veterans access community 
care. When the Choice Program was first implemented, the VA wait time 
standard required a veteran to wait at least 30 days beyond the date a 
veteran's provider deemed clinically necessary--the clinically 
indicated date--before being considered eligible for the Choice 
Program. This meant that a veteran who was told by a VA doctor that he 
or she needs to be seen within 60 days was only eligible for the Choice 
Program if he or she was scheduled for an appointment that was more 
than 90 days out, or more than 30 days after the doctor's 
recommendation.
    After the VFW expressed concern that veterans' health may be at 
risk if they are not offered the ability to receive care within the 
timeframe their doctors deem necessary, Congress amended Public Law 
(PL) 113-146, the Veterans Access, Choice, and Accountability Act of 
2014, to require VA to offer veterans the option to receive care 
through the Choice Program if VA is unable to provide an appointment 
before the clinically indicated date.
    The VFW strongly believes that when and where veterans receive 
their health care is a clinical decision made by veterans and their 
doctors. This bill would rightfully base eligibility for the proposed 
Care in the Community Program on whether receiving care through 
community providers is in the clinical best interest of the veteran.
    Another lesson learned from the Choice Program is that geographic 
accessibility is difficult to define because it means different things 
in different locations and changes depending on the health care needs 
of the veteran concerned. That is why the VFW supports basing access to 
community care on whether a veteran would experience an undue burden if 
the veteran seeks care from VA. However, the VFW believes it necessary 
to authorize VA and veterans to work together to define what is 
considered an undue burden instead of establishing systemwide 
definitions that do not account for local variances.
    This bill would also require VA to place veterans on an electronic 
waiting list. Instead of placing veterans on electronic waiting lists, 
the VFW recommends VA provide veterans an appointment that is beyond 
the wait time standards of the department and offer veterans the 
opportunity to receive community care. When veterans accept an 
appointment in the community, their VA appointments must be canceled to 
prevent no-shows. However, this would require VA to track community 
care appointments better than they have with the Choice Program.
    This bill would charge VA with scheduling and coordination of 
community care appointments and management of the community care 
networks. In so doing, it would also limit VA's ability to use a third 
party administrator for the proposed Care in the Community Program. The 
Choice Program has experienced many issues because VA elected to simply 
contract virtually every aspect of the community care process. However, 
not every issue that the Choice Program has faced is the fault of the 
third party administrators, and there is no guarantee that VA would not 
have experienced the same issues without a third party administrator. 
What is clear from the VFW's continued evaluation of the Choice Program 
is that the third party administrators have the capability to 
accomplish certain tasks more efficiently than VA. For example, the VFW 
does not believe VA has the capability to manage a network of hundreds 
of thousands of private sector health care providers.
    The VFW supports utilizing VA community care staff to schedule 
Choice Program appointments when possible, but it is unreasonable to 
expect VA to be able to hire enough staff to keep pace with the 
expanded use of community care or downsize after surges have passed. 
For that reason, the VFW recommends VA build on its co-located staff 
model and rely on contracted staff to support VA's community care staff 
when demand for community care spikes. To ensure veterans are not 
negatively impacted when they are rolled over to contract staff, VA 
must ensure the contracted staff has access to the same systems as VA 
community care staff.
    The VFW supports section 3, which would establish a VA provider 
agreement authority. Authorizing VA to enter into non-Federal 
acquisition regulation (FAR) based agreements with private sector 
providers, similar to agreements under Medicare, would ensure VA is 
able to quickly provide veterans with care when community care programs 
like the Choice Program are not able to provide the care.
    Provider agreements are particularly important for VA's ability to 
provide long-term care through community nursing homes. The majority of 
the homes who partner with VA do not have the staff, resources, or 
expertise to navigate and comply with FAR requirements, and have 
indicated they would end their partnerships with VA if required to bid 
for FAR contracts. In fact, VA's community nursing home program has 
lost 400 homes in the past two years and will continue to lose 200 
homes per year without provider agreement authority. This means 
thousands of veterans are forced to leave the place they have called 
home for years simply because VA is not able to renew agreements with 
community nursing homes.
    However, the VFW urges the Committee to amend section 3 of the bill 
to make it clear that provider agreements may only be used if VA is 
unable to schedule an appointment at its medical facilities or through 
the Care in the Community Program. Authorizing local medical facilities 
to enter into provider agreements with providers who are in or are 
being perused to join the community care network would erode the 
networks, and could result in such networks failing to meet needed 
coverage and size requirements.
    The VFW supports section 4, which would reform VA emergency and 
urgent care options for veterans. The VFW continues to hear from 
veterans that VA refuses to pay the cost of their emergency room 
visits, which may have saved their lives or was their only option for 
receiving the urgent care they needed. That is why the VFW supports 
this legislation's expansion of emergency and urgent community care. 
Specifically, the VFW is pleased to see that this legislation would 
ensure copayments associated with emergency and urgent community care 
would be equal to the copayments paid by veterans at VA medical 
facilities. This would ensure veterans are not punished for using 
community care.
    However, this legislation would require veterans to have received 
VA care with the past 24-months in order to be eligible to receive 
reimbursement for the cost of community emergency and urgent care, 
which is similar to the eligibly requirements under VA's current 
emergency care reimbursement program. This barrier to access has caused 
undue hardship on veterans who enroll in VA health care, but have been 
denied access due to wait times, and subsequently require emergency 
services. VA is aware of this problem and has requested the authority 
to make an exemption to the 24-month requirement for veterans who find 
themselves in this situation. The VFW recommends that the Committee 
amend this legislation to ensure veterans who face long appointment 
wait times are not precluded from seeking the emergent and urgent care 
they need.
    The VFW strongly supports section 5, which would require VA and the 
Centers for Medicare and Medicaid (CMS) to enter into a memorandum of 
understanding. The VFW has long supported Medicare subvention, because 
our members see no logical reason VA lacks the ability to bill their 
Medicare plans for the cost of providing non-service-connected care. 
This section would require VA and CMS to do the next best thing--
coordinate referrals. By requiring Medicare providers to accept 
referrals from VA doctors, this section would enable veterans who want 
to use private sector doctors but maintain all their records and health 
care management at VA the ability to do so.
    The VFW support sections 6 and 7, which would establish education 
programs to teach veterans, community care providers and VA employees 
about VA's community care programs. The VFW believes that community 
care providers must also have the opportunity to obtain military 
competency training and continuing medical education (CME) on how to 
provide veteran-centric care. That is why we recommend the Committee 
expand section 7 by requiring VA to also provide CME on veteran-
specific health care and military competency training.
           s. 1325, better workforce for veterans act of 2017
    The VFW strongly supports this bill and thanks the Committee for 
including it in the agenda. If enacted, this bill would significantly 
improve VA recruitment and retention authorities. When the VFW asked 
veterans how they would improve the VA health care system in our latest 
survey of VA health care entitled ``Our Care 2017,'' the most common 
suggestion was to hire more health care staff to reduce wait times.
    The VFW thanks the Committee for recognizing that VA's ability to 
hire and retain high quality employees is important. Considering that 
more than 30 percent of VA employees will be eligible for retirement by 
2020, it is vital that Congress focuses on ways to improve VA's hiring 
and retention authorities to ensure veterans have timely access to the 
care they have earned.
    Title I of this important bill would improve VA recruitment and 
hiring practices. It would improve authorities for quickly hiring 
students who complete their residency or internships at VA. With more 
than 70 percent of America's health care workforce receiving some or 
all of its training at VA, it should be easy for VA to develop a 
pipeline of students who become employees. However, VA's cumbersome 
human resources (HR) requirements limit its ability to recruit the 
students it trains. The VFW supports eliminating such H.R. barriers to 
ensure VA is able to quickly hire the high quality health care 
professionals it trains.
    The VFW is also pleased this bill takes steps toward improving 
veterans preference to ensure veterans who served in the National Guard 
and Reserve are afforded the same hiring preferences as their active 
duty counterparts. Currently, veterans who served after September 11, 
2001, are required to have served at least 180 consecutive days on 
active duty. Due to our all-volunteer military and the nature of the 
wars in Iraq and Afghanistan, the Guard and Reserve have been utilized 
much more than they have during past conflicts.
    However, not all Guard and Reserve servicemembers receive active 
duty orders for more than 180 days. Thus, many veterans that deployed 
into harm's way in support of the wars in Iraq and Afghanistan are not 
eligible for veterans hiring preferences. Changing the eligibility for 
veterans preference from ``180 consecutive days'' to ``for a total of 
more than 180 days,'' ensures Guardsmen and Reservists are afforded the 
same opportunity to obtain meaningful civilian employment after 
military service as their active duty brothers and sisters.
    This important bill also makes several administrative changes to 
VA's H.R. processes. The VFW strongly supports amending VA's reduction 
in force procedures to make certain VA ranks its employees based on 
performance instead of tenure. Doing so would ensure the highest 
quality employees would remain to care for our Nation's veterans if VA 
is required to implement a reduction in force.
           discussion draft, the veterans choice act of 2017
    This legislation would expand the Choice Program, establish VA 
provider agreements authority, require VA to assign each veteran a 
primary care provider, and establish demand capacity analyses, among 
other things. The VFW supports sections 4, 5, 6, 9, 10 and 11; supports 
the intent of section 7; has serious concerns with section 3; and takes 
no position on sections 8 and 12.
    The VFW has serious concerns with section 3 as written and would be 
forced to oppose the underlying bill if changes are not made to the 
bill before it is advanced by the Committee. While the Veterans Choice 
Program has made significant progress since it was implemented in 
November 2014, it has yet to achieve what Congress envisioned when it 
passed the Veterans Access, Choice, and Accountability Act of 2014. The 
purpose for this landmark program was to address the national access 
crisis that has plagued the VA health care system, where veterans wait 
too long or travel too far for the care they need. The VFW has made a 
concerted effort to ensure the program works as intended by evaluating 
what aspects of the program are working and identifying common sense 
solutions to aspects that are not working well. We have done this 
because we agree that VA must leverage its community care partners in 
order to fulfil its obligation to our Nation's veterans. However, we 
firmly believe that community care must complement, not supplant or 
compete with, the high quality, comprehensive and veteran-centric care 
veterans receive from their VA health care system.
    Section 3 would make any veteran enrolled in VA health care 
eligible for the Choice Program. The VFW is seriously concerned that 
such a significant expansion of eligibility would result in veterans 
receiving disparate and uncoordinated care. Medical research has 
determined and the Commission on Care has reiterated that integrated 
and managed health care systems provide better health care outcomes 
than fee-for-service systems. That is why the majority of high 
performing health care systems, including VA, have implemented the 
patient-centered medical home model of delivering health care, which 
ensures patients receive the care they need when they need it.
    While the idea that veterans should be free to choose between VA 
and community care providers whenever they want and every time they 
seek care sounds enticing, it is unsustainable because of the cost, and 
the VFW would vehemently oppose any future efforts to pass that cost 
onto veterans. The Commission on Care estimated that the cost of a 
proposal very similar to Choice Program eligibility proposed by section 
2 would have ranged from $156 billion to $237 billion once fully 
implemented. The VFW is not concerned that veterans will flee VA 
medical facilities for private sector doctors. To the contrary, VFW 
health care surveys show that nearly 60 percent of veterans who use VA 
health care prefer it, despite having other health care options. Yet, 
the increased reliance on VA health care due to such a generous benefit 
and VA's inability to keep pace with the increase in demand would 
require Congress to shift already strained and insufficient 
appropriations from direct care to community care. Such a shift of 
resources would further limit VA's ability to update its aging 
infrastructure, hire needed health care professionals, compete with the 
private sector, and would lead to the gradual erosion of the VA health 
care system.
    The VFW is also concerned that a ``choose your own adventure'' 
approach to health care would lead to veterans receiving fragmented 
health care that the Commission on Care found would lower health care 
outcomes and endanger patient safety. Veterans deserve the highest 
quality health care possible, not fragmented care that fails to meet 
their health care needs. The VFW urges the Committee to amend this 
section by ensuring veterans who are unable to receive a VA appointment 
by a clinically indicated date, or within a distance an enrolled 
veteran and such veteran's health care provider agree is reasonable, 
are offered community care options.
    The VFW supports provisions which authorize VA to enter into 
regional contracts to establish and manage networks of health care 
providers, schedule appointments, process claims and payments, and 
collect medical documentation. However, the VFW believes the specific 
processes that are completed by the contractor should be determined by 
VA in consultation with Veterans Service Organizations, the current 
third party administrators and entities interested in becoming a third 
party administrator.
    VA has worked on this process for the past year, and has determined 
that it is best for VA community care staff to schedule Choice Program 
appointments when feasible, and to turn to the third party 
administrators when local facilities are unable to timely process 
appointments. While different parts of the country have experienced 
mixed results with the current third party administrators, the VFW does 
not believe it would be in the best interest of veterans for every 
aspect of the Choice Program to be managed by a third party 
administrator or VA. By evaluating issues the Choice Program has faced, 
and with increased communication and management of the current third 
party administrators, VA must strike the right balance between what is 
handled internally and what can be contracted out. The most important 
factor is that veterans must have a seamless transition from VA care to 
community care and vice versa.
    This section would also prohibit VA from using tiered networks to 
direct veterans to specific providers. While the VFW agrees that 
veterans must not be forced to receive care from specific community 
care providers, VA must have the authority to recommend providers in 
higher tiers to incentivize network providers who show dedication to 
developing military competency and veteran-centric health care 
practices. The VFW recommends the Committee amend this section to 
prohibit VA from requiring veterans to obtain care from specific 
doctors, but still make recommendations based on a provider's tier 
level.
    The VFW supports the provision to authorize VA to collect 
reasonable charges from a veteran's other health care plans. Doing so 
would ensure VA is able to offset some of the costs of providing 
community care to veterans. Specifically, the VFW is glad this bill 
would not impose a financial penalty on veterans who may not be aware 
that their other health care coverage has changed. We do, however, 
recommend that the Committee expand the definition of other health care 
coverage to include Medicare. VFW members who pay for Medicare coverage 
see no justifiable reason for VA to be treated differently than private 
sector providers when a Medicare- enrolled veteran receives non-
service-connected care from a VA doctor. Doing so would further offset 
the cost of providing community care.
    The VFW supports section 4, which would authorize VA to enter into 
provider agreements. Specifically, the VFW is glad this bill would 
require VA to provide care through its facilities or the Choice Program 
before considering provider agreements. This would ensure provider 
agreements do not impact the integrity of the Choice networks or VA's 
ability to provide direct care.
    Section 7 would require VA to assign each enrolled veteran a 
primary care provider. It would also authorize veterans to freely 
choose a community primary care provider when such veteran enrolls into 
the VA health care system. The VFW supports including community care 
options when veterans seek primary care and, to ensure continuation of 
care, veterans must be given the opportunity to receive all their 
primary care from their assigned community primary care provider. 
However, the VFW does not support giving veterans a list of providers 
and leaving them to fend for themselves to find a community primary 
care provider who is accepting new patients and is willing to see them. 
Instead, VA must work with every veteran who requests primary care to 
determine what option and doctors are best for each individual veteran.
    Furthermore, the VFW recommends the Committee require community 
primary care providers give VA the right of first refusal when 
referring veterans to specialty care. Under the current Choice Program, 
community care providers do not have they ability to refer veterans 
back to VA for specialty care or follow-up care. Doing so would ensure 
proper utilization of VA resources and strengthen the relationship 
between VA and local community care providers.
    The VFW strongly supports section 9, which would require VA to 
conduct demand capacity analyses. The VFW believes that community care 
networks and VA's footprint must be tailored to each health care 
market. There are some areas in this country were wait time for private 
sector care is much greater than VA. In other areas, VA is duplicating 
services that are readily available in the private sector or through 
other public health care systems. By conducting periodic demand/
capacity analyses, VA would be able to determine when it should 
leverage the capabilities of its community care partners and when it 
must expand internal access. Doing so would ensure VA devotes its 
finite resources to capabilities the community lacks.
 discussion draft, improving veterans access to community care act of 
                                  2017
    This legislation would consolidate VA's community care authorities 
and improve VA community care, among other things. The VFW supports 
sections 102, 103, 201, 202, 204 and 205; has concerns with section 
101; and agrees with the intent of section 203.
    The Choice Program has faced a number of challenges since it was 
implemented in November 2014. The VFW has made a concerted effort to 
evaluate what aspects of the program have worked and identify common 
sense solutions to aspects that have not worked as intended. That is 
why we are pleased to see that this legislation would incorporate many 
of the lessons learned from the implementation of the Choice Program 
and other community care programs, such as consolidating all of VA's 
community care authorities to ensure veterans, VA employees and private 
sector providers understand how to navigate VA's community care 
program.
    Section 101 would reconstitute and make a number of improvements to 
the Choice Program, to include ensuring a veteran's continuation of 
care is not interrupted by bureaucratic rules. The VFW supports 
provisions to allow veterans who receive authorized care from a 
community care provider to continue to see their community care 
provider or another community care provider to complete an episode of 
care, or enter into follow-up treatment without the need to request 
additional authorization.
    The VFW is glad to see that this legislation includes recent 
improvements to the eligibility criteria in the proposed Veterans 
Community Care Program, such as the Secretary's authority to determine 
that there is a compelling reason for a veteran to use community care 
in lieu of VA care. However, the VFW is concerned that the bill 
continues the flawed 40-mile and 30-day eligibility criteria to 
determine when veterans are afforded the opportunity to access 
community care. The VFW believes that the distance a veteran is 
required to travel or how long a veteran is required to wait for health 
care must be a clinical decision made by the veteran and his or her 
health care provider.
    Another lesson learned from the Veterans Choice Program is that VA 
provides health specialties that do not have a Medicare rate, including 
obstetrics and gynecological care. While the VFW understands the need 
to set limits on the amount VA is authorized to reimburse community 
care providers, the VFW believes that a consolidated community care 
program should authorize VA to provide community care options for every 
health care specialty it delivers. That is why we are glad to see the 
legislation would authorize VA to establish a fee schedule for services 
it provides that do not have a Medicare rate. It would also authorize 
VA to negotiate rates, which the VFW supports.
    This section would also authorize VA to establish tiered networks 
to operate the Veterans Community Care Program. The VFW supports 
establishing tiered networks to incentivize community care providers to 
develop military competency and veteran-centric health care practices. 
However, a veteran's choice of community care provider should not be 
limited by a specific tier. Each veteran should be given the 
opportunity to work with VA to determine what community care options 
are best suited to the veteran's clinical needs and preferences.
    The VFW supports section 102 which would require VA to comply with 
prompt payment requirements. The VFW continues to hear from veterans 
that they have been billed for care that VA is responsible for paying 
simply because the community care provider VA sent them to was unable 
to collect payment from VA in a timely manner, so the provider elected 
to bill the veteran instead. Prompt payment is vitally important to 
ensuring VA's community care network is able to attract and maintain 
high quality private sector health care providers.
    The VFW supports section 103, which would expand medical 
malpractice protections to veterans who use VA community care. Veterans 
who receive care at VA medical facilities are eligible for disability 
compensation and other benefits if they have been injured or negatively 
impacted by VA care. Veterans who use the Choice Program are not 
offered the same opportunity and are required to seek legal action in 
order to be compensated for malpractice.
    The VFW agrees with the intent of section 203, which would 
authorize VA to transfer resources between its medical services and 
community care accounts. If veterans receive care from community care 
providers or VA, health care facilities must be determined at the local 
level by each veteran and his or her health care team, not by Congress 
or VA bureaucrats who favor one option over the other. That is why the 
VFW supports authorizing VA to transfer resources between its internal 
care and community care accounts based on demand. Instead of 
implementing this section, the VFW would recommend doing away with the 
community care appropriations account and simply require VA to report 
on the use and cost of community care, rather than continuing to fence 
off certain appropriations for community care.
    The VFW supports section 204, which would authorize VA to obligate 
funds when care is approved, not when VA authorizes community care. If 
enacted, this provision would enable VA to better forecast community 
care expenditures and reduce the amount of resources it is required to 
deobligate, because it obligated more money than it was required to pay 
in an effort to prevent the department from violating anti-deficiency 
laws.
   the department of veterans affairs quality employment act of 2017
    The VFW strongly supports this legislation which would improve 
employment practices at VA. If VA is not able to quickly hire high 
quality employees, it will lack the staff needed to accomplish its 
mission. In its report, ``Hurry Up and Wait,'' the VFW highlighted 
deficiencies in VA Human Resources practices. The VFW recommended 
Congress ease Federal hiring protocols for VA health care professionals 
to ensure VA can compete with private industry to hire and retain the 
best health care providers in a timely manner.
    In their review of VA's scheduling system and software development 
as required by the Veterans Access, Choice and Accountability Act of 
2014, the Northern Virginia Technology Council (NVTC) reinforced the 
VFW's concerns that VA's hiring process moves too slowly. NVTC 
suggested that for VA to be successful, it must aggressively redesign 
its human resources processes by prioritizing efforts to recruit, 
train, and retain clerical and support staff. This important bill would 
make many needed improvements to the way VA hires and retains high 
quality employees.
    The VFW strongly supports the creation of an Executive Management 
Fellowship Program. This ideas was advocated by a VFW-Student Veterans 
of America fellow. In his proposal, ``Connecting America's Best to 
Serve America's Best,'' Karthik A. Venkatraj highlighted how a private-
public partnership program such as the Executive Management 
Fellowship--where VA leaders are detailed to a private sector company 
and vice versa--can infuse private sector expertise and disciplines 
into VA governance and management. The proposed fellowship would also 
grant private, non-profit and academic institutions the ability to 
immerse its leadership in the highest levels of our Nation's public 
policy to better understand how the public and private sector can learn 
from each other and work together to improve the lives of America's 
veterans.
    This bill includes other ideas the VFW has suggested and supported 
in the past, such as expedited hiring authority for students enrolled 
in a VA residency or internship program and recent graduates who are 
being poached by private sector health care systems, because VA's 
hiring process is to too long and cumbersome. It also includes a 
requirement for VA to conduct and use exit surveys to determine why its 
medical professionals are leaving. Doing so would ensure VA is able to 
address retention issues, which is one of the biggest reasons behind VA 
staff shortages.
                                 ______
                                 
         Prepared Statement of John Rowan, National President, 
                      Vietnam Veterans of America
    Good morning 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 for 
your consideration our Statement for the Record on pending legislation 
before this Committee

    S. 115, the Veterans Transplant Coverage Act, introduced by Senator 
Dean Heller (R-NV). This bill would authorize the Department of 
Veterans Affairs to provide for an operation on a live donor to carry 
out a transplant procedure for an eligible veteran, notwithstanding 
that the live donor may not be eligible for VA health care.
    According to the Health Resource Services Administration (HRSA), 
the demand for organs far outweighs the number of donors. Living 
donations offer another choice and extend the supply of organs. Of the 
28,954 organ transplants performed in the U.S. in 2013, more than one-
fifth (5,989) were living donor transplants.
    While VVA has no objection to this bill, as it provides another 
avenue for veterans who receive transplants in the VA, the bill does 
not address potential liability issues for the department concerning 
operating on someone who is not eligible for VA health care. This would 
create a situation that will have to be addressed should S. 115 be 
enacted.

    S. 426, the Grow Our Own Directive: Physician Assistant Employment 
and Education Act of 2017, introduced by Senator Jon Tester (D-MT). 
This bill would increase assistance provided by the VA for education 
and training of physician assistants of the department, and establish 
pay grades and require competitive pay for physician assistants.
    VVA supports this important bill. Access to safe, quality health 
care has always been critical to veterans. Physician Assistants (PAs) 
play a significant role in the Veterans Health Administration's model 
for delivering comprehensive health care. Yet in September 2016, the VA 
Inspector General reported that PAs ranked third among health 
professions experiencing troubling provider shortages (psychologists 
were tied with PAs in this ranking).
    This bill would provide scholarships to veterans who have medical 
or military health experience. Upon completion of training and 
education, a new PA would be required to work for the VA in a medically 
underserved area and in a state with a per capita veteran population of 
more than 9 percent (according to the National Center for Veterans 
Analysis and Statistics and the US Census Bureau).
    Importantly, the bill also establishes pay grades for PAs as well 
as competitive pay requirements, and mandates that the VA implement a 
national strategic plan for the retention and recruitment of physician 
assistants.

    S. 683, the Keeping Our Commitment to Disabled Veterans Act of 
2017, introduced by Senator Mazie Hirono (D-HI). This bill would extend 
the requirement for the VA to provide nursing home care to certain 
veterans with service-connected disabilities through December 31, 2018.
    VVA fully supports this extension.

    S. 833, the Servicemembers and Veterans Empowerment and Support Act 
of 2017, introduced by Senator Jon Tester (D-MT), would expand VA 
health care and benefits for Military Sexual Trauma.
    VVA supports this legislation. It is no secret that incidents of 
cyber-harassment of a sexual nature are on the rise. Earlier this year, 
it was reported in the San Diego Tribune that a private Facebook forum 
called Marines United allowed postings of sexually suggestive or 
explicit photos of female servicemembers, often without their knowledge 
or consent. Members of the forum, both active-duty military and 
veterans, made lewd and offensive remarks. When some of the victims 
learned about this and complained, they were bullied and/or subjected 
to threats.
    This bill seeks to expand the coverage of counseling and treatment 
for military sexual trauma to include cyber-harassment of a sexual 
nature and relax the standard of proof for service-connection of mental 
health conditions related to MST. The expanded coverage would include 
members serving on active duty, active duty for training, as well as 
inactive duty for training.
    VVA understands that the devil is in the details and we extend to 
the Committee an offer to work with staff to refine and clarify this 
legislation.

    S. 946, the Veterans Treatment Court Improvement Act, introduced by 
Senator Jeff Flake (R-AZ), would require the Secretary of Veterans 
Affairs to hire additional Veterans Justice Outreach specialists to 
provide Veterans Treatment Court services to justice-involved veterans.
    Justice-involved veterans too often are forgotten by the Nation 
they once served. They did wrong; they do time. Yet the VA does not 
abandon these vets. Its Veterans Justice Outreach program specialists 
play a crucial role not only in assisting many to reintegrate into 
society but in helping others avoid incarceration. They are vital cogs 
in the workings of Veterans Treatments Courts.
    Senator Flake's well-conceived bill recognizes the value of the 
work done by VJO specialists, and affirms the need to ensure that this 
program is available throughout the VA. And S. 946 is not an unfunded 
mandate: it would appropriate $5,500,000 to support this program for 
each fiscal year through 2027. Hence, VVA endorses this bill without 
reservation.

    S. 1153, the Veterans ACCESS Act, introduced by Senator Tammy 
Baldwin (D--WI), would prohibit or suspend certain health care 
providers from providing non-VA health care services to veterans.
    VVA has no objection to this bill. Ensuring that health care 
providers are fully vetted before integrating them into the VA 
healthcare system is the standard VVA expects from the department. Too 
often, however, some less-than-honorable healthcare providers fly below 
the disciplinary radar before something in their past catches up to 
them.
    This bill authorizes the Secretary to review the status of each 
non-VA clinician. The review would include the history of any 
employment with the department to determine if they have violated one 
of several criteria as laid out in the legislation.

    S. 1261, the Veterans Emergency Room Relief Act, introduced by 
Senator Bill Cassidy (R-LA), would require the Secretary of Veterans 
Affairs to pay reasonable costs of urgent care provided to certain 
veterans, and establish cost-sharing payments for veterans receiving 
care at a VA emergency room.
    VVA supports the inclusion of urgent care services as a choice for 
veterans to receive health care. Many urgent care clinics are 
conveniently located in communities where veterans live and seek 
treatment. This is generally consistent with what VA proposed as part 
of their community care program.
    VVA has no objection to the establishment of cost-sharing for 
emergency room care at a VA facility. However, there is no floor or 
ceiling as to how much of the cost-sharing payment for which the 
veteran would be responsible, nor how this figure might be arrived at, 
although this is a detail perhaps best left to the regulation that 
would follow enactment of this bill.
    The VA has struggled to implement emergency care services as 
established by the Millennium Act with regards to non-service-connected 
conditions. Eligibility of the veteran for what services, inappropriate 
denials of payment, and who should pay for what services are just a few 
of the problems reported by the GAO as recently as March 2014. GAO's 
report, ``Actions Needed to Improve Administration and Oversight of 
Veterans' Millennium Act Emergency Care Benefit,'' was not flattering 
for the VA and demonstrated that, nearly 15 years after enactment, VA 
emergency care services are still in need of repair.
    VVA urges the Committee to provide hardcore oversight of the VA on 
their emergency care services in general, with the goal of making it 
easier for both the employees and veterans understand the benefits 
offered at VA emergency rooms.

    S. 1266, the Enhancing Veteran Care Act, introduced by Senator 
James Inhofe (R-OK). This bill would authorize the Secretary of 
Veterans Affairs to enter into contracts with nonprofit organizations 
to investigate VA medical centers.
    VVA does not object to the concern behind this legislation. 
However, VA health care is far more transparent generally than health 
care in the private sector is. And we question just what circumstances 
would warrant an outside investigation as opposed to requesting the VA 
OIG to step in--or asking for firm yet fair oversight on the part of 
Congress.

    S. 1279, the Veterans Health Administration Reform Act of 2017, 
introduced by Senator Mike Crapo (R-ID), would permit furnishing health 
care for eligible veterans by non-VA healthcare providers.
    This legislation, which is similar to the trio of draft bills up 
for discussion, would establish a Care in the Community Program through 
contracts, care agreements, or other laws or practices administered by 
the VA. We feel compelled to point out that, while we appreciate the 
eligibility criteria outlined in this bill for such a program, VA 
medical centers have long engaged outside clinicians to engage in care 
that the VA cannot provide, and under the guidance by the current VA 
Secretary and under the critical--and watchful--eye of you here in 
Congress, the VA is developing and implementing what we trust will be a 
vibrant community care program navigated by the VA, and one in which 
outside providers will be carefully vetted.
    However, this legislation does not address the assignment of a 
primary care physician upon enrollment, which is essential to ensuring 
that care is coordinated through and navigated by the VA. Primary care, 
in our view, must remain in the VA.
    We also must point out that, while ``choice'' has been the go-to 
word in Congress in recent years, patients don't usually have 
``choice'' available to them in the private sector; rather, they take 
the advice of their doctor, or the recommendation of a friend or 
relative or colleague. Such ``choice'' for VA patients, if ordered by 
law, has the very real possibility of causing considerable 
consternation--on the part of veterans seeking to go to clinicians who 
do not or cannot provide the quality of care the VA would demand; on 
the part of the VA, which would have to tell a veteran that s/he cannot 
use a particular clinician with the VA footing the bill; which would 
only cause major headaches to Members of Congress when veterans 
complain about the VA having rejected the clinician they have 
``chosen.'' Besides, ceding unfettered choice outside the VA was never 
a recommendation of the Commission on Care
    VVA, though, is supportive of the provider agreement language in 
this bill, the authority for which the VA has asked for previously. 
Provider agreement authority is essential in any care in the community 
program.

    S. 1325, Better Workforce for Veterans Act, introduced by Senator 
Tester, seeks to improve the authorities of the Secretary of Veterans 
Affairs to recruit, hire, train, and retain employees.
    For years, the VA has struggled to recruit, then hire and retain 
employees, particularly the clinicians so essential to the provision of 
quality health care. VVA has no objection to the improvements of 
authorities and reporting requirements set forth in this legislation. 
We note that the VA has reported critical staffing shortages across the 
system, aggravating an already stressed access issue. The VA OIG 
reported in September 2016 on the top five occupational staffing 
shortages for VHA. In order ranked as most critical is Medical Officer, 
followed by Nurse, Psychologist and Physician Assistant (tied), and 
Physical Therapist and Medical Technologist (also tied).
    Title II of this legislation addresses accountability, oversight, 
transparency, and personnel matters. VVA has a long history of 
advocating for stronger programs on all of these issues.
    Section 204 would establish pay for medical center directors and 
VISN directors. The Secretary would be required to consult not fewer 
than two national surveys on pay for similar positions to determine 
market pay. Additionally, the Secretary would be required to set forth 
a department-wide minimum and maximum for total annual pay once every 
two years. Pay inequity is one of the biggest barriers to recruiting 
and retaining high-quality employees to oversee the health care 
facilities where veterans receive care. VVA believes this reform is 
long overdue.
    Sections 205 and 208 address long-standing problematic issues. The 
VA has reported a critical shortage of trained Human Resources 
professionals, which only adds to the already glacial hiring practice 
that exists across the Federal bureaucracy.
    Section 205 would establish a Human Resources Academy in VHA to 
provide annual training for and insights on how to best recruit and 
retain employees. While this is a solid approach to the problem, we 
offer this caveat: vigilant oversight by Congress and the VSOs of the 
establishment and implementation of this will be needed.
    Section 208 requires the Secretary, via the Under Secretary for 
Health, to develop a comprehensive assessment tool to measure 
competency within the H.R. ranks, and to ensure that the knowledge 
gained by the training provided at the academy is effectively employed. 
Section 208 also requires the establishment and clarification of lines 
of authority within VHA to conduct proper oversight at all levels of 
the H.R. process. This is a critical piece in ensuring the responsible 
parties are held accountable for any failure to comply.

    S.____ Discussion Draft: The Veterans Choice Act of 2017 (Isakson) 
would permit all veterans enrolled in the patient enrollment system of 
the Department of Veterans Affairs to receive health care from non-VA 
health care providers.
    Section 3 of this draft establishes the Veterans Choice Program and 
goes on to delineate how that establishment would take place. Of note 
to VVA are a few issues we would like to bring to this Committee's 
attention:

    Chairman Isakson's bill would authorize the Secretary to enter into 
consolidated, competitively bid regional contracts to establish 
networks of health care providers, who would be responsible for 
everything with the exception of the maintenance of interoperable 
Electronic Health Records. This construct is very similar to the 
current third-party administrator model that has been a source of 
problems at every level. The Secretary has expressed his desire to keep 
in-house the scheduling of the appointments for veterans, which this 
section would not allow. It is not clear to us why the legislation 
prohibits VA from using a tiered network. As the Committee is well 
aware, development of a tiered network model is the basis for VA's care 
in the community vision going forward and was outlined in VA's care 
consolidation plan in October 2015. We do, however, appreciate the 
inclusion of language that would require a veteran to be assigned a 
primary care provider upon enrollment. This is of course necessary for 
effective and efficient care coordination.
    The authorization for provider agreements is a welcome addition and 
would enhance the delivery of care to veterans, including those 
residing in state homes. This has been an ongoing legislative priority 
for VA moving forward with community care once the dollars remaining in 
the current Choice Program run out. Medicare and TRICARE use provider 
agreement authority to bypass Federal acquisition regulations. There is 
no reason why the VA cannot be afforded the same.
    Section 9 would require the Secretary to assess the demand for 
health care services furnished by the department. The VA should already 
be doing this. It would help to inform their budget projections with 
real-time information. VVA supports this requirement.
    Section 11 directs the Secretary to procure a COTS EHR platform for 
health care services that conforms to the standards of interoperability 
with DOD. Billions of dollars have been spent, and wasted, over the 
past decade to get the two agencies together on the interoperability 
issue. VVA supports this section as well.

    S.____ Discussion Draft: Improving Veterans Access to Community 
Care Act of 2017 would establish the Veterans Community Care Program of 
the Department of Veterans Affairs to improve health care provided to 
veterans by the VA.
    Similar to the previous draft, ``The Veterans Choice Act of 2017,'' 
this draft legislation establishes the Veterans Community Care Program. 
This draft legislation, however, takes a decidedly different approach. 
It would require the VA's Non-VA Care Coordination Program to 
coordinate the care, which would embrace the scheduling of appointments 
for eligible veterans. Additionally, it does allow for the development 
of a tiered network construct, but prohibits the Secretary from 
prioritizing providers in one tier over providers in any other tier if 
it limits the veteran's choice of a clinician in a particular 
specialty.
    VVA would note that the eligibility criteria outlined in this draft 
are complicated, somewhat arbitrary, and will pose a nightmare for both 
VA employees and veterans to figure out eligibility. The Secretary has 
expressed many times that he is attempting to shift away from an 
administrative system to one that is clinical in nature. The goal, as 
VVA understands it, is for a clinical decision be arrived at between 
the veteran and the doctor as to where the best care for that veteran 
resides. Which is as it should be.
    Section 102 addresses payment of health care providers and 
compliance with the Prompt Payment Act. This is very similar to other 
legislative language included on the agenda today and for which VVA has 
no objection to this section.
    VVA supports Section 103, which amends Section 1151 (a) by adding a 
new paragraph addressing benefits for persons disabled by treatment 
under the Veterans Community Program.
    Section 201 authorizes Veterans Care Agreements. The language is 
similar to that in other pieces of legislation on today's agenda. VVA 
fully supports giving the VA the authority to enter into such 
agreements, including with state homes.

    S.____ Discussion Draft: The Department of Veterans Affairs Quality 
Employment Act of 2017 seeks to improve the authority of the Secretary 
to hire and retain physicians and other employees.
    This draft legislation sets forth a number of requirements to 
improve the quality and competency of VA employees. It also addresses 
recruiting, retention, and training of personnel through the 
establishment of recruiting databases for critical position vacancies 
and mental health vacancies. VVA has no objection to this draft 
legislation.
    In conclusion, we note that there are many provisions in the bills 
and drafts that seek to accomplish the same goal, albeit not quite in 
the same way. We would encourage this Committee and your counterpart in 
the House to evaluate the different approaches, continue to work with 
all of the stakeholders, including the VA, and put a comprehensive 
package together that strengthens the Department of Veterans Affairs 
and improves health care delivery and services for veterans.
    Thank you for the opportunity to submit VVA's views on these very 
important pieces of legislation.
                                 ______
                                 
             Prepared Statement of Wounded Warrior Project
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