[Senate Hearing 115-387]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 115-387

                    THE STATE OF VA SERVICES IN OHIO

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           NOVEMBER 21, 2017

                               __________

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

                   Johnny Isakson, Georgia, Chairman

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

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

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

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


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

                              ----------                              

                           November 21, 2017
                                SENATORS

                                                                   Page
Brown, Hon. Sherrod, U.S. Senator from Ohio......................     1

                               WITNESSES

Hon. Beatty, Joyce, Congressional Representative, 3rd District of 
  Ohio...........................................................     5
Tansill, Chip, Director, Ohio Department of Veterans Services....     7
    Prepared statement...........................................     8
        Supplemental statement...................................    10
Harman, Keith, Commander-in-Chief, Veterans of Foreign Wars of 
  the United States..............................................    12
    Prepared statement...........................................    14
Twine, Melissa M., Veteran, Batavia, OH..........................    19
    Prepared statement...........................................    21
Powers, James, Veteran, Massillon, OH............................    22
    Prepared statement...........................................    24
Burke, Ronald, Assistant Deputy Under Secretary for Field 
  Operations, Veterans Benefits Administration, U.S. Department 
  of Veterans Affairs; accompanied by Robert Worley, Director of 
  Education Service, Veterans Benefits Administration; Robert 
  McDivitt, Director of Veterans Integrated Service Network 10, 
  Veterans Health Administration; Kameron Matthews, M.D., Deputy 
  Executive Director, Provider Relations and Services, Veterans 
  Health Administration..........................................    36
    Prepared statement...........................................    39
    Response to posthearing questions submitted by Hon. Sherrod 
      Brown......................................................    57

                                APPENDIX

Fitzgerald, Benjamin, Veteran, Westlake, OH; prepared statement..    67

 
                    THE STATE OF VA SERVICES IN OHIO

                              ----------                              


                       TUESDAY, NOVEMBER 21, 2017

                                        U.S. Senate
                             Committee on Veterans' Affairs
                                                      Columbus, OH.
    The Committee met, pursuant to notice, at 1:15 p.m., at the 
Columbus Metropolitan Library, Columbus, OH, Hon. Sherrod Brown 
presiding.
    Present: Senator Brown [presiding].

           HON. SHERROD BROWN, U.S. SENATOR FROM OHIO

    Senator Brown. Thank you again. I introduced the head of 
the library, Patrick. Thank you.
    Thanks for all of you to join us. It is the first hearing I 
have done with the Senate Veterans' Affairs Committee here in 
Columbus, so thank you all for joining us.
    I will make an opening statement, an official opening 
statement for the Committee, followed by one from Congresswoman 
Beatty. We are in her district. She represents a district in 
most of the center of Columbus, representing some 700,000-plus 
people. She has been an ally to me on veterans' issues and 
other things. I am very appreciative that she is here with us 
today.
    Then, we will ask for opening statements from our four 
witnesses to tell us what you want to tell us, and then I will 
begin questioning each of the you. That is the way we do a 
Washington, DC, hearing with Senate Veterans' Affairs. Then, I 
will have a couple questions, then Joyce will ask questions.
    Joyce is having a meeting with the Speaker later today 
about a project in Columbus, and we will be glad if that 
meeting is successful. Joyce will not be here as long as I 
will, because I want to stay, obviously, through the whole 
hearing.

                       OPENING STATEMENT

    Hearings like this are important because the best ideas, 
frankly, do not come out of Washington. They come from 
conversations like the ones we will have today with the women 
and men who served this country, and the VA officials who serve 
them.
    For today's hearing, we not only invited veterans to 
testify, we solicited questions online. I have spent much of 
the last week, as Anna and Amber in my office have, asking 
veterans all over to come to Brown.Senate.gov to express 
concerns, ideas, and thoughts they have about the services, 
health, and education benefits that the VA provides.
    If there are veterans in the audience who need assistance 
to access health care benefits, please get in touch with Anna 
or Amber or anybody on my staff, and John in the back. John and 
Anna are here from our Washington, DC, staff. John himself is a 
veteran.
    We will hear first from Ohio veterans, including Director 
Chip Tansill. Mr. Tansill, thank you for being here for the 
Department of Veteran Services. Next, Keith Harman, who is 
commander-in-chief of the VFW. Later we will hear from VA 
officials. The two veterans I will introduce in a moment will 
give their remarks.
    Ohio, as you probably know, has almost 800,000 veterans, 
where we proudly have one of the largest veteran populations of 
any of the 50 States. The majority of veterans in our State, 
like in our country, are over the age 55.
    I thank every veteran in this room. Could all veterans 
raise their hands, please? Thank you. I thank all of you.
    I also never forget to thank the families of soldiers, 
sailors, Marines, and air men, because their sacrifice maybe 
just about as great when their loved ones are overseas. The 
anxiety and the worry and the financial struggles that family 
members have are always there. Thank you for supporting your 
men and women, your loved ones, who serve our country.
    Many veterans describe hurdles when transitioning from 
active duty to civilian life. Whether it relates to claims 
processing or simply obtaining a medical appointment, or using 
education benefits, veterans and their families face far too 
many obstacles in using the benefits that they have earned 
serving our country. We should be doing more to ease that 
transition for those who have served.
    I will be asking both of you about your transitions, 
because I know that is something particularly you and I have 
worked on, Ms. Twine, that is so important and that needs 
improvement.
    That is really why the Committee is here, to hear firsthand 
from Ohioans about the experiences they are facing as veterans, 
so we can do better.
    We must continue to fight to ensure the VA is delivering 
the highest quality health care, that veterans have the 
flexibility to receive care in the community when it is in 
their clinical interests to do so. I have heard from veterans 
who believe that only the VA can give them the comprehensive 
care to meet their specific needs.
    I was asked on the way in about the privatization efforts. 
Some people want to privatize the VA. I think that is just 
simply wrong, and I know that most veterans' organizations 
agree with that. If people want to speak about that, I am 
certainly open to talking about it.
    Many VA employees, as we know, are veterans themselves. 
They have a shared experience. Go to the Chillicothe VA, you 
will walk down the hall, and many, many of the people you meet 
taking care of patients are veterans themselves.
    We must do what we can to shore up service lines at medical 
facilities, so veterans have access to more timely, quality 
care that meets their specific needs. We must work to shorten 
the time it takes for a veteran or a family member to receive a 
response to a claim or to an appeal. VA has made strides in the 
last few years to reducing the claims processing time, but 97 
days is simply, without doubt, too long to wait.
    We made improvements in VA education programs, like the Fry 
Scholarship and the Yellow Ribbon Program. But too often, 
veterans fall prey to predatory, for-profit recruiting tactics. 
For-profit schools that have closed abruptly have left men and 
women who served our country unable to secure the good-paying 
jobs that those schools and their fancy marketing have 
promised. They have left too many veterans trapped under a 
mountain of debt. They have defrauded too many veterans out of 
their G.I. education benefits. The Forever G.I. Bill took steps 
to help veterans recoup their losses, but we must do more to 
protect them on the front end.
    With congressional support, the VA has made inroads to 
combat veterans' homelessness. One of the best programs in the 
country is just 60 miles or so south of here in Chillicothe.
    There are many other topics we will cover during the 
hearing, including steps the VA has taken to combat the opioid 
epidemic; toxic exposure, especially in Vietnam from Agent 
Orange; and health implications for veterans and their 
families; and to never forget the burden that caregivers face 
taking care of veterans and their illnesses in their older age.
    As I said earlier, if there are veterans in the audience 
who need assistance to access health care benefits, get in 
touch with me directly or with Jonathan or with Anna behind me.
    Most importantly, I want to continue this conversation to 
hear directly from you.
    I will turn it over to Congresswoman Beatty.

 STATEMENT OF HON. JOYCE BEATTY, CONGRESSIONAL REPRESENTATIVE 
                   FROM 3RD DISTRICT OF OHIO

    Ms. Beatty. Thank you so much, Senator Brown.
    First, let me just say welcome to the Third Congressional 
District. You are sitting in the heart of my district, but I am 
here because there is a great Senator; a Senator who is not 
afraid to stand up for people; a Senator, as you heard, who has 
served on the Veterans' Committee and continues to fight and 
advocate for veterans.
    It was a delight for me when I received his call telling me 
that he wanted to do this field hearing. First of all, I would 
have probably driven to Chillicothe, to Cleveland, or anywhere 
else to spend some time with those who have served and make it 
possible for me to be here today.
    Earlier, I saw a gentleman as we were coming in, a veteran. 
He had been in my office in Washington. I want to thank him 
because he remembered me telling the story about my father who 
served, and served with honor, and said to me before he passed, 
``Always make sure that you fight for those who fight for 
you.'' When he said that, it was interesting because he said 
sometimes those are not the people who are sitting at the head 
of the table. It is the folks who are out in the trenches. It 
is the folks who could be doing something else, but they put 
their lives on the line.
    I am here today to not only say thank you and to join our 
Senator, but I am also here because I think it is important for 
you all to understand that we need you, and we need you more 
than ever now, because, certainly, as you know, our Nation has 
made a commitment to those who serve. I believe that we must 
honor that obligation by providing the best benefits, the best 
education, the best health care possible.
    Now, with that said, there are predators everywhere. As 
Senator Brown talked about higher education, we have to make 
sure that we protect the G.I. Bill funds from institutions that 
would want to take those dollars and not provide appropriate 
education.
    While I want to be positive and give hope and say that 
there is great opportunity, I also have to be honest and say 
that we have fallen short. That is another reason that we are 
here to hear from you.
    In the Third Congressional District--as you heard Senator 
Brown say, we have some 800,000 veterans in Ohio--we have some 
45,000 who live right here in the Third Congressional District. 
So, we must do better for all veterans.
    I was so pleased when the Senator asked you to raise your 
hands and I saw women power. Would the women just raise your 
hands again? Thank you for your service, and thank you for 
being here. We must do better about women's health and access 
for you as well.
    Today, we are going to ask a lot of questions, and I will 
be here, as the Senator said, for most of the first panel. I 
want you to know, I am not just showing up today. I want you to 
know that I have been a strong advocate. I serve on the 
Financial Services Committee, but the subcommittee that is 
equally as important to me is the Subcommittee on Housing.
    I have only been in Congress for three terms, so to some, I 
am the baby on the Hill. But, I can tell you that I have 
introduced and signed on as a cosponsor to bills, and I can 
tell you a large number of those bills are centered around 
Veterans Affairs, making sure that there are adequate and 
appropriate legal services for veterans, housing for homeless 
veterans.
    So often, people only look at veterans like those of you 
who are here on the panel and in the audience. Far too many of 
our veterans were not able to get up this morning. They will 
not be thankful as we will be tomorrow on Thanksgiving because 
they have not had all of the benefits that we have had.
    That has not gone unnoticed by us, which is why having a 
voice like Senator Brown's voice there speaking up--he is 
making a difference. That is one of the reasons I am here.
    This is not a gender or race or ethnicity or partisan 
issue. One of the first things I did was I went to my two 
colleagues, my two white, male, Republican colleagues, and 
asked how can I be part of the partnership to make a difference 
for veterans? We introduced a bill to help veterans.
    Last, let me just say one of the greatest honors for me 
that will go down in the history of my term as a Member of the 
U.S. Congress will be that, right here in my district, I played 
a major part in the writing, the orchestrating, the going and 
testifying this month, that we passed in the House to have 
right here in the Third Congressional District the National 
Veterans Memorial and Museum--one of a kind, the first and only 
one in the country. We know that is going to go over to the 
Senate, and Senator Brown will probably just single-handedly 
walk it through. [Laughter.]
    We will get that signed.
    We have started it and got it through the House, and it 
will be a wonderful museum of artifacts for people to come and 
live part of the history, to say thank you to you for your 
service.
    Thank you. Again, I am Congresswoman Joyce Beatty from the 
Third Congressional District. I have my deputy outreach 
director, Larry Seward, with me. We want to say thank you, 
thank you, and thank you.

    Senator Brown. This hearing will begin.
    Thank you, Congresswoman Beatty, for your serious and 
sometimes humorous introduction. I appreciate that.
    I will ask the four of you to give opening statements. I 
will introduce all four of you right now.
    Mr. Tansill, we will start with you, and then on the 
questions, I am going to start with the two veterans who are 
here as veterans, not as what you do with Veteran Services.
    Chip Tansill is Governor Kasich's director of the Ohio 
Department of Veteran Services, a relatively new department, 10 
years old maybe, something like that. He will testify.
    Keith Harman, Commander-in-Chief of the Veterans of Foreign 
Wars, one of our great veterans' service organizations that 
really keeps the VA--always gives guidance to me personally, to 
my staff, and to the VA. Thank you for the work you do.
    James Powers is a veteran from Massillon, OH, Northeast 
Ohio.
    And, Melissa Twine, my office has worked with Melissa Twine 
on a number of issues, and I appreciate seeing you here in 
person. She is from Batavia, which is a community just east of 
Cincinnati.
    Mr. Tansill, we will start with you.

             STATEMENT OF CHIP TANSILL, DIRECTOR, 
              OHIO DEPARTMENT OF VETERANS SERVICES

    Mr. Tansill. Senator Brown, Congresswoman Beatty, thank you 
so much for allowing me to testify today.
    I had the privilege of serving in the U.S. Army for 32 
years, including serving as chief of staff for the Ohio 
National Guard. Following my military retirement, I served as 
the executive director of the Franklin County Veterans Service 
Commission.
    I am proud to continue serving former members of our 
military as the director for the Ohio Department of Veteran 
Services under Governor John Kasich. Our department is a State 
Cabinet agency, which was created in 2008 to partner with 
county veterans service commissions and the U.S. Department of 
Veterans Affairs in order to serve those who have served our 
country.
    Ohio is home to nearly 800,000 veterans and their families, 
the sixth-largest population of veterans in the United States.
    Our team actively identifies, advocates for, and connects 
Ohio's veterans with jobs, education, and the local, State, and 
Federal benefits for which they are eligible.
    Last fall, we established a Regional Veterans Workforce 
Team. They engage businesses across the State to highlight the 
unique and advantageous skill sets veterans contribute to our 
workforce. The team provides customized training for employers 
on areas such as understanding military culture, how to 
interview veterans, how to review their resumes, and how to 
create a veterans hiring process. In their first year alone, 
our Regional Workforce Team conducted nearly 100 trainings for 
representatives from nearly 800 of Ohio's employers.
    I have had the pleasure of visiting some of the employers 
that they have worked with who have truly embraced the concept 
our team introduces to recognize their significant improvement 
in veteran hiring processes.
    During one of these visits at a veteran-owned business, I 
was told that if we could connect them with 50 qualified 
veterans, they would hire them that very day. We commonly see 
this type of incredible support and demand for hiring veterans 
across Ohio.
    Our trainings also make a big impact on human resources 
directors who experience first-hand what a huge contribution 
Ohio's veterans make to their team.
    Ohio employers' efforts to recruit and retain veterans go a 
long way in developing a framework for the successful 
transition of military members back into civilian life. 
Building a network of military-friendly employers across the 
State, currently totaling over 2,800 businesses, is just one 
way that our department seeks out ways to ease the often-
stressful transition back to civilian life.
    Our department also works in collaboration with the 
Department of Defense and other veteran and military support 
organizations to examine opportunities for improved 
coordination between Federal, State, and local resources to 
help servicemembers transition to civilian life. I am aware the 
discussions surrounding ways to improve this process are well-
established and ongoing.
    Currently, most State resources for recently-transitioned 
veterans and their families require the veterans themselves to 
be proactive in seeking out services and benefits. This is 
problematic because many veterans are unaware that resources 
are available and, therefore, are not inclined to seek them 
out, especially while they are balancing the many other 
challenges that accompany transitioning from the military to 
civilian life.
    Going from an environment where lifestyle and career paths 
are very predictable to suddenly being on your own is not 
something that comes with an instruction manual. The transition 
experience would be improved if State veteran support agencies 
like our department were provided with the contact information 
for individuals as early as possible prior to their separation 
from the military, primarily by sharing the nonmilitary 
civilian email address they intend to use.
    If this email address were included as part of the DD-214 
discharge document, it could better facilitate not only rapid 
and successful transition to civilian life with support from 
State and local services, but also improve communication with 
veterans who still have an Individual Ready Reserve commitment.
    This new method of communication would enable the Ohio 
Department of Veteran Services to proactively inform military 
members about services and benefits relevant to their 
experiences, health concerns, and other personal interests. 
These might include: targeted career and education 
opportunities; veterans' claims and financial assistance 
locally available; and enrollment in VA health care facilities.
    We hear frequently from stakeholders and peers in other 
States that increased avenues for communication would make a 
big impact on our ability to ensure that veterans are presented 
with significant opportunities for success instead of ambiguity 
upon their military discharge.
    Our experiences have demonstrated that the most successful 
transitions are those in which the veteran and their family are 
quickly connected to employment, education, housing, benefits, 
healthcare, and veterans service organizations that empower 
them to thrive in their new community.
    It is my hope that by contributing to continuing 
conversations, the next generation of veterans can garner the 
benefits of improved procedures.
    I understand that there are many topics of interest today, 
and I will be glad to answer any questions regarding the other 
services, benefits, and resources available to Ohio's veterans 
or the areas outlined in the supplemental information that I 
submitted with my testimony.
    [The prepared statement of Mr. Tansill follows:]
             Prepared Statement of Chip Tansill, Director, 
                  Ohio Department of Veterans Services
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


    Senator Brown. Thank you, Mr. Tansill, especially your 
comments about transition and how important that is. We know 
that the VA and the Department of Defense do not always work 
together as well as they should. I think we are seeing 
improvements, but not enough yet.
    Commander Harman, thank you for your service and for being 
here.

  STATEMENT OF KEITH HARMAN, COMMANDER-IN-CHIEF, VETERANS OF 
                          FOREIGN WARS

    Mr. Harman. Senator Brown, Congresswoman Beatty, on behalf 
of the Veterans of Foreign Wars of the United States, the 
Nation's largest organization of combat veterans, and its 
Auxiliary, thank you for giving us the opportunity to discuss 
issues important to Ohio's veterans.
    In the past 3 years, the VFW has assisted hundreds of 
veterans who have faced delays receiving care through the 
Choice Program, identified issues with the program, and 
compiled several reports with common-sense recommendations on 
how to address these issues. The VFW must commend the VA, 
Congress, and the program administrator for resolving or 
addressing most of the issues that we have identified.
    However, the Choice Program continues to face several 
challenges that must be addressed, to include ensuring that the 
decision of whether a veteran will receive care with the VA or 
the community is determined by the veteran and their health 
care team, consolidating all community care programs into one 
easy to understand and to administer program, and establishing 
one appropriations account.
    The VFW urges this Committee to quickly pass a community 
care bill that will develop a consolidated care program that 
supplements, not supplants, the VA's health care system.
    In September 2016, the VFW partnered with five excellent 
organizations to launch our mental wellness campaign, which 
helps servicemembers, veterans, and their families, with mental 
health conditions. We did so to address the stigma associated 
with seeking metal health care, but this is not new.
    Thirty years ago, people were ashamed to talk about cancer. 
It was a shameful word. Today, people are ashamed to admit they 
have a mental health condition. Why? The brain is an organ. It 
is part of our body. It needs treatment to address injuries, 
but can recover just as any other part of the body can.
    The VFW has worked tirelessly in the past 2 years to get 
people talking about mental health, to notice when someone may 
be in a mental health crisis, and to finally eliminate the 
stigma our society has placed on mental health. VFW posts 
around the world have hosted nearly 300 events within their 
communities to share with their members about the resources 
available to veterans and family members suffering from mental 
health conditions, and it is working. Just 2 weeks ago, I had a 
veteran tell me at a Veterans Day event in our Nation's capital 
that the VFW had saved his life.
    In order to completely eliminate veteran suicides, VA must 
increase access to military competent health care and conduct 
more studies to find innovative ways to treat mental health 
conditions. The VA has conducted research on therapies such as 
service animals, but other therapeutic alternatives, such as 
medical marijuana, must be studied.
    Women veterans are the fastest growing population within 
the military and veteran community. There are currently 2 
million female veterans, with nearly 68,000 of them in Ohio. 
Now more than ever, it is important that the VA and Congress 
address their gender-specific needs.
    The most common recommendation the VFW has received from 
Ohio women veterans is that the VA must increase access to 
gender-specific VA providers. We also hear from women veterans 
that VA outreach efforts are increasingly ineffective because 
the VA relies heavily on electronic communications such as 
social media. The VA must reach all generations of women 
veterans who have earned the ability to receive their health 
care at the VA.
    While the VFW applauds Congress for passing S. 1025, the 
Veterans Appeals Improvement and Modernization Act of 2017, we 
have significant concerns with regard to how the VA intends to 
implement the prescribed changes by way of the Rapid Appeals 
Modernization Program, and we would call on Congress to conduct 
oversight on this process.
    The VFW would like to thank this Committee for its hard 
work and dedication on the swift passage for the Forever G.I. 
Bill, which will make a difference for countless veterans in 
Ohio and throughout the country. Specifically, we would like to 
thank Senator Brown for his continued push to ensure survivors 
can achieve their educational goals without accruing large 
student debt.
    With more than 187,000 overpayment notices being sent to 
veterans nationwide in this past year alone, one would hope 
that the VA would not only be prepared to share the most 
precise information that triggered that notice in the first 
place, but also be prepared to assist the veteran in a timely 
manner. Sadly, this is not the case.
    In our experience, we have found legitimate overpayments 
most often occur with G.I. Bill benefits when a veteran's 
enrollment status changes at his or her college. If a student 
decides they are having a difficult time meeting their 
educational obligation and chooses to switch to part time, it 
is the responsibility of the school, not the student, to notify 
the VA.
    To address the overpayment issues, the VFW urges passage of 
H.R. 3705, the Veterans Fair Debt Notice Act of 2017, which 
would require VA to use certified mail to notify veterans about 
the collection of debt.
    Ending sequestration has been the top priority for the VFW 
since it was created by the Budget Control Act of 2011. It has 
forced VA and DOD to work within the confines of outdated 
spending caps that fail to account for increased demands for VA 
benefits and services, or for the cost required to man and 
equip a force capable of deterring and defeating emerging 
global threats. While Congress has negotiated temporary deals 
in the past to avoid dangerous cuts, the issue of sequestration 
has not been addressed, and it continues to impact our 
servicemembers, veterans, and their families.
    In my travels across the country and the world, I have seen 
firsthand the impact sequestration is having on our troops: 
pilots barely flying enough to maintain their certifications; a 
shortage of replacement parts to maintain equipment; and the 
lack of troop training needed to combat the ever-increasing 
threats to national security. Congress must end sequestration 
once and for all.
    Mr. Chairman, this concludes my remarks. I would be happy 
to answer any questions that you or Members of the Committee 
may have. Thank you.
    [The prepared statement of Mr. Harman follows:]
  Prepared Statement of Keith Harman, Commander-In-Chief, Veterans of 
                   Foreign Wars of The United States
    Chairman Isakson, Ranking Member Tester and Members of the 
Committee, On behalf of the men and women of the Veterans of Foreign 
Wars of the United States (VFW) and its Auxiliary, thank you for the 
opportunity to discuss the issues important to Ohio's veterans, which 
also impact veterans throughout the country.
    Community Care: In the past three years, the VFW has assisted 
hundreds of veterans who have faced delays receiving care through the 
Choice Program, and has surveyed more than 8,000 veterans specifically 
on their experiences using Department of Veterans Affairs (VA) 
community care. Through this work, the VFW has identified a number of 
issues and has proposed more than 15 common sense recommendations on 
how to improve this important program. Some of these common sense 
recommendations include making VA the primary payer for Choice Program 
care, removing restrictions on when VA is able to share medical records 
with Choice providers and making clinical necessity the trigger for 
community care.
    The VFW must also commend VA and the third party administers for 
their willingness to work with us to address issues veterans encounter 
when obtaining care through the Choice Program. VA has made more than 
70 modifications to the Choice Program's contract to address many of 
the pitfalls that have plagued the program, such as allowing the 
contractors to conduct outbound calls when they have the proper 
authorization to begin the scheduling process.
    However, the Choice Program continues to face several challenges 
that must be addressed. Some of these challenges include assuring the 
decision of whether a veteran will receive care within VA or the 
community is determined by a patient and their provider, consolidating 
all community care programs to one and making the program discretionary 
instead of mandatory.
    The VA health care system delivers high quality care and has 
consistently outperformed private sector health care systems in 
independent assessments. The VFW's numerous health care surveys have 
also validated that veterans who use VA health care are satisfied with 
the care they receive. In fact, our latest survey found that 77 percent 
of veterans report being at least somewhat satisfied with their VA 
health care experience. When asked why they turn to VA for their health 
care needs, veterans report that VA delivers high quality care which is 
tailored to their unique needs and because VA health care is an earned 
benefit.
    VA has made significant strides since the access crisis erupted in 
2014 when whistleblowers across the county exposed how long veterans 
were waiting for the care they have earned and deserve. However, VA 
still has a lot of work to do to ensure all veterans have timely access 
to high quality and veteran-centric care. Veterans deserve reduced wait 
times and shorter commutes to their medical appointments. This means 
turning to community care when needed, but also means improving VA's 
ability to provide direct care.
    The VFW urges this Committee to quickly pass a community care bill 
that would continue to invest in VA's ability to improve its internal 
system and develop a consolidated care program that supplements, not 
supplants, the VA health care system. The VFW looks forward to working 
with this Committee to pass veteran-centric reforms to VA's community 
care programs.
    Mental Health: In September 2016, the VFW launched our mental 
wellness campaign. We partnered with five organizations in our efforts 
to help servicemembers, veterans and their families cope with their 
mental health conditions. During this process we consistently heard 
from our members that the biggest barrier they face when trying to 
address the health of their brains is stigma, but this is not new. 
Thirty years ago people were ashamed to talk about cancer. It was a 
shameful word. Nobody used to talk about diabetes either. It was 
embarrassing to admit you had a health condition people wrongly 
associated with an improper diet. Today, people are ashamed to admit 
they have a mental health condition. Why? The brain is an organ. It is 
part of our body. It needs treatment to address injuries and illnesses, 
but can recover just as any other part of the body can.
    The VFW has worked tirelessly in the past two years to get people 
talking about mental health; to notice when someone may be in a mental 
health crisis; and to finally eliminate the stigma our society has 
placed on mental health. The more we talk about it, educate people 
about it and address the actualities of mental health and suicide, the 
more comfortable society and individuals suffering from mental health 
conditions are going to become with accessing the care they need. Most 
citizens can identify somebody experiencing a heart attack. People who 
have a heart attack know they must seek medical treatment. Now it is 
time for people to recognize the five signs of mental distress and to 
know when to seek help.
    This is why VFW Posts throughout the world have hosted nearly 300 
events in the past two years in partnership with the Campaign to Change 
Direction. Many of these Posts partnered with VA, Given an Hour 
providers and Walgreen pharmacies to ensure their communities know 
about the resources available to veterans and family members suffering 
from mental health conditions. Now they know to identify the five signs 
of mental distress: personality change, agitation, withdrawn behavior, 
poor self-care and feelings of hopelessness.
    This past year VA released the most extensive study ever conducted 
on veteran suicide. This study was possible thanks to interagency 
cooperation and the necessity for VA, the Department of Defense (DOD) 
and more than 30 states to fully understand the details such as who is 
more at risk, how many veterans are dying by suicide and where these 
veterans reside.
    The study found that on average, twenty veterans die by suicide 
each day, yet only six out of these twenty use VA health care. To the 
surprise of many, 65 percent of veterans who die from suicide are 50 
years old or older. Additionally, the risk for suicide in the female 
veteran population is 2.4 times higher when compared to their civilian 
counterparts. While these numbers are all alarming, they are also 
incredibly insightful for purposes of helping Congress and VA work 
toward eliminating this current plague of suicide in the veteran 
population.
    This summer, VA released a more thorough analysis of last year's 
study. This analysis focused on the data broken down at a state level. 
With the national veteran suicide rate being 38.4, the state of Ohio is 
doing better than the national average at 32.1, but is not a 
statistically significant difference. In 2014, 244 veterans died by 
suicide in the state of Ohio.
    In order to eliminate veteran suicides, VA must increase access to 
competent mental health care that is individualized to the patient. 
While the data shows VA mental health care is making a positive impact 
on those who use it, there is still room for improvement. More studies 
must be conducted to find more innovative ways to treat mental health 
conditions. VA has conducted research pertaining to areas such as 
service animals and emerging technologies, but other therapeutic 
alternatives, such as medicinal marijuana, need to be studied.
    The VFW continues to hear from veterans that VA needs to hire more 
mental health care providers. This shortage of providers has been 
continually highlighted by Government Accountability Office and VA 
Office of Inspector General (OIG) reports in past years. Specifically, 
the VAOIG's yearly determination of occupational staffing shortages 
across the VA health care system has placed psychologists among the top 
five VA health care professions' staffing shortages. This is due in 
large part to a general lack of mental health care professionals in the 
United States.
    But we must not forget about the importance of public-private 
partnerships. Providing veterans with resources such as Ohio's Star 
Providers is absolutely crucial in addressing needs for veterans who 
may not trust VA or be able to access the care they need and want in a 
timely manner.
    Whether PTSD or any other mental health conditions stem from combat 
in Afghanistan or rape, veterans deserve the treatments that work best 
for them. Yet, VA struggles to arrange group therapy sessions for 
sexual trauma survivors, simply due to the lack of patients willing to 
partake in group therapy. Though there may only be one, two or three 
veterans wanting group therapy, it does not mean they should be denied 
access or placed in uncomfortable group therapy sessions. That is why 
the VFW supports expanding VA's telemedicine authorities to ensure 
sexual assault patients within VA have the opportunity to talk 
comfortably in a virtual group setting of people who endured the same 
traumas.
    Women Veterans: Women veterans are the fastest growing population 
within the military and veteran community. There are currently two 
million female veterans, with nearly 68,000 of them in Ohio. Of the 
women who have served in Iraq and Afghanistan, more than 160 of them 
have paid the ultimate sacrifice and, as of 2016, women servicemembers 
are able to serve in any career field they desire. Now more than ever, 
as their population and roles in the military continue to increase, it 
is important VA and Congress address their gender-specific needs.
    There are certain gender-specific needs for both men and women. Our 
Nation's women veterans are younger than the average male veteran. They 
are more likely to have served in Gulf War or Post-9/11 eras than in 
previous conflicts. Women veterans are also more likely to come from 
diverse racial backgrounds. They are more likely to have a service-
connected disability and are more likely to use VA health care when 
compared to their male counterparts.
    VA reports that more than 447,000 women veterans used the VA health 
care system in fiscal year 2015, which is a 123 percent increase since 
fiscal year 2003. VA has worked to improve their gender-specific care 
for this population of veterans, but more work needs to be done. In 
2016, the VFW conducted a survey of nearly 2,000 women veterans as a 
way to identify the most important issues they were facing in VA. Of 
those respondents, three percent were from Ohio. The most common 
feedback the VFW received from Ohio respondents was clear--increase the 
number and accessibility to gender-specific providers. With 58 percent 
of Ohio's women veterans using VA's gender-specific care, this concern 
must be addressed.
    To make sure these issues are addressed, and the voices of women 
veterans are heard, the Ohio Department of Veterans Affairs hosts a 
quarterly women veteran's advisory committee meeting. The Committee 
also hosts a statewide conference every two years, which is open to all 
veterans and has seen turnouts of as many as 750 attendees.
    This Committee has found that funding and outreach are the largest 
barriers for VA's gender-specific care in Ohio. When outreach is 
conducted to women, the outreach does not appear to the population as 
being targeted specifically toward them. The Committee commonly hears 
back that outreach to get women veterans into VA seems to be heavily 
reliant on electronic outreach and social media, when women veterans in 
Ohio report to the Committee that they would rather have face-to-face 
outreach conducted. This makes sense as 46 percent of VFW's survey 
respondents from Ohio were 55 or older. VA must ensure its outreach 
efforts are effective with all generations of women veterans.
    Last, the Ohio committee has found recognition of women veterans 
within VA to be a continuing struggle. As one member put it, ``Women 
are not as likely to have on a ball hat or t-shirt that states she is a 
veteran.'' Women veterans who use women's clinics in Ohio VA medical 
facilities have reported an increase in recognition of their service, 
but for women not using women's clinics there are still continuous 
battles. When a woman walks into a clinic there is no reason for VA 
staff to ask what her spouse's information is--it should be assumed 
that she is a veteran.
    Oversight: Earlier this year, a damning report was released by the 
VA Office of Inspector General concerning the Louis Stokes Cleveland VA 
Medical Center (VAMC). The report identified discrepancies regarding 
patient safety, environmental cleanliness, and VAMC staff training 
related to disruptive and violent behavior, just to name a few. Even 
more reprehensible was that the report concludes by stating that the 
VAOIG was not confident that the facility employees were properly 
trained; that clinicians were effectively monitoring patients receiving 
high-risk medications, such as anticoagulants; nor that patient 
equipment was clean.
    To be frank, this is beyond unsatisfactory. A facility with a 
yearly budget of approximately $1B which serves more than 110,000 
veterans per year should not have untrained staff and dirty equipment.
    Since 2014, VA has told us the situation is improving, but to the 
veterans' community, this is not good enough. VA's obligation is to 
provide our veterans with the best health care our Nation has to offer. 
This investigation only adds to the hundreds of concerns we heard from 
veterans at VA facilities from coast to coast over the past three 
years.
    In light of these findings, we must reject any urge to paint 
Veterans Health Administration (VHA) as an overall failure that should 
be abandoned in exchange for privatized care. If the system is failing, 
it is the duty of the leadership to fix it. While this task at one time 
was daunting and yielded little in the way of results, thanks to the 
recent passage of the Department of Veterans Affairs Accountability and 
Whistleblower Protection Act, leaders now are empowered to hold 
underperforming employees accountable, regardless of seniority.
    Appeals Modernization: Currently, Ohio is home to 769,267 veterans 
of which 470,192 are receiving VA benefits in some form or another. An 
all-out push by the Veterans Benefits Administration (VBA) in the past 
few years has reduced the disability compensation and pension workload 
by more than 164,000 claims. In doing so, VBA continued to define its 
``workload'' and ``backlog'' as only initial disability and pension 
claims, diverting nearly all its people to working on those cases.
    As a result, the significant backlog reduction came at the expense 
of more difficult work. Appeals soared by more than 28,000 during this 
period, bringing the total number of appeals pending to more than 
300,000. Appeals continue to average more than three years before the 
Board of Veterans Appeals makes its first decision. Initial pension 
claims continue to rise, and disability claims with eight or more 
conditions remain unreasonably high at nearly 43,000. Pending 
dependency claims remain unreasonably high at over 231,000--up from 
40,000 just a few years ago.
    In 2015 alone, the Cleveland VA Regional Office processed 32,187 
claims. Since the first discussions on appeals reform with VA, the VFW 
has been very clear that any changes to the system must be coupled with 
aggressive initiatives to adjudicate legacy appeals in a timely manner 
through both legislative authority and proper resourcing.
    While VFW applauds Congress for passing S. 1024, the Veterans 
Appeals Improvement and Modernization Act of 2017, we have significant 
concerns with regard to how VA intends to implement these prescribed 
changes by way of the Rapid Appeals Modernization Program. Furthermore, 
the VFW urges Congress and VA to properly resource VBA and the Board of 
Veterans Appeals to ensure they are able to timely adjudicate appeals 
from veterans who do not opt into the new appeals process, and the 
potential influx of supplemental claims and higher level review 
requests at VA Regional Offices. VA must be empowered to manage its 
workload if the new framework to expected to succeed.
    Forever G.I. Bill: The VFW would like to thank this Committee for 
its hard work and dedication on the swift passage of the Forever G.I 
Bill, which will make a difference for countless veterans in Ohio and 
throughout the country. Specifically, we would like to thank Senator 
Brown for his continued push to ensure survivors who use the Marine 
Gunnery Sergeant John D. Fry Scholarship can achieve their educational 
goals without accruing large student loan debts. The VFW is 
particularly proud that the G.I. Bill is now a lifetime benefit. 
Veterans who were discharged after 2013 no longer have to worry about 
an expiration date for their G.I. Bill benefits. This rightfully 
recognizes that many transitioning servicemembers do not need to use 
their G.I Bill benefits immediately after separating from military 
service. The VFW will closely monitor the implementation of the Forever 
G.I. Bill to ensure veterans are aware of their expanded educational 
benefits and ensure VA meets its obligations to America's student 
veterans.
    Overpayments: With more than 187,000 overpayment notices being sent 
to veterans nationwide in the past year alone, one would hope that VA 
would not only be prepared to share the most precise information that 
triggered the notice in the first place, but also be prepared to assist 
the veteran in a timely fashion. Sadly, this is not the case.
    In the past year, the VFW's National Veterans Service (NVS) has 
directly assisted more than 200 veterans who have experienced issues 
stemming from overpayments. According to our estimates, about 60 
percent of the cases where NVS has intervened have resulted in the 
veteran being granted either partial or full relief from the debt from 
VA's Debt Management Center.
    In our experience, we have found that legitimate overpayments most 
often occur with G.I. Bill benefits when a veteran's enrollment status 
changes at his or her college. If a student decides that they are 
having a difficult time meeting their educational obligations and 
chooses to switch to part-time, it is the responsibility of the school, 
not the student, to notify VA. In the event that the school fails to 
notify VA of the change in status, the veteran will continue to receive 
the full living stipend and the school will continue to be paid the 
full-time rate for tuition.
    Once the error is noticed, VA will send an ambiguously worded 
notification of overpayment, which also provides options for repayment. 
If the veteran is unable to contact VA to establish that the debt is 
erroneous, make a repayment in a timely manner, or enter into a payment 
agreement with VA, their debt is sent to collections and VA will 
garnish payments from their disability compensation benefits until the 
debt is satisfied.
    The VFW understands that overpayments must be recouped in order for 
benefit programs to work efficiently. However, it is important to state 
that not only must debt notices be clear and provide the proper 
information regarding what steps veterans need to take in order to 
resolve any outstanding debts as soon as possible; but it is also 
imperative that these notices actually reach the veterans in the first 
place.
    That is why the VFW fully supports H.R. 3705, the Veterans Fair 
Debt Notice Act of 2017, which directs VA to require that certified 
mail be used to send a veteran any debt demand or debt information 
notification concerning collection of debts resulting from the 
veteran's participation in a VA benefit or home loan program. This 
piece of legislation passed the House earlier this month and we urge a 
swift passage by the Senate.
    Sequestration: Ending sequestration has been a top priority for the 
VFW since it was created by the Budget Control Act of 2011, which set 
spending caps for the Federal budget through fiscal year 2022 and 
included a provision to activate automatic cuts if such spending caps 
are exceeded. As a result, VA and DOD are forced to work within the 
confines of spending caps that were set more than six years ago which 
fail to account for increased demand for VA benefits and services, or 
for the costs required to man and equip a force capable of deterring 
and defeating emerging global threats. While Congress has negotiated 
temporary deals in the past to avoid the dangerous cuts, the issue of 
sequestration has not been addressed and continues to impact the 
resources afforded to DOD and VA.
    Compounding the problem is Congress' increasing reliance on 
continuing resolutions (CRs) to fund the government. CRs bring 
instability and uncertainty into the funding process by limiting long-
term decisionmaking, preventing new acquisitions and constraining 
spending to predetermined category levels. For DOD, this means canceled 
training, penalties on contracts, delayed maintenance on weapons 
systems, lack of equipment, cuts to quality of life programs, longer 
deployments, wear on materials, and an overall decreased readiness 
status.
    In my travels across the country and the world, I have seen 
firsthand the impact sequestration is having on our troops stationed 
overseas. Pilots barely fly enough hours to maintain their 
certifications and troops lack the training needed to combat the ever-
increasing threats to our national security. The effect mandatory 
sequestration will have on recruiting and retention, when combined with 
better job opportunities in a healthy civilian market, could jeopardize 
the continued viability of the all-volunteer force. For example, the 
Army Reserve has nearly 5,800 soldiers and more than 2,600 civilians 
employed (DOD and non-DOD combined) in Ohio. It is projected that 
sequestration has an impact of $16.7 million for fiscal year 2018 just 
in Ohio as it relates to the Army Reserve.
    What this means for veterans is that the resources VA is given to 
care for our Nation's veterans has increased in past years, but 
outdated and arbitrary budget caps on Federal discretionary spending 
have prevented budget increases from keeping pace with the growing 
demand on the VA health care system. Budget caps have forced VA to 
request less resources than needed to accomplish its mission and 
required Congress to provide VA less resources than it has requested, 
which hinders VA's ability to meet its obligation to our Nation's 
veterans.
    Until now, VA has been exempt from sequestration, but no one said 
that will be the case in the future since nearly half of VA's budget 
comes through the discretionary process. Despite recent legislative 
victories, sequestration could dramatically affect VA's ability to 
reduce the claims backlog or improve hospital infrastructure that is 
already in rapid decline, potentially diminishing access and timeliness 
of care. Additionally, programs that have not been exempt from 
sequestration would have a direct impact on our Nation's veterans, such 
as services the Department of Labor-VETS provides for veterans seeking 
employment, as well as the number and size of housing grants that the 
Department of Housing and Urban Development would have available for 
homeless veterans.
    Blue Water Navy: When asking my fellow Ohio veterans what issues 
are important to them, one that continued to come up is the frustration 
with continued inaction to provide Blue Water Navy veterans the 
benefits they deserve. The VFW strongly supports S. 422, the Blue Water 
Navy Vietnam Veterans Act of 2017, which would expand disability 
compensation benefits to veterans who were exposed to Agent Orange 
while serving in the territorial seas of the Republic of Vietnam in 
support of ground operations during the Vietnam War.
    Currently, VA relies on what the Court of Appeals for Veterans 
Claims has called an ``arbitrary and capricious'' interpretation of 
inland waterways, which unjustly denies veterans who served aboard 
ships in the coastal waters of Vietnam the benefits they deserve. The 
VFW calls on Congress to swiftly pass the Blue Water Navy Vietnam 
Veterans Act of 2017. However, we recognize the position that Congress 
is in concerning the cost of this legislation. To help move this issue 
forward, the VFW has written a letter to President Trump asking him to 
change the regulations associated with Title 38 of the United States 
Code. Doing so would alleviate the need for congressional action or 
reduce the cost associated with the passage of S. 422. The VFW call on 
this Committee to move this important bill as soon as possible.
    Burn Pits: The use of open air burn pits in combat zones has caused 
invisible but grave health complications for many servicemembers, past 
and present. Particulate matter, polycyclic aromatic hydrocarbons, 
volatile organic compounds and dioxins--the destructive compound found 
in Agent Orange--and other harmful materials are all present in burn 
pits, creating clouds of hazardous chemical compounds that are 
unavoidable to those in close proximity.
    The VFW is glad to see that nearly 100,000 veterans have enrolled 
in VA's burn pit registry. The VFW is also anxiously awaiting the 
results of the National Academies of Science's study on the burn pit 
registry which will serve to determine whether veterans exposed to 
airborne hazards from burn pits experience certain pulmonary 
conditions. The VFW urges VA and Congress to act swiftly on 
recommendations from this important study.
    VA must also take measures to improve the Airborne Hazards and Open 
Burn Pits Registry. For example, a similar registry operated by Burn 
Pit 360 allows the spouse or next of kin of registered veterans to 
report the cause of death for veterans. VA must add a similar feature 
to its registry to ensure VA is able to track trends. Other 
improvements include streamlining the registration process, updating 
duty locations, and eliminating technical glitches to ensure veterans 
are able to register.
    While the VFW is glad to see VA has commissioned independent 
research on the burn pit registry, more independent research is 
necessary. That is why the VFW supports funding for research through 
the Congressional Directed Medical Research Program (CDMRP) 
specifically for burn pit related conditions. The CDMRP for Gulf War 
Illness has shown some progress in identifying causes, effective 
treatments and biomarkers for Gulf War Illness, and the VFW is 
confident that similar research for burn pits will help veterans 
finally determine whether their exposure to burn pits during combat is 
associated with their negative health care outcomes.

    Senator Brown. It is an honor to have the national 
Commander-in-Chief of VFW, and thank you especially for your 
comments about the stigma of mental health. That issue is so 
important, and women veterans, and veteran student debt. Thank 
you.
    Next, we would like to hear from Melissa Twine.
    Ms. Twine, thank you for joining us.

        STATEMENT OF MELISSA TWINE, VETERAN, BATAVIA, OH

    Ms. Twine. First, I would like to thank Senator Brown for 
inviting me to participate in today's hearing, sharing my 
experiences with the Veterans' departments here in Ohio, both 
in Cincinnati and in Dayton, where my husband is buried.
    There is nothing more important than gaining insight from 
customers--in this case, the actual veterans. Having State or 
regional hearings to gain this valuable information can only 
lead to the betterment of the entire VA program, from 
educational services, health care access, and all entities in 
between. In addition, these hearings afford a collaborative 
bridge between the veterans and their lawmakers.
    A little about myself: I was a military brat and brought up 
in the military way of life, as my father was retired Air Force 
and a Vietnam veteran. When I was 17, I entered the U.S. Air 
Force and served for 10 years. I separated from the Air Force 
in 1998 with the label of a disabled veteran with 40 percent 
service connection.
    My husband, who was Active Duty Air Force, died at Langley 
Air Force Base in August 2002. I then gained a new label of a 
surviving spouse, a military widow, and a Gold Star wife. Our 
fourth child arrived 3 weeks later, and I moved myself and all 
four children home to Ohio to the Cincinnati area.
    I have been an advocate in supporting the initiatives 
brought forth by Senator Brown and many others for increasing 
survivors benefits via the VA's Forever G.I. Bill in 
conjunction with the Fry Scholarship for surviving spouses, and 
I hope to go back to school to continue my education, which was 
halted when I became a widow raising four children alone.
    Regarding access to the VA health care here in Ohio, I 
personally try to avoid the VA system at all costs. When I did 
try to utilize the VA system several years ago, over 12 years 
ago, I experienced only hassle and frustration. I quickly 
learned that using my survivors benefits for TRICARE was much 
easier and allowed for many more options, even though it came 
with a higher monetary cost to myself and family. Any attempt 
to see a VA medical provider was met with long wait times and a 
run-around when attempting to get medications for my diabetes, 
high blood pressure, and high cholesterol. When I did get an 
appointment, I waited a long time through a confusing process 
of lab testing and shuffling around through several hallways 
and departments.
    Additionally, I have a very close friend that tried to get 
help for substance addiction last year, which is a huge issue 
here in Ohio, a former marine. He was put through a month-long 
process of three appointments to different departments and tons 
of paperwork only to be told he did not qualify in the VA 
program because his wife had insurance, so he would not qualify 
for VA help, something that could have been identified up front 
in the very first appointment and not have caused a delay in 
him obtaining treatment that he so desperately needed.
    This only reiterated to me that avoiding the VA medical 
system was a no-brainer.
    I will continue to assist in the fight for increased 
awareness in the VA medical system struggle, fairness for 
survivor benefits for all surviving family members, and 
increased availability to all veterans' benefits that we earned 
while serving our country.
    Again, thank you for allowing me to appear here and testify 
today, and to achieve the previously mentioned topics.
    Thank you, Senator Brown and Congresswoman Beatty, for 
inviting me to appear today; for all the work that you do and 
that your office does; for helping military families, military 
veterans, and surviving spouses.
    [The prepared statement of Ms. Twine follows:]
      Prepared Statement of Melissa M. Twine, Veteran, Batavia, OH
    First, I would like to thank Sen. Brown for inviting me to 
participate in today's hearing by sharing my experiences with the VA 
departments here in Ohio, both in Cincinnati and in Dayton.
    A little about myself: I was brought up in the military way of 
life, as my father retired from the USAF. When I was 17, I entered the 
USAF and served for 10 years. I separated from the AF in 1998 and am a 
Disabled Veteran of over 40% service related. My husband, who was ADAF 
died at Langley AFB, VA in Aug of 2002. I then gained a new title or 
label of a Surviving Spouse. Our 4th child arrived 3 weeks after his 
death. I moved myself and all 4 children home to Ohio.
    Before separating from the AF, I gained an Associate's Degree in 
Allied Health Sciences. I then returned to school at the University of 
Cincinnati, where I earned my Undergraduate Degree in Biology, pre-med 
while taking care of 3 children; my husband was sent overseas without 
the family during this timeframe, also serving a tour with the United 
Nations in the Western Sahara. The VA helped me achieve this degree 
from UC via the VocRehab Program for DAVs.
    I have been an advocate in supporting the initiatives brought forth 
by Sen. Brown and many others for increasing Survivor's Benefits in 
Education via the VA's Fry Scholarship Program and hope to go back to 
school to continue my education that was halted when I became a widow 
raising 4 children alone.
    Regarding access to VA Healthcare in Ohio, I personally try to 
avoid the VA system at all costs. When I did try to utilize the VA 
system several years ago, I experienced only hassle and frustration. I 
quickly learned that using my Survivor's benefits for TRICARE was much 
easier and allowed for many more options, even though it came with a 
higher monetary cost to myself. Any attempt to see the VA medical 
provider was met with long wait times and a run-around when attempting 
to get medications for Diabetes, Hypertension, and high cholesterol. 
When I did get an appointment, I waited for a long time through a 
confusing process of lab testing and shuffling around through several 
hallways and departments . . . all the while being handed donuts and 
coffee from a push cart by volunteers . . . not exactly what Diabetics 
and patients with heart disease should be eating!
    I have a very close friend that tried to get help for substance 
addiction last year; a former Marine. He was put through a month-long 
process of 3 appointments to different departments and tons of 
paperwork only to be told that because his wife had insurance, he did 
not qualify for VA help . . . something that could have been identified 
up front and not have caused a delay in him obtaining treatment he so 
desperately needed. This reiterated to me that avoiding the VA Medical 
system is a no-brainer.
    I will continue to assist in the fight for:

     increased awareness in the VA Medical System struggle
     fairness in Survivor Benefits for all Surviving Family 
Members
     and increased availability to all Veterans benefits that 
we earned while serving our country

    Again, thank you for allowing me to appear and testify today to 
help achieve the previously mentioned topics. Thank you, Sen. Brown, 
for inviting me to appear today and for all of the work that you and 
your office does to help the military and their families.

    Senator Brown. Thank you, Ms. Twine. Thank you for your 
testimony. [Applause.]
    Thank you for pointing out to us what happens with benefits 
expiring. It is ideas like that that come from veterans in 
places like Batavia that really help me do this job. Thank you 
so much for that.
    Mr. Powers, welcome. We would love to hear your testimony.

       STATEMENT OF JAMES POWERS, VETERAN, MASSILLON, OH

    Mr. Powers. Thank you, Senator. Let me begin by thanking 
yourself and this Committee for an invitation to testify 
regarding topics concerning veterans.
    Of the over 850,000, of course, 8 percent of the State's 
population, the sixth most here nationally, veterans here in 
Ohio, and over 20 million nationally, this Committee has given 
me, of all people, the opportunity to give testimony regarding 
veteran issues.
    I personally view this as a great honor but also a great 
responsibility to tell my story and to be a voice for veterans 
that need to be heard.
    Senator Brown. Take your time.
    Mr. Powers. My name is James Powers. I served in the U.S. 
Army and the Ohio Army National Guard for a combined 12 years. 
I deployed in support of Operation Iraqi Freedom in 2009 to 
2010. During my career, I served as an infantryman, an 
instructor, and a recruiter. I achieved the rank of sergeant E-
5. And I, like any good soldier, held our creeds, our oaths, 
our ethos sacred and served to the best of my abilities.
    During my service, I, like over 3.8 million other veterans, 
became injured. The majority of my injuries I sustained over my 
military career, they are not easily visible, but one of them 
almost cost me my life, PTSD.
    When I came home from Iraq in 2010, my transition, like 
many others, did not go well. My life for the next 4 years 
slowly spiraled out of control. It was like quicksand. The more 
I tried to fix it, the worse things got.
    I let it consume everything, my livelihood, my military 
career, relationships, and my overall well-being. I turned to 
drugs and alcohol. I would do anything to numb what I still 
today trouble to describe until, finally, on a Tuesday morning 
in May 2014, when I had no other choice, I thought, put a 
pistol in my mouth and pulled the trigger. Click. A misfire 
occurred. I had improperly loaded a pistol that I had loaded 
and unloaded millions of times in my career because of how 
drunk I was.
    Fortunately, for me in that moment, something else clicked 
in my mind and I said something is not right. This is not you. 
Three and a half years later, I sit here before this Committee.
    It has been a bumpy road, to say the least. I completed an 
intensive 10-week residential treatment program. Had it not 
been for the PTSD substance use disorder residential treatment 
program at the Wade Park VA, I do not think I would be here to 
testify today. That program and the providers involved should 
serve as the standard of care for veterans with mental health 
issues, especially PTSD.
    It is unfortunate that VA funding and availability for 
programs like this are next to none.
    I have had to learn the art of finding a parking spot at 
overcrowded VA facilities. I have gotten used to going back and 
forth with the VA about trying to double collect on a debt. I 
got to experience the Integrated Disability Evaluation System. 
I spent 9 months at the Warrior Transition Unit in Fort Knox, 
Kentucky, for that. At least it seemed more efficient to me 
than the VA's traditional claim processing.
    I finally got the torn ligament in my wrist repaired. It 
only took 5 years from when I originally presented with pain.
    I continued to try things to ease the chronic pain in my 
left foot during that time, too. I drove 6 hours back home on 
the weekends, as my wife was expecting our now 2-year-old son.
    Finally, in February 2016, my military career ended, and I 
was medically discharged retired. Since then, I keep to myself. 
I am Sergeant Powers turned Mr. Mom to my little man Connor and 
my soon-to-be-little dude Luke.
    I strive to be a good husband to my wife, Shannon. She 
keeps me grounded and coolheaded. I only wish that the VA would 
do a better job with the caregiver program. At times, too, she 
has questioned the VA's shortcomings, which at least helps me 
feel validated my issues and not that I am just losing my mind.
    She was even understanding and simply said, ``Drive safe 
and call me when you get there,'' when I made the spur-of-the- 
moment decision and drove all the way to D.C. in July to see my 
elected officials about the congressional inquiry that the VA 
seemed to be stalling on. To my luck, Senator Brown and his 
staff were able to finally get answers about a grossly 
inaccurate $11,000 VA overpayment debt. The VA's eventual 
response was that the debt was miscalculated due to a ``manual 
processing system failing to properly communicate with an 
automated system.'' If you ask me, it sounds like a fancy way 
of saying human error.
    I just keep my routines, and I try to stay mindful. I still 
struggle daily, but not nearly what I used to. For that, I am 
happy.
    I surround myself with a small group of veterans, some that 
I have known since childhood, others that I have had the 
pleasure of meeting along the way in my life. Two of them, 
fortunately, join me here today. We look out for each other 
just like we did in the service, covering each other's six. I 
think I did this for them just as much as for myself.
    I have been prescribed medications over the years, at times 
three-to-five medications, some requiring routine lab work, 
some that would be to counteract side effects of the other 
medications, which cause new side effects. I began to feel like 
the VA doctrine was increase the dosage or increase the number 
of medications, and that will fix any problem.
    All of this became too much for me. I finally broke down 
and turned to medical marijuana. I figured that it cannot be 
any worse than all the pills. For the last 10 months, I have 
been using it. I only hope the Federal Government might change 
the law and see the medical benefits of marijuana, like the 29 
States that have medical marijuana programs in place. I have no 
adverse side effects, and I feel the combination of therapy has 
been far greater managing my symptoms than the traditional 
medication regimens that the VA prescribes.
    Some things that I and veterans all across this country 
would like for this Committee to think about: Tonight, when we 
go to sleep, around 40,000 veterans will go to bed homeless. 
Men and women this great Nation of ours hold in such high 
regard for the selfless service are being lost to suicide at a 
rate of 22 per day. That is 18.5 percent of all daily suicides. 
Thirty-plus day wait times are still happening for 
appointments. Female veterans, who account for 10 percent, 
about 2 million, as has been said here today, of all veterans, 
still struggle to get access to women's health services. The VA 
is still unable to provide the same quality of care that is 
available in the private sector. Evening and weekend primary 
mental health care appointments, and access to the urgent, 
convenient, and emergency services, are next to nonexistent. 
Claims are still taking too long for initial processing, being 
improperly processed, and taking even longer to be reviewed in 
the appeals process. Automated phone systems and Web services 
are helpful, but still need improvement. How hard would it be 
to ensure all needed phone extensions are available online when 
you pull up a VA facility, or printing the extension on the 
appointment reminder when you need to reschedule? The Choice 
Program concept is great; however, implementation and execution 
of it were ill-conceived and lackluster. Disability claims and 
issues regarding burn pit exposure are beginning to seem just 
like Vietnam veterans who are still fighting about Agent 
Orange.
    This list is far from inclusive, not to mention these 
things are far from anything new. These issues continue to be 
echoed by veterans of all generations.
    If this Committee really wants to know about the issues 
that are facing veterans, it is not hard. Go back to your 
homestates, walk in the nearest VA facility, and ask the 
nearest veteran. Talk to 20 percent of your States law 
enforcement and first responders who are veterans. Walk into a 
VFW and American Legion or AMVETS post. Heck, talk amongst 
yourselves. Twenty percent of politicians are veterans. Get on 
social media. Listen to the veterans' organizations in D.C. who 
represent us.
    Now, I know that only so much can come from my testimony 
here today. I know this will not be the turning point in the 
care of this Nation's veterans. Effective change and progress 
do not happen overnight. I more than anything hope this 
testimony and any results it produces helps even one veteran. 
This is my measure of success: that my words have not fallen on 
deaf ears and blind eyes, that this Committee has been reminded 
of how big of a responsibility they have in ensuring this 
country's veterans are not forgotten.
    [The prepared statement of Mr. Powers follows:]
           Prepared Statement of James Powers, U.S. Army and 
                    Ohio Army National Guard (Ret.)
    Let me begin by thanking both Senator Brown and this Committee for 
the invitation to testify regarding topics concerning veterans.
    Of the over 850,000+ (8% of population 6th most nationally) 
veterans here in Ohio and over 20 million nationally, this Committee is 
giving ME the opportunity to give testimony regarding veteran issues. I 
personally view this as a great honor but an even greater 
responsibility. To tell my story and to be a voice of veterans that 
need to be heard.
    My name is James Powers. I served in the U.S Army and Ohio Army 
National Guard for a combined 12 years. I deployed in support of 
Operation Iraqi Freedom in 2009-2010. During my career I served as an 
Infantryman, Instructor, and Recruiter. I achieved the rank of SGT/E5. 
I, like any good soldier, held our creeds, oaths, and ethos scared and 
served to the best of my abilities. During my service I, like over 3.8 
million other veterans, became injured.
    The majority of my injuries I sustained over my military career are 
not easily visible. But one has almost cost me my life. PTSD. When I 
came home from Iraq in 2010 my transition back didn't go well. My life 
for the next 4 years slowly spiraled out of control. It was like 
quicksand. The more I tried to fix what was wrong the worse I made 
things. I let it consume everything. My livelihood, military career, 
relationships, and my overall well-being. I turned to alcohol and 
drugs. I would do anything to numb what I still to this day find 
trouble describing. Until finally on a Tuesday morning in May 2014 when 
I felt I had no other choice but to put my pistol in my mouth and pull 
the trigger. CLICK! A misfire occurred, I had improperly loaded the 
pistol because of how drunk I was. Fortune for me in that moment 
something else ``clicked'' in my mind and said ``something isn't right, 
this isn't you.''
    Three-\1/2\ years later and here I sit before this Committee. It 
has been a bumpy road to say the least. I completed an intensive 10 
week residential treatment program. Had it not been for the PTSD/SUD 
residential treatment program at the Wade Park VA Medical Center I 
don't think I would be here to testify before you today. That program 
and the providers involved should serve as the standard of care for 
veterans with mental health problems especially PTSD. It is unfortunate 
that VA funding and availability for programs like this one are next to 
none. I have learned the art of finding a parking spot at crowded VA 
facilities. I have gotten used to going back and forth with the VA 
about them trying to double collect on a debt. Got to experience the 
Integrated Disability Evaluation System (IDES) process. Spent 9 months 
at the Warrior Transition unit in Fort Knox, KY for that. At least it 
seemed more efficient that traditional VA claim processing. I finally 
got the torn ligament in my wrist repaired. Only took 5 years from when 
I originally presented with pain. I continued to try things to ease the 
chronic pain in my left foot during that time too. I drove 6 hours back 
home on the weekends as my wife was expecting our now almost 2 year old 
son. But finally my military career ended when I was medically 
discharged/ retired in February 2016.
    Since then I keep to myself. I'm SGT Powers turned Mr. Mom to my 
little man Connor and soon to be little dude Luke who is expected to 
join us in February. I strive to be a good husband to my wife Shanon. 
She keeps me grounded and cool headed. I only wish that the VA would do 
a better job with the caregiver program. At times she too has 
questioned the VA shortcomings, which at least helps me feel valid in 
my issues and it not be me just losing my mind. She even was 
understanding simply saying ``drive safe and call me when you get 
there'' when I made the spur of the moment decision and drove all the 
way to D.C. in July to see my elected officials about a Congressional 
Inquiry that the VA seemed to be stalling on responding to. To my luck 
Senator Brown and his staff were able to help finally get answers about 
a grossly inaccurate $11,000 VA overpayment debt. The VA's eventual 
response was that the debt was ``miscalculated'' due to a ``manual 
processing system failing to properly communicate with an automated 
system.'' If you ask me it sounds like a fancy way to say human error. 
I keep routines so to help me stay mindful. I still struggle daily. But 
not nearly what I used to and for that I am happy.
    I surround myself with a small group of veterans. Some that I have 
known since childhood and others I have had the pleasure to meet along 
the course of my life. We look out for each other. We know each other's 
signs and symptoms. Many times they are just like our own. Just like in 
the service we are covering each other's six o'clock. I think I agreed 
to this for them more than for myself.
    I have been prescribed medication over the years. At times being on 
3-5 medications. Some requiring routine lab work. Some that would be to 
counteract side effects of other medications while causing new side 
effects. It began to feel as if VA doctrine was increased dosage or 
increase number of medications that will fix any problem. All of this 
became too much for me. I ended up turning to medical marijuana. I 
figured it can't be any worse than all of the pills. For the last 10 
months I have been using it. I only hope the Federal Government might 
change the law and see the medical benefits of marijuana like the 29 
states that have medical marijuana programs. I have no adverse side 
effects and feel with in combination with therapy has been far better 
at managing my symptoms than with traditional medication regimens.
    Some things that I and veterans all across this country would like 
for this Committee to think about:

     Tonight when we all go to sleep, around 40,000 veterans 
will go to bed homeless.
     Men and women this great nation of ours holds to such high 
regard for their selfless service are being lost to suicide at a rate 
of 22 a day (18.5% of all daily suicides). 30+ day wait times are still 
happening for appointments.
     Female veterans who account for 10 percent (about 10 
million) of all veterans still struggle to get access to Women's Health 
services. The VA is still unable to provide the same quality of care 
that is available in the private sector.
     Evening and weekend primary or mental health care 
appointments, Access to urgent, convenience, and emergency services are 
next to nonexistent.
     Claims are still taking too long for initial processing, 
being improperly processed, and taking even longer to be reviewed in 
the appeals process. Automated phone systems and web services are 
helpful but still need improvement. Like how hard would it be to ensure 
all needed phone extensions are available online when you pull up a VA 
Facility. Or printing the extension on an Appointment reminder should 
we need to call and reschedule.
     The CHOICE program conception is great. However 
implementation and execution of it were ill conceived and lack luster.
     Disability claims/issues with Burn pit exposure are 
beginning to seem just like Vietnam veterans who are still fighting 
about Agent Orange.

    This list is far from being all inclusive. Not to mention these 
things are far from anything new. These issues continue to be echoed by 
veterans.
    If this Committee really wants to know about the issues that are 
facing veterans it's not hard. Go back to your home state's, walk into 
the nearest VA facility and ask the nearest veteran. Talk to the 20% of 
your state's law enforcement and first responders that are veterans. 
Walk into a VFW, American Legion, or AMVETS post. Heck talk amongst 
yourselves. 20% of politicians are veterans. Get on social media. 
Listen to the veterans organizations in DC who represent us.
    Now I know that only so much can really come from my testimony here 
today. I know this won't be the turning point in the care of this 
Nation's veterans. Effective change and progress don't happen 
overnight. I more than anything hope this testimony and any results it 
produces helps even 1 veteran. That is my measure of success . That my 
words haven't fallen on deaf ears and blind eyes. That this Committee 
has been reminded of just how big of a responsibility they have in 
ensuring this country's veterans are never forgotten.

    Senator Brown. Thank you, Mr. Powers.
    Thank you for talking about transition. Your survival has 
meant a better life for a lot of veterans and especially, 
obviously, for Shannon, Connor, and soon, I understand, for 
Luke.
    Mr. Powers. Super Bowl Sunday--I only hope that it is 
slightly before kickoff. [Laughter.]
    Senator Brown. I assume you do not expect the Browns or the 
Bengals to be in that game either. Just guessing. Just 
guessing.
    Mr. Powers. I am expecting to be at the--parade.
    Senator Brown. Yes, since where you come from, there is a 
tradition in your city, isn't there, in Massillon, OH?
    Mr. Powers. In Massillon, of course, football is everything 
down there. They are getting ready to play in the State 
semifinals against another team, but if they win, 
unfortunately, they will be losing to my alma mater----
    Senator Brown. Glad you pointed that out. Thank you.
    Also, I want to recognize two people: Mike Dustman from 
Senator Portman's office and Luke Crumley from Congressman 
Tiberi's office. Thank you for joining us also.
    I want to start with the two of you, Mr. Powers and Ms. 
Twine. I want to read you--we asked earlier, a couple weeks 
ago, in anticipation of this hearing, just for veterans to go 
on Brown.Senate.gov, go on my Web site and give us thoughts, 
ideas, and questions. I want to just read you a few kind of 
random thoughts from about a half dozen different veterans, and 
I would like you to listen to these statements. Then, starting 
with you, Ms. Twine, tell me what you think.
    Just react in any way you want, in terms of: is the VA 
doing what it should? What about our obligation? Just any kind 
of thoughts you have on any of these statements. I will just 
read the half dozen of them.

         ``It was very hard to come from killing in a jungle to 
        adjusting into life. The demons never go away.''
         ``It was a long time ago, but I remember it as being 
        OK.''
         ``Difficult. I was medically discharged, felt like I 
        wasn't given enough guidance on what to do next, 
        especially with the disability.''
         ``I went from Active Duty to Reserves then civilian 
        completely, so not too bad.''
         ``Several employers told me I just wasted 8 years of 
        my life due to PTSD. I had many altercations with 
        strangers. I once hit my wife when she bent over me 
        while I was sleeping. I still sleep with a spotlight 
        and a gun.''
         ``It sucked. While no one would come out and say it, 
        no one would hire a vet or even someone that was on 
        drill status. I was unemployed for a bit over 2 years 
        because of this.'' And,
         ``I am still in transition in some ways. It will never 
        leave you.'

    Ms. Twine, any thoughts about any of that?
    Ms. Twine. I think it is very representative of the 
veterans of today. What you just said speaks to 80 percent of 
veterans who were having issues and problems, not only 
transitioning but also with continued care, while 10 to 20 
percent say, ``I served my time. I'm OK. I don't need any other 
services.'' So, I think those are absolutely very 
representative of what we are seeing today.
    Senator Brown. If I could follow up, how many of those, you 
just said 20 percent who come back do not need to use services. 
I hear so many stories in part from what the two gentlemen here 
said of soldiers that come back: they do not know, Mr. Tansill, 
they do not know the veterans service organization, the 
veterans service office, the commissioners in Delaware or 
Newark or Circleville. They do not get in touch with anybody. 
Then their sister calls and says, ``My brother is having 
problems.'' They came back without needing anything. How often 
do you hear that?
    Ms. Twine. I hear it all the time. I was just explaining to 
him earlier that I had never been approached by any of the 
veterans organizations except the Gold Star Wives organization.
    Senator Brown. Even though you are a veteran yourself.
    Ms. Twine. I am a veteran, and I live in Clermont County, 
which tends to be one of the highest counties in the State of 
Ohio for loss of veterans. I have not been approached by VFW, 
the VA, Disabled American Veterans, other than for a donation 
when I leave Sam's Club. I have not been approached by The 
American Legion, any of those organizations.
    I absolutely agree that there is a huge disconnect in 
communication. In fact, it took them 1.5 years to find me to 
give me more benefits from the changing of life insurance for 
my husband after he died, and I go to Wright-Patterson all the 
time. But, because Langley could not connect with Wright-
Patterson to know anything, I was in a hole.
    I agree. When I separated from the service, I was a 
captain's wife. I went back to school. I did what I needed to 
do. I did not need any services from the VA at that point--
until my husband died, until I got a letter from the VA saying 
you have a primary care provider. It may take you 6 months to 
see him, but here is your letter with who your PCP is.
    I think it is a huge disconnect. There are veterans who are 
well-adjusted, do not need any services. But then, you have 
veterans that obviously need help and services and cannot get 
that access.
    Senator Brown. I would argue that Ohio is better served 
than many States because we have Mr. Tansill's previous job, we 
have a Franklin County Veteran Services office, and I believe 
half the States do not have that, more or less, something like 
that.
    Mr. Tansill. Senator, most States do not have a county-
specific office. They may have people who work out in a county, 
but not a specific county office for every county.
    Senator Brown. Mr. Powers, those five or six statements I 
was reading, what comes to mind for you as you heard those?
    Mr. Powers. For me, those statements, I mean, they are 
nothing new. I have said them myself or have heard my friends 
say them.
    Transition is rough. When it comes to the VA, I feel like 
you get the benefits book, which I call the VA bible. To try 
reading through that and understanding the programs and 
everything else, it is dry, it is bland, and if you can make it 
past 10 pages trying to find something in there, you are doing 
better than me.
    You have that book, and that is about it. I mean, you try 
asking about programs from the VA, and it is, ``Fill out a 
form,'' not information about the program or anything.
    My wife did try doing the caregiver program, and it almost 
felt like they were more concerned with eliminating her for a 
caregiver's stipend, which we were not interested in, as 
opposed to really providing her with the support that she 
realistically needs to deal with my symptoms. I am not always 
the most pleasant person. Prior to today, in grocery shopping, 
the last time I went out and did something for myself was 
probably about a month ago.
    I keep to myself. I have a small circle, which shouldn't be 
the case. Organizations, myself, personally, when I came home 
from Iraq, I was telling Colonel Tansill before this that I 
took my DD-214 and ran to the VFW like I was Charlie and I got 
the golden ticket to go to the chocolate factory. That is what 
the VFW was for me. That is what I thought it was going to be.
    For the year that I was a quartermaster of a post up in 
Sandusky, it was an extension of being in the military, the 
brotherhood, the tribe, so to speak. There needs to be a 
continuity of that when you move from the service back into the 
civilian world, because if you spend even 3 years away from 
what you called home for the first 18 years of your life, you 
come home and everybody has changed, but you still feel like 
the same person. I mean, kids get older, you lose friends, 
friends move away. What was once your life is not anymore, and 
now you are trying to jump right back into it.
    We need to ensure that the availability is there for us to 
connect. Some of the veterans' service organizations, they do 
fantastic work both in their communities and nationally, but 
their active ranks, they are aging and declining, 
unfortunately. The younger generations are not coming in.
    I get it, to some extent. I mean, reaching out to a whole 
different generation of veterans, it is different every time. 
It was different for World War II veterans who were welcomed 
home with parades, and different for Vietnam veterans who were 
welcomed home to protest. We have to find a way, both as 
veterans and veterans' organizations, of how to stay connected 
to the guy to the right and the guy to the left, and look out 
for each other.
    Also, Congress and this country needs to step up and have 
real-world solutions for looking out for us, because I know 
when I served, and everyone that I have known, that I have had 
the pleasure of knowing, who has served, we served this country 
no questions asked. We took oaths that still to this day I can 
recite it verbatim, and most still probably can, too. It is 
time for this country to be reminded that we are here, and we 
are equals, and sometimes we need help.
    Some of us do not. Some of us always land on her feet. But, 
even when you land on your feet enough, you are liable to break 
a leg. It happens.
    It is time for the transition to be eased.
    Senator Brown. Thank you, Mr. Powers.
    Mr. Tansill, Mr. Powers mentioned one of the challenges is 
employment, obviously. Employment is difficult for a whole lot 
of reasons, coming back, obviously, in civilian life. Talk to 
us about your role now, what you see now and what you saw when 
you were in Franklin County. Talk about the specific challenges 
that veterans face, particularly newly returned veterans, about 
employment.
    Maybe give us a short, little scenario of what a veteran 
faces when looking for a job coming home, especially maybe if 
they were a medic in Iraq; they come back and they could maybe 
get certified a little quicker if they had done it right--we 
still have not done it quite right--to be a first responder, 
and those that do not have sort of a specific skill that 
translates, other than serving their country really well and 
being a good soldier.
    Talk that through, if you would.
    Mr. Tansill. A couple of things, Senator.
    First, the transition is the most difficult for a veteran 
when they come home, the first 120 days, typically, especially 
if they have a family, because they are assimilating back into 
what they had as a civilian life prior to that. That is a very 
critical time, the biggest transition. Just like if you move 
from one country to another, the first few months is a very 
difficult time.
    The issue is no one knows they are coming back until they 
are here. They are actually home 3 months to 4 months before we 
actually know that they are home, so there is 3 or 4 months 
that they have not had any contact to get jobs because they do 
not know where to go.
    Right now, we receive the DD-214s from DOD when they come 
home. The problem is the average length of time to receive 
those is 120 days. That means they have been home 120 days. 
That is the struggle they have to find out where they need to 
go for jobs.
    One of the biggest problems----
    Senator Brown. What do they do for money in those 120 days?
    Mr. Tansill. Many of them have some terminal leave, so they 
have built up some leave and they are using it. For the most 
part, they go on unemployment, and DOD is paying them 
unemployment.
    Senator Brown. Unemployment, I assume, is never contested 
by the government, I hope?
    Mr. Tansill. I do not know the answer to that. I have not 
heard of anyone complaining.
    Senator Brown. Let me ask it this way. Do you know of men 
and women who have had trouble getting unemployment?
    Mr. Tansill. I personally do not. I personally do not.
    Senator Brown. OK. If any of you in the audience know, 
particularly those in veterans' service organizations like VFW, 
if you hear of those stories, you should always contact 
Congresswoman Beatty or me or Senator Portman. We will go to 
bat on that. That should never happen.
    Go ahead. I am sorry.
    Mr. Tansill. There are many vets who come home and do not 
know what they want to do. They have served their country in 
whatever capacity, an infantryman or whether they were a medic. 
Many veterans come home and do not want to use those same 
skills. They want to get a different skill.
    One of the things that has been really advantageous to 
veterans coming home to Ohio is our apprenticeship programs.
    They come home. They do not want to be a medic anymore. 
They want to be a carpenter. The problem is they do not know 
about those programs until they are here a year because they 
have no visibility of those things while they are still on 
Active Duty transitioning back.
    Senator Brown. Are the union apprenticeship programs, if 
you decide you want to be a carpenter, you want to be a union 
carpenter, or you want to be a union electrician, and you go 
through the apprenticeship program being paid a decent wage 
while you are going through it--it is a several years' 
prospect, but you make a living doing it--newly returned 
veterans, how do they find out about those?
    Mr. Tansill. In the cases that I know of, they have heard 
it from a friend or a family member who is part of a union and 
tells them to go to that apprenticeship program.
    Senator Brown. Nothing more formal than that?
    Mr. Tansill. Nothing more formal than that.
    Senator Brown. There is a program Helmets to Hardhats.
    Mr. Tansill. There is a program.
    Senator Brown. But, that does not reach far enough that 
enough people know about it, I assume?
    Mr. Tansill. It does not. It is very difficult, again, when 
a veteran comes home, they are here for 120 days before most 
people know that they are here. That is a real challenge.
    If the availability to reach them before they leave, let's 
say, Fort Sill, Oklahoma, to say, ``Hey, we know you are coming 
home in 6 months. Here are all the educational opportunities. 
Here are all the job opportunities. If you go to Ohio, it means 
veterans jobs''----
    Senator Brown. Why are we not doing that?
    Mr. Tansill. We have no way of knowing that they are coming 
home, at this point.
    Senator Brown. Who is responsible? Is the DOD the problem? 
The local veterans' service commission, could they play a role? 
Why is this not happening?
    Mr. Tansill. Senator, we can all play a role. Right now, 
the communication needs to be greatly improved between the 
Department of Defense, the branches of the military, and the 
States that these folks are returning to.
    My counterparts and I across the country are looking for 
ways to reach out to the servicemember before they become our 
veteran, so we can help them understand what is available to 
them.
    One of the common problems that we have is a veteran will 
come home, and most veterans go where? Back to mom and dad's or 
the same town that mom and dad lived in. Well, there may not be 
a lot of great jobs in the hometown. Yet, they have a skill set 
that they could have moved three towns over and utilized that 
skill set to get a job. But, they did not know that until they 
moved home, and now they are out of money, and now they are 
trying to figure out how to get a job.
    Getting information to these folks before they come back to 
Ohio's borders is the best way to help them transition into 
their civilian life, not after they have been here 3 months to 
4 months.
    Senator Brown. Thank you.
    Commander Harman, Mr. Powers said, rightly, that veterans, 
soldiers, air men, sailors, and Marines coming home now may see 
a parade, while your era of veteran too often saw a protest.
    Talk to us, if you would, about Agent Orange exposure, 
everything from Navy veterans to burn pit exposure in Iraq and 
Afghanistan, too, for that matter.
    What steps should this Committee, this Congress, and the 
Administration take to improve the lives of veterans suffering 
from exposure to toxic materials?
    Mr. Harman. Any veteran exposed to any type of toxin, 
whether it is burn pits, Agent Orange, radiation, or whatever, 
during their time of service must be given the benefits and 
care that they have earned. To deny those individuals that care 
and medical benefits forces them to incur sometimes 
insurmountable amounts of medical expenses to treat those 
illnesses and injuries.
    We have heard reports of many veterans dying because they 
have been denied that particular benefit, again, which just 
amounts to a huge amount of huge expense incurred by that 
family when it should have been the government's responsibility 
to pay them for that disability or award them a disability 
rating due to that exposure to any toxin.
    Senator Brown. You have been an advocate. You would not be 
the national commander if you had not been an advocate for 
pretty much your whole life for veterans. You went through a 
period where government, because Congress did not respond 
quickly enough, where soldiers that developed cancer from Agent 
Orange in Vietnam in the 1990s were seeing that become more and 
more common. They had to go to the VA and prove it was 
connected to Agent Orange. Congress then responded, in the 
right way, and put those illnesses on a presumptive eligibility 
list, right?
    Mr. Harman. Correct.
    Senator Brown. Is that list, I think most people here know 
that, but there is a list of, how many? Sixteen or 18, 
something like that, illnesses that are connected that are 
believed to have been contributed to or caused by Agent Orange, 
are now eligibilities for any soldier, sailor, air man, or 
Marine who put a foot on the ground that were on a ship that 
docked in Saigon or whatever.
    That list, we have added some illnesses to it over time.
    Mr. Harman. Correct.
    Senator Brown. Is that list up-to-date? First question.
    Second question, does that list reflect Iraq and 
Afghanistan? Or is that list really just too reflective of 
Vietnam and not more recent history?
    Mr. Harman. I think, for the most part, it is pretty much 
reflective of Vietnam and exposure to Agent Orange. There are 
some presumptive conditions as a result of burn pit exposure, 
and I know that Secretary Shulkin is looking at some potential 
new presumptive conditions due to exposure to Agent Orange and 
toxic exposure.
    Senator Brown. I would ask you, with your prestige and 
reach around the country, to update us as much as you can, and 
really you too, Mr. Tansill, and the two of you also, Ms. Twine 
and Mr. Powers. I mean, I think we are always looking to 
perfect this.
    Mr. Harman. Sure.
    Senator Brown. We have not done that. But, when medical 
science connects an illness to an environmental condition like 
burn pits or Agent Orange, that Congress needs to know it and 
move quickly. Anything you know that you feed to us is really 
important.
    Mr. Harman. I will have our Washington office be in touch 
with you.
    Senator Brown. Thank you, Commander.
    Congresswoman Beatty for questions.
    Ms. Beatty. Thank you, Senator.
    Let me say thank you to all our witnesses for your powerful 
testimony.
    As I was sitting here, I had a list of questions, Senator, 
but I want to go to one that just came to me as I listened to 
the testimony. I guess it becomes a question that it seems like 
we are hearing a lot about the lack of access when there is a 
need, first, just maneuvering through getting access and then 
the timeliness of access.
    Certainly, for all of us, whether you are a veteran or 
served in the military, when you are in crises, you need quick 
intervention. I guess the question becomes, maybe Mr. Tansill, 
or even to us, are there exit plans? Are there counseling 
sessions, exit plans?
    I am thinking about the biggest thing young folks do today 
if they are not going into the military, let's say they are 
going to college. In addition to having their commanders who 
are their professors and who are their lab tech folks, they 
have counselors. You know, people change their majors. They get 
ready to graduate. They find out a month before graduation or 
the quarter before that they have to take another class.
    Should we in Congress be looking at what is there along the 
way. Whether I am here or in the district, I hear this 
constantly. ``I could not get access to my X, Y, Z. I was in 
depression,'' or, ``My wife couldn't,'' or my spouse couldn't. 
We know this; this is not new. I am hearing powerful stories 
that I have heard before.
    What is it that we need to put in place that helps us to 
have quicker and better access for those who have served who 
are coming back? What should I be looking at as a Member of 
Congress for getting that access? Is it more of something? Is 
it simplifying something? We know eventually somebody is going 
to leave. If they are here for 120 days, even if someone has a 
medical crisis and they are injured, they are in the hospital, 
they cannot get released--let me give you a good one.
    If you are home, I had a relative who went to the hospital 
the other day, and the outcome was not good, but they would not 
release them until I went out and found a rehab center. They 
would not release them to go home. We had to have a rehab 
center for them to go to, so they would not be in crisis at 
home.
    It seems like we could have some plan that says Jane and 
John Doe are going to be released whether it is for medical 
reasons, whether it is they have served their time, that there 
is some type of 30-day, 120-day exit plan.
    If I knew that I was going to mom's but I could go 60 miles 
up the street and get in a program, why didn't somebody know 
that to tell me that?
    Mr. Tansill. Congresswoman, the military does out-process 
the folks. It is called Transition Assistance Program. TAP is 
the acronym for it. It is typically done within the last 12 
months of their service that they start going through this 
process.
    The process is more about getting them to understand that 
they are going to need to look for a job. They need to get 
connected to the VA. They need to do different programs like 
that.
    I will circle back to the best way to help a veteran coming 
home is to get them information before they get here.
    DOD installations do a pretty good job of out-processing 
them, but it ends at the front gate. We need to make sure we 
get to them before they leave whatever installation under DOD 
they are stationed at to ask them: Are you coming back to 
whatever State? What are you going to do? Are you going to 
college? If you are going to look for a job; what are you 
interested in? If you are looking for an apprenticeship 
program, here is where you can go to find out all the 
apprenticeship programs in all of the cities.
    Finding out at the 120-day mark that someone has returned 
to Ohio has put them at an extreme disadvantage to get their 
life jump-started back as a civilian. Being able to reach them 
prior to their exit from the military, to allow them to 
understand all the things that are available to them back in 
whatever State they are going to--by the way, we want every 
veteran to come to Ohio even if they are not from Ohio. They 
need to know what is available.
    Most people coming out of the military getting ready to go 
to college, they already know that. They know what college they 
want to go to. They have already done most of the work online. 
But, it is the jobs and the apprenticeship programs and those 
folks that have not figured out yet what they are going to do.
    A lot of people leave the military and say, ``I need time 
to figure out what I want to do.'' If we are able to frontload 
them with all the available opportunities for them, it sure 
might make their decision a little easier when they get home.
    Ms. Beatty. Thank you.
    Senator Brown. Thank you very much.
    Ms. Beatty. Let me just say thank you for allowing me to 
participate. We will follow up, our staff with your staff.
    Senator Brown. Good.
    Ms. Beatty. Thank you for being here.
    Senator Brown. Thank you, Congresswoman. [Applause.]
    Thank you for changing your day around to join us. I really 
appreciate it.
    I would add, I was just informed there are 14 illnesses, 14 
diseases, that are presumptive eligibility with Agent Orange. 
Secretary Shulkin is making a decision on three more, so there 
will likely be up to 17 illnesses that are connected, that 
someone is automatically eligible for benefits if diagnosed 
with that illness.
    One more question for this panel, and for you specifically, 
Ms. Twine. I know you do not speak for all women veterans. I 
understand that you do not speak for all Gold Star wives, but I 
want to ask you two things.
    One is, talk about, if you would, how the VA can improve 
services and health care outcomes for veterans, for female 
veterans. About 10 percent of Ohio veterans now, slightly under 
10, are female. That percentage, obviously, is going up because 
among young veterans, the percentages are obviously higher. 
Talk about that.
    Talk about, if you would, if you have thoughts on what we 
should do to reduce sexual violence in the military, if you 
feel comfortable answering that. You have been out for a while, 
I understand.
    Ms. Twine. That is huge, open-ended----
    Senator Brown. Yes, I know those are two really broad 
questions.
    Ms. Twine. Personally, I did not experience sexual violence 
as a veteran, and as an Active Duty military person, so I 
cannot speak for those people. However, being a woman in the 
military and also in the medical field, even today, there is 
always a good old boys club. Unfortunately, that has been the 
accepted norm for many, many and thousands of years. So, 
overcoming that----
    Senator Brown. It is not just the military, is it?
    Ms. Twine. No, it is everywhere. You turn the TV on and all 
you are going to hear, every update on your iPhone is going to 
be some new person coming out because they were kissed hard. It 
is going to be a huge issue.
    Unfortunately, the lack of communication and the lack of 
holding those accountable has created an environment that 
allows for that type of behavior to be considered the norm.
    I do not have a good answer to that other than people need 
to step up and do what is right. They also not only need to 
step up and do what is right, they need to speak up.
    That is a huge problem with women and men, is speaking up 
when there is a problem. We are seeing now, you turn the TV on, 
``Twelve years ago, I had a problem.'' ``Thirty years ago, I 
had a problem.'' ``Forty years ago, I had a problem.'' But, 
nobody spoke up.
    Now we are looking at this issue that was an issue 30, 40 
years ago. It is a huge problem.
    It creates a huge problem in the mental health field for 
women who have PTSD because of those issues. I can only assume 
that that is another area of major concern for women.
    Personally, the issues that I have heard about from 
patients that I treat or from people that I know personally is 
that the VA has very little tolerance for women's health 
issues, such as annual Pap smears or birth control or the need 
for different surgeries for birth control or for hysterectomies 
and different type of programs. And, getting access to those 
from the VA is difficult.
    Senator Brown. We will hear from the VA in a moment.
    Ms. Twine. My understanding, my experience with the VA, 
like I said, I have avoided it like the plague, and I will go 
civilian. But, then again, in the civilian world, it is not 
always easy either, if you go to a Catholic hospital versus a 
regular hospital.
    I cannot really answer to a lot of those questions, 
unfortunately.
    Senator Brown. Thank you.
    Did you want to add something?
    Mr. Powers. Yes, Senator Brown.
    As a member of the IAVA, our major bill initiative, your 
cosponsor on it, I believe. I think it is S. 681. That would be 
the Deborah Sampson Act. It is common-sense legislation to get 
the VA priority funding for peer-to-peer-women's programs for 
the mental health care, for the primary care.
    There is a common-sense bill in Congress right now, both in 
the House and in the Senate. Fortunately, there are 21 
cosigners to it, I believe, right now. I am wondering, I mean, 
what is it going to take to get the rest to do this? This 
should be common-sense legislation, getting 10 percent of our 
veterans the care that they need.
    Unfortunately, short of you guys holding a hearing on it 
over 6 months ago, it almost feels as if it has stalled. I 
mean, common-sense legislation for appropriations for veterans 
should be a no-brainer, as long as it is going to be effective.
    Given the fact of the scarcity of the resources to female 
veterans for their care, I could not see any more of an urgency 
for a bill like that to get passed.
    The solutions are out there, and the VA has the programs, 
depending on where you live, to help address this for veterans, 
like the 10-week program I spoke of in my opening statement. 
That program in Cleveland helps 50 veterans a year. That is it, 
50 veterans. There is another one, I believe, in San Diego. The 
other one recently closed in Baltimore.
    That is all they can help. They have an 80 percent 
reduction in symptoms for PTSD and substance abuse. They have 
the military sexual trauma group and individual programs that 
are there, but most of them tend to be pilot programs. There 
are 3-, 5-, 6-, and 10-year pilot programs. If it is effective 
after a year, we have frontline issues with PTSD, with military 
sexual trauma, with substance abuse, if the treatments seem 
effective, it would only make sense to get them out there 
further to where you have a larger veteran population being 
treated so we can find out for sure that it is going to work, 
to where we can get the help that is needed for whatever our 
veterans issue is.
    It should not be so hard for us to access care, especially 
female veterans. I mean, my own sister, my own little sister, 
she was a medic in the National Guard. She hurt herself during 
her initial training with her hip, and I know that she still 
has problems with fighting with the VA for treatment on a host 
of things related to women's health.
    I personally can say that I have been affected by it, and 
it did not even pass my mind sitting here. I mean, it is 
affecting everybody, and it needs addressing. That is why we 
are here right now having this hearing.
    Senator Brown. All right.
    Ms. Twine, thank you for serving, and thank you for your 
activism, and thank you for testifying. Mr. Tansill, thank you. 
Commander Harman, you make us proud--over near the Indiana 
border. Thanks to all four of you.
    I will call up the next panel. Thank you. [Applause.]
    It is my honor to resume the Senate Veterans' Affairs 
Committee. Thank you all again for joining us in the audience.
    I asked the others if they wanted to stay. I know Mr. 
Powers is staying. Thank you all for all of that.
    The second panel, only Mr. Burke will speak, but I will 
have questions of all four of the panelists. We will start with 
Ronald Burke, who is Assistant Deputy Under Secretary for field 
operations with the Veteran Benefits Administration, Department 
of Veterans Affairs. Welcome to Columbus.
    He is accompanied by Robert Worley, who is the director of 
education service, Veterans Benefits Administration, Department 
of Veterans Affairs. Mr. Worley, welcome to Ohio.
    Robert McDivitt, who is director of Veterans Integrated 
Service Network 10, Veterans Health Administration, Department 
of Veterans Affairs, I see Mr. McDivitt pretty often. Welcome.
    Dr. Kameron Matthews, deputy executive director, provider 
relations and services with Veterans Health Administration, 
Department of Veterans Affairs. Welcome to Ohio to you, too.
    Mr. Burke, give us your statement, and then I will begin 
the question period of all of you. Thank you.

STATEMENT OF RONALD BURKE, ASSISTANT DEPUTY UNDER SECRETARY FOR 
   FIELD OPERATIONS, VETERANS BENEFITS ADMINISTRATION, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY ROBERT WORLEY, 
       DIRECTOR OF EDUCATION SERVICE, VETERANS BENEFITS, 
     ADMINISTRATION; ROBERT MCDIVITT, DIRECTOR OF VETERANS 
INTEGRATED SERVICE NETWORK 10, VETERANS HEALTH ADMINISTRATION; 
AND KAMERON MATTHEWS, M.D., DEPUTY EXECUTIVE DIRECTOR, PROVIDER 
     RELATIONS AND SERVICES, VETERANS HEALTH ADMINISTRATION

    Mr. Burke. Good afternoon, Senator Brown. Thank you for 
inviting the VA to this important hearing to discuss topics 
that affect veterans nationwide and here in Ohio.
    My colleagues have already been introduced. We are here 
today and happy to discuss the topics included in your 
invitation.
    As you know, on August 16, 2017, the President signed the 
Harry W. Colmery Veterans Educational Assistance Act of 2017, 
commonly referred to as the Forever G.I. Bill, which made 
numerous changes to the post-9/11 G.I. bill. This new law 
enhances or expands education benefits for veterans, 
servicemembers, families, and survivors.
    This law will, however, require a significant IT effort. 
Rough estimates place this number up to $40 million in addition 
to the authorized $30 million, bringing the IT costs to $70 
million.
    The implementation of the Forever G.I. Bill will require 
approximately 200 additional claims examiners at the regional 
processing offices. The VA has begun the process of bringing 
those full-time equivalents on-board in the form of temporary 
employees. All employees are expected to be on-board by May 30, 
2018.
    With regard to overpayments, VA makes every attempt to 
timely and accurately process payments to veterans and their 
family members based on benefits to which they are entitled to 
receive under the law. However, in certain instances where an 
individual is not entitled to a benefit payment, such as 
changes in life events or dual payments for multiple agencies, 
the VA is required by law to recoup these payments.
    VA's policy for recovering these types of overpayments 
includes notifying veterans and beneficiaries about the reasons 
for and amounts of overpayment, along with the steps they must 
take to make repayment. The VA also take steps to minimize the 
overpayment amounts and has established recoupment policies 
that allow veterans to request repayment plans or waivers of 
these amounts.
    VBA is also committed to providing veterans with the care 
and services they have earned and deserve. For the eighth 
consecutive year, VBA has completed over 1 million disability 
claims and anticipates completing a record number of claims in 
2018. As of October 28, 2017, VBA had 321,208 compensation and 
pension claims pending, with an average age of 93.8 days; 22.4 
percent of that inventory has been pending for over 125 days. 
For Ohio veterans, the average age of a pending claim for 
compensation was 97.5 days, with 22 percent pending over 125 
days.
    VA's modernization efforts focus on improving its 
performance to better serve veterans, their families, 
caregivers, and survivors, while being good stewards of 
taxpayer dollars. As such, VBA has initiated several process 
improvements, leveraged operational tools such as its National 
Work Queue, and implemented new employee performance standards 
to improve claims processing timeliness and quality.
    Another way that VBA is striving to improve the veteran's 
overall experience is through realignment of its appeals policy 
and operations under its appeals management office and its work 
with the Board of Veterans Appeals, veterans' service 
organizations, and other stakeholders to design a modern 
appeals process for veterans.
    The current VA appeals process, which is set in law, is 
broken and is providing veterans a frustrating experience. In 
the current process, appeals have no defined endpoint and 
require continuance evidence-gathering and re-adjudication. 
Veterans wait much too long for final resolution of their 
appeals.
    With the current legal framework, the average processing 
time for all appeals resolved in fiscal year 2017 was 3 years. 
For those appeals that reach the Board of Veterans Appeals, on 
average, veterans waited 7 years from the date they filed their 
notices of disagreement for a decision, which means that many 
are waiting much longer.
    We appreciate the Committee's work on this issue, which was 
enacted as the Veterans Appeals Improvement and Modernization 
Act of 2017, and signed into law by the President on August 23, 
2017.
    Although the appeals modernization act ensures that 
veterans who disagree with the VA's benefit decisions after 
February 2019 will have all of the benefits of the new modern 
review process, the VA is also committed to addressing the 
470,000 appeals that are currently pending in the legacy 
process.
    On November 1, 2017, VBA initiated its Rapid Appeals 
Modernization Program, otherwise known as RAMP, for veterans 
with pending appeals. This program allows participants the 
option to have their decisions reviewed in the higher level 
review or supplemental claim lanes outlined in the new law. 
Participation in RAMP is voluntary. However, veterans can 
expect to receive a review of VA's initial decision on their 
claim much faster in RAMP than if they were to remain in the 
legacy appeals process.
    The program will continue through monthly invitation 
mailings to eligible veterans until February 2019, when VA 
expects to fully implement the appeals modernization act.
    Now to the health-related issues that face VA. Recent 
research suggests that 20 veterans die by suicide every day, 
putting veterans at even greater risk than the general public. 
The VA is committed to ensuring the safety of our veterans, 
especially when they are in crisis. Losing a veteran to suicide 
shatters their family, loved ones, and caregivers. Veterans who 
are at-risk or reach out for help must receive assistance when 
and where they need it in the terms that they value. Our 
commitment is to do everything possible to prevent suicide 
among the veterans who we serve.
    The VA has developed the largest integrated suicide 
prevention program in the country. We have more than 1,100 
dedicated and passionate employees, including suicide 
prevention coordinators, mental health providers, veterans 
crisis line staff, epidemiologists, and researchers who spend 
each and every day working on suicide prevention efforts and 
care for our veterans.
    Every veterans suicide is a tragic outcome. Regardless of 
the number or rates, one veterans suicide is too many.
    We continue to spread the word throughout VA that suicide 
prevention is everyone's business. The ultimate goal is to 
eliminate suicide among veterans via strategic community 
partnerships, identification of risks, training, treatment 
engagement, effective treatment, lethal means education, 
research, and data science.
    Although we understand why some veterans may be at 
increased risk, we continue to investigate and take proactive 
steps to understand all risk factors for all veterans.
    The VA is also committed to providing timely access to 
high-quality, evidence-based mental health care that 
anticipates and responds to veterans' needs and supports the 
reintegration of returning servicemembers into their 
communities.
    While focusing on suicide prevention, we know that 
preventing suicide for the population we serve does not begin 
with an intervention as someone is about to take an action that 
could end his or her life. Just as we work to prevent fatal 
heart attacks, we must similarly focus on prevention, which 
includes addressing many factors that contribute to someone 
feeling suicidal.
    We are aware that access to mental health care is one 
significant part of preventing suicide. VA is determined to 
address systemic problems with access to care, in general, and 
to mental health care, in particular.
    VA has recommitted to a culture that puts the veteran 
first. Making it easier for veterans to receive care from 
mental health providers has allowed more veterans to receive 
care. Furthermore, VA is leveraging telehealth by establishing 
11 regional tele-mental health hubs across the VA's health care 
system.
    The VA remains focused on providing the highest quality 
care our veterans have earned and deserve, and which our Nation 
trusts us to provide.
    The VA appreciates the support of Congress, and we look 
forward to responding to any questions that you may have. Thank 
you.
    [The prepared statement of Mr. Burke follows:]
 Prepared Statement of Ronald Burke, Assistant Deputy Under Secretary 
       for Field Operations, U.S. Department of Veterans Affairs
    Good afternoon, Senator Brown, and distinguished Members of the 
Committee. Thank you for inviting us to discuss Veterans health care, 
educational, and disability benefits. I am accompanied today by Robert 
Worley, Director of Education Services, Mr. Robert McDivitt, Network 
Director for the Veterans Integrated Service Network (VISN) 10, and Dr. 
Kameron Matthews, Deputy Executive Director, Provider Relations and 
Services. We have provided a brief background and important context for 
all of the topics that this hearing will cover since there are a wide 
range of issues.
                           post-9/11 gi bill
    The Post-9/11 GI Bill (Chapter 33) provides eligible Veterans, 
Servicemembers, dependents, and survivors with educational assistance, 
generally in the form of tuition and fees, monthly housing allowance, 
and a stipend for books-and-supplies all to assist these men and women 
in reaching their educational or vocational goals. This program also 
assists in the Veteran's readjustment to civilian life, supports the 
armed services recruitment and retention efforts, and enhances the 
Nation's competitiveness through the development of a more highly 
educated and productive workforce.
    Since inception of this benefit in August 2009, VA has issued over 
$80 billion in benefit payments on behalf of approximately 1.8 million 
individuals. In fiscal year (FY) 2017 alone, all of VA's education 
programs (chapters 30, 32, 33, 35, 1606 and 1607) provided 1 million 
beneficiaries with educational assistance. Of those, 21,000 direct 
beneficiaries received education benefits in the state of Ohio. 
Further, VA provided Post-9/11 GI Bill benefits to approximately 
790,000 Veterans, Servicemembers and dependents in this same period; of 
those, approximately 15,000 were in Ohio. Since FY 2013, VA has 
processed an average of 4 million education claims per year. In fiscal 
year 2017, the average time to process all education claims was 
approximately 25 days for original claims and nine days for enrollment 
certifications.
Colmery Act
    On August 16, 2017, the President signed the Harry W. Colmery 
Veterans Educational Assistance Act of 2017, also referred to as the 
``Forever GI Bill.'' This law made numerous changes to the Post-9/11 GI 
Bill. The Harry W. Colmery Veterans Educational Assistance Act of 2017 
contains 34 new provisions, the vast majority of which will enhance or 
expand education benefits for Veterans, Servicemembers, Families and 
Survivors. Most notably, the new law eliminates the 15-year time limit 
on the use of Post-9/11 GI Bill benefits for Veterans who transitioned 
out of the military on or after January 1, 2013. This law also restores 
benefits to Veterans impacted by school closures since 2015, expands 
benefits for certain Reservists, surviving dependents, Purple Heart 
recipients, and provides many other enhancements to education benefits. 
13 of the 34 provisions were effective on the date of enactment, while 
the remaining provisions have future effective dates ranging from 
January 1, 2018, to August 1, 2022.
    VA is utilizing social media to inform individuals about these 
changes. In addition, VA has launched a multifaceted campaign (social 
media, website, targeted emails, and traditional media) to highlight 
the Colmery Act. The campaign will heavily focus on restoration of 
entitlement, Reserve Educational Assistance Program (REAP), work-study 
permanent authorization, and expansion of independent study to career 
and technical education schools.
    The implementation of the Forever GI Bill will require additional 
claims examiners at regional processing offices. VA has begun the 
process of bringing those full time equivalents on board in the form of 
temporary employees. All employees are expected to be on board by 
May 30, 2018.
    To manage the overall process for implementing this legislation, VA 
Education Service established a program executive office comprised of 
business-line managers, management analysts, individuals with program 
and project management experience, and contract support. This office is 
responsible for monitoring and coordinating all Forever GI Bill 
implementation activities. In addition, we will need to make targeted 
investments in our IT infrastructure to support the expanded access to 
education benefits the new law provides. We look forward to working 
with the Administration and the Congress to ensure these initiatives 
are properly resourced.
                        overpayment/debt issues
    VA makes every attempt to timely and accurately process benefit 
payments to Veterans and their family members, based on benefits to 
which they are entitled to receive under the law. However, in certain 
instances where the Veteran is not entitled to receive payments, such 
as those resulting from life events or dual payments from multiple 
agencies, VA is required by law to recoup payments in excess of what is 
allowable. VA's policy for recouping such overpayments includes 
notifying Veterans and beneficiaries regarding the reason(s) for and 
amounts of overpayment, along with the steps they must take to make 
repayment. VA also takes steps to minimize overpayments and has 
established policy regarding the recoupment processes by which Veterans 
can arrange repayment or waivers.
Reasons for Overpayments
    In general, VA identifies an overpayment when it finds a Veteran or 
other beneficiary has received monetary payment for benefits to which 
he or she was not entitled. Overpayments are considered improper 
payments under the Improper Payments Elimination and Recovery Act of 
2010. VA is required by law to retroactively recover overpayments to 
the extent the Veteran or beneficiary was not entitled to them. Title 
38 of the U.S. Code Sec. 5112, and Title 38 of the Code of Federal 
Regulations Sec. 3.500, directs the effective dates of reduction or 
discontinuance of an award.
    Overpayments may occur when Veterans or beneficiaries, receiving 
disability compensation or pension benefits, fail to timely notify VA 
of certain circumstances or life events such as divorce, incarceration, 
return to active duty, or other loss of dependent status. They may also 
occur when Veterans or beneficiaries advise VA of changes but VA is 
untimely in processing the claim. It is important to note VA does not 
require repayment when VA employees make claims processing errors. Such 
cases are resolved as administrative errors and are not required to be 
recouped.
Process of Notifying Beneficiaries of Overpayments
    Before a debt can be established, VA is required by law to provide 
due process notice to the Veteran or beneficiary, advising him or her 
of the proposed adjustment to his or her benefits. The beneficiary then 
has 60 days to submit evidence regarding why VA should not make the 
proposed adjustment to the award. Veterans or beneficiaries may also 
request a predetermination hearing to provide information pertaining to 
this proposed action. After the due process period expires, VA reviews 
all evidence submitted and makes the final decision to create a debt or 
to adjust the proposed action based on the evidence received. VA 
notifies the Veteran or beneficiary of the decision or date of benefit 
termination, and provides applicable appeal rights. If VA determines 
there has been an overpayment, the beneficiary also receives a letter 
explaining the debt owed and repayment options.
Steps VA is Taking to Prevent Overpayments
    VA employs a number of measures to minimize overpayments. First, 
the Veterans Benefits Administration (VBA) includes important reminders 
in benefit decision notification letters about the need for Veterans 
and beneficiaries to inform VA immediately of issues or life events 
that could impact monthly payment amounts.
    Second, VA has data matching agreements with the Social Security 
Administration, Federal Bureau of Prisons, and other Federal agencies 
to minimize individuals receiving benefits that are not statutorily 
permissible. VA also works with these agencies to ensure critical data 
feeds, such as information for dates of death, dates of incarceration, 
etc., are transmitted to VA as timely and efficiently as possible.
    Third, VBA is deploying technological solutions and leveraging 
automation to reduce overpayments. For example, drill pay from the 
Department of Defense (DOD) has been a major contributor to VA 
overpayments. By law, Servicemembers are not entitled to receive both 
drill pay and VA disability compensation for the same periods of time. 
In 2016, VA automated the notification process required when Guardsmen 
and Reservists receiving VA compensation actively drill and receive 
pay. The new process, with DOD collaboration, has improved VA's 
management of drill pay adjustments. Prior to the new process, drill 
pay claims took a monthly average of 308 days (May 2016) to complete 
compared to a current monthly average of 97 days (August 2017) to 
complete. This progress results in Veterans receiving more timely 
adjustments.
VA's Policy Regarding Recouping Overpayments and Potential Waivers
    VA's Debt Management Center (DMC) provides the collection 
guidelines and practices for recouping overpayments that have been 
established against a beneficiary. VA navigates recoupment of the 
overpayment (or debt collection process) in a manner that provides the 
best care to our Veterans and beneficiaries and complies with Federal 
debt collection statutes and policy. The DMC services beneficiary debts 
through a centralized debt collection program while offering all 
Federal collection tools provided by the Department of the Treasury. 
Most importantly, DMC counselor's work with Veterans and beneficiaries 
individually to resolve debts through extended payment plans, benefit 
offsets, waivers, compromises, dispute resolution and hardship refunds.
    A Veteran can request a waiver of his/her debt within 180 days of 
receiving the debt notice. If the Veteran requests a waiver outside of 
the 180 day timeframe, the debtor receives appeal rights. If received 
timely, the waiver request goes to the VBA Committee on Waivers and 
Compromises (COWC) at the Regional Offices in St. Paul, MN, or 
Milwaukee, WI. Once the COWC receives a waiver request, elements such 
as fault, unjust enrichment, and financial hardship are considered when 
deciding to grant, partially grant, or deny the request following the 
principles of equity and good conscience.VA will not demand payment 
when it would be unfair, unconscionable, or unjust. However, the COWC 
will automatically deny a waiver if there is any indication of fraud, 
misrepresentation, or bad faith. If the waiver is not approved, the 
debtor receives applicable appeal rights. Completed waiver decisions 
are returned to DMC for processing. If denied, the debt collection 
process resumes. If the waiver is granted, collection action is 
terminated, and any collections received are refunded, if required.
    A separate process also enables Veterans and/or beneficiaries to 
submit a compromise offer for acceptance of a partial payment in 
settlement and full satisfaction of the offeror's indebtedness.
                       disability claims backlog
    VBA is committed to providing Veterans with the care and services 
they have earned and deserve. For the eighth consecutive year, VBA has 
completed over a million disability compensation claims and anticipates 
sustaining this effort in FY 2017. As of October 28, 2017, the average 
age of pending compensation and pension (C&P) claims was 93.8 days. For 
Ohio Veterans, the average age of pending C&P was 97.5 days. 321,208 
C&P claims were pending nationally, with 23.1 percent pending over 125 
days. In Ohio, there are 8,945 compensation claims pending, with 22.4 
percent pending over 125 days.\1\
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    \1\ Source: 30 October 2017--Monday Morning Workload Report--WHCO: 
Please provide a full citation and a link.
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    VA's claims modernization efforts focus on improving its 
performance to better serve Veterans, their families, caregivers, and 
Survivors while being good stewards of taxpayer dollars. As such, VA 
has initiated several claims process improvements and leveraged 
operational levers to improve claims timeliness.
Overtime
    Mandatory overtime was re-instituted at all VBA regional offices 
effective March 7, 2017, in a strategic effort aimed at reducing the 
number of claims pending longer than 125 days. Overtime requirements 
are assessed every 30 days and guidance provided to the regional 
offices based on workload management needs.
    VA executed $114.6M in Compensation and Pension overtime nationally 
in FY 2017, while executing $2.6M at the Cleveland Regional Office.
    Through October 28, 2017, VA has executed nearly $10M in C&P 
overtime nationally in FY 2018, while executing $208.SK at the 
Cleveland Regional Office.
National Work Queue
    In 2016, VBA transitioned to the National Work Queue (NWQ), which 
nationally prioritizes and distributes rating claims to VBA's network 
of stations, matching their capacity with resources available, and 
minimizing the time to adjudicate a claim. . Implementation of NWQ has 
improved timeliness for several phases of the claim processing process. 
Average time for initial development of a claim has improved from 25 
days in January 2016 to 8 days is September 2017. In the rating phrase, 
average time for rating decisions on claims has improved from 29 days 
in January 2016 to 3 days in September 2017. In award and 
authorization, NWQ has improved timeliness by 2.9 days, down to 5.9 
days. Combined, these improvements result in more timely service for 
Veterans and move VBA closer to the goal of processing 90 percent of 
claims within 125 days.
    These administrative adjustments are part of VBA's non-rating 
workload. During FY 2017, VBA made several changes to allow for a more 
balanced approach to the overall workload. VBA appreciates Congress' 
support in providing resources to staff specific teams across the 
Nation dedicated to the non-rating workload, and we have prudently used 
these additional resources to lower the non-rating claims inventory. As 
of April 2017, NWQ is distributing non-rating claims, which allows this 
work to be moved efficiently based on capacity. Additionally, VBA has 
adapted a strategic approach to how we use our overtime resources. We 
now target specific claims and steps within the claims process to 
ensure we direct our overtime expenditures on where we receive the most 
benefit. These enhancements have led to improvements in performance. 
Overall non-rating inventory dropped by 23 percent with a 19 percent 
decrease in the average number of days pending for these claims. The 
inventory of Dependency claims decreased by 26 percent with a 50 
percent improvement in timeliness, and the inventory of Drill pay 
claims dropped by 58 percent. We still have work to do and will remain 
focused on continuing our work on appropriate preventative measures.
Decision Ready Claims
    Beginning in May 2017, VBA initiated a pilot program in the St. 
Paul Regional Office (RO) called Decision Ready Claims (DRC), an 
expedited claims submission option available to Veterans who have 
elected accredited Veterans Service Organizations (VSOs) to assist them 
with preparing and submitting their supplemental disability claims. , 
National implementation of this program was completed in September 1, 
2017.
    Under the DRC Program, VSOs work with Veterans to ensure all 
supporting evidence for a claim is included at the time of submission. 
This program will also enhance partnerships with VSOs by improving 
access and capabilities to assist with gathering all required evidence 
and information to accelerate claims decisions. Claims submitted in the 
DRC Program will result in a supplemental claims decision within 30 
days of submission to VA.
Centralized Mail
    VBA completed deployment of the Centralized Mail Program to all ROs 
in 2015, and to the Pension Management Centers in FY 2016. Since 
deployment, VBA has gained proficiency in electronic mail processing 
and is now able to provide assistance with virtual mail processing, as 
needed across ROs. In FY 2017, VBA focused on File Bank Extraction 
(FBE), an effort to rapidly extract all inactive paper claims from ROs 
on a national level while having the Office of Business Process 
Integration and its Veterans Claims Intake Program assume logistical 
tracking control at the point of origin. FBE is a continuation of VBA's 
transformation and transition from paper-based to electronic claims 
processing. The benefits of FBE are it ensures claim materials are in 
the Veterans Benefits Management System (VBMS) on day 1 of future 
claims, as well as reduces the overall amount of space dedicated to 
storage and directly supports VBA's strategic transformation goal to 
become completely paperless.
                         appeals modernization
    VBA is striving to improve its appeals processing, support appeals 
modernization, and provide relief for Veterans with pending appeals 
particularly in light of recently enacted legislation. The system is 
complex, inefficient, ineffective, confusing, and splits jurisdiction 
of appeals processing between VBA and the Board of Veterans' Appeals 
(Board). Veterans wait much too long for final resolution of an appeal. 
Within the current legal framework, the average processing time for all 
appeals resolved in FY 2017 was 3 years. For those appeals that reach 
the Board, on average, Veterans are waiting at least 7 years from the 
date that they filed their notice of disagreement for a decision, which 
means that many are waiting much longer. In an effort to maximize its 
appeals resources, effective January 4, 2017, VBA realigned its appeals 
policy and operational control under a single responsible office, the 
Appeals Management Office (AMO). This realignment provides direct 
control of appeals policy activities, field staffing and resource 
allocation, the appeals budget, and program performance by AMO. 
Critical to VBA's success in transforming its administration of appeals 
is the ability to quickly and directly influence operational staffing 
and resource allocation, and accountability for policy implementation, 
program performance, and Veterans' and stakeholders' satisfaction with 
the program. By the end of FY 2017, VBA had processed 272,986 appeal 
actions and resolved 124,666 appeals, which was 24 percent above its 
appeals production in FY 2016. Moreover, despite receiving 
approximately 160,000 new appeals in 2016, VBA reduced its total 
appeals inventory by 10 percent.
    The Cleveland VA RO, which serves approximately 800,000 Ohio 
Veterans and their families, has shown significant progress in its 
appeals processing metrics since the realignment. Consistent with the 
AMO's guidance of processing the oldest appeals first, the RO has 
decreased its appeals inventory in each appeal stage, to include a 62 
percent decrease in its inventory of Veterans waiting for certification 
of their appeal to the Board and a reduction of remands by 29 percent.
    VA was aware that increased oversight and accountability alone 
would not resolve the pending legacy appeals inventory. Accordingly, VA 
also sought legislation to replace the current VA appeals process with 
a new legislative framework that makes sense for Veterans, their 
advocates, VA and other stakeholders. On August 23, 2017, President 
Trump signed into law, the Veterans Appeals Improvement and 
Modernization Act of 2017 (Appeals Modernization Act), creating a new 
claims and appeals process for disagreements with VA's decisions on 
benefit claims. The new process provides streamlined choices for 
claimants seeking review of a VA decision. The framework for the new 
process features three lanes: a higher-level review lane, which 
consists of an entirely new review of the claim by a senior 
adjudicator, a supplemental claim lane, which provides an opportunity 
to submit additional evidence, and an appeal lane that provides an 
opportunity to appeal directly to the Board. VA's goals in this new 
process are an average of 125 days in the supplemental claim and 
higher-level review lanes and 1year in the Board's appeal lane for 
those Veterans who do not seek a hearing or wish to submit additional 
evidence.
    In an effort to provide some of the benefits of the new law's 
streamlined process, VA has initiated the Rapid Appeals Modernization 
Program (RAMP) for Veterans with pending appeals. This program allows 
participants the option to have their decisions reviewed in the higher-
level or supplemental claim lanes outlined in the new law. 
Participation in RAMP is voluntary; however, Veterans can expect to 
receive a review of VA's initial decision on their claim much faster in 
RAMP than if they were to remain in the legacy appeals process. The 
program began on November 1, 2017, and will continue through monthly 
invitation mailings to eligible Veterans until February 2019 when VA 
expects to fully implement the Appeals Modernization Act.
                           suicide prevention
    Recent research suggests that 20 Veterans die by suicide each day, 
putting Veterans at even greater risk than the general public . After 
adjusting for age and sex, the risk for suicide is 22% higher among 
Veterans than among non-Veterans. (The National suicide rate is 17.0 
suicides per 100,000 and the Ohio Veteran suicide rate is 32.1 suicides 
per 100,000). VA is committed to ensuring the safety of our Veterans, 
especially when they are in crisis. Losing a Veteran to suicide 
shatters their family, loved ones and caregivers. Veterans who are at 
risk or reach out for help must receive assistance when and where they 
need it in terms that they value. Our commitment is to do everything 
possible to prevent suicide among the Veterans we serve and to reach 
all Veterans. To accomplish this objective, VA is instituting public 
health approach to reach all Veterans, whether or not they are enrolled 
in VA care, through partnerships and collaboration.
    VA has developed the largest integrated suicide prevention program 
in the country. We have over 1,100 dedicated employees, including 
Suicide Prevention Coordinators, Mental Health providers, Veterans 
Crisis Line staff, epidemiologists and researchers, who spend each and 
every day working on suicide prevention efforts and care for our 
Veterans. Screening and assessment processes have been set up 
throughout the system to assist in the identification of patients at 
risk for suicide. VA also has developed a chart ``flagging'' system to 
ensure continuity of care and provide awareness among providers about 
Veterans with known high risk of suicide. Patients who have been 
identified as being at high risk receive an enhanced level of care, 
including missed appointment follow ups, safety planning, weekly 
follow-up visits and care plans that directly address their 
suicidality.
    We also have two centers devoted to research, education, and 
clinical practice in the area of suicide prevention. VA's Veterans 
Integrated Service Network (VISN) 2 Center of Excellence in 
Canandaigua, New York, develops and tests clinical and public health 
intervention strategies for suicide prevention. VA's VISN 19 Mental 
Illness Research Education and Clinical Center in Denver, Colorado, 
focuses on: (1) clinical conditions and neurobiological underpinnings 
that can lead to increased suicide risk; (2) the implementation of 
interventions aimed at decreasing negative outcomes; and (3) training 
future leaders in the area of VA suicide prevention.
    Every Veteran suicide is a tragic outcome, regardless of the 
numbers or rates; one Veteran suicide is too many. We continue to 
spread the word throughout VA that ``Suicide Prevention Is Everyone's 
Business.'' The ultimate goal is to eliminate suicide among Veterans 
via public health strategies, which include initiatives focusing on 
strategic community partnerships, identification of risk, training, 
treatment engagement, effective treatment, safe storage of lethal means 
(such as medications and firearms), research, and data science. 
Although we understand why some Veterans may be at increased risk, we 
continue to investigate and take proactive steps to understand all risk 
factors for all Veterans. VA's strategy for suicide prevention 
addresses suicide prevention as a public health issue for all Veterans. 
This requires programs designed to help individuals and families 
problem solve effectively, and to engage in care when needed, with 
ready access to high-quality mental health services.
    Suicide prevention is VA's highest clinical priority. As part of 
VA's commitment to make resources, services, and technology available 
to reduce Veteran suicide, VA initiated Recovery Engagement and 
Coordination for Health Veterans Enhanced Treatment (REACH VET) in 
November 2016, and fully implemented it by February 2017. REACH VET 
uses a new predictive model to analyze existing data from Veterans' 
health records to identify those who are at a statistically elevated 
risk for suicide, hospitalization, illnesses, and other adverse 
outcomes. Once a Veteran is identified, his or her mental health or 
primary care provider reviews the Veteran's treatment plan and current 
condition(s) to determine if any enhanced care options are indicated. 
The provider will then reach out to Veterans to check on their well-
being and inform them that they have been identified as a patient who 
may benefit from enhanced care. This allows the Veteran to participate 
in a collaborative discussion about his or her health care, including 
specific clinical interventions to help reduce suicidal risk.
    DOD and VA have a new joint effort to institute a public health 
approach to suicide prevention, intervention, and post intervention 
using a range of medical and non-medical resources through data and 
surveillance, messaging and outreach, evidence-based practices, 
workforce development, and Federal and non-government organization 
partnerships. We know that 14 of the 20 Veterans who die by suicide on 
average each day did not receive care within VA in the past two years. 
We need to find a way to provide care or assistance to all of these 
individuals. Therefore, VA is expanding access to emergent mental 
health care for former Servicemembers with other than honorable (OTH) 
administrative discharges. This initiative specifically focuses on 
expanding access to assist former Servicemembers with OTH 
administrative discharges who are in mental health distress and may be 
at risk for suicide or other adverse behaviors. It is estimated that 
there are a little more than 500,000 former Servicemembers with OTH 
administrative discharges.
    VA has authority to furnish care for service-connected conditions 
for former Servicemembers with OTH administrative discharges if those 
individuals are not subject to a statutory bar to benefits. Individuals 
with OTH discharges may access the system for emergency mental health 
services by visiting a VA emergency room, outpatient clinic, Vet Center 
or by calling the Veterans Crisis Line. Services may include 
assessment, medication management/pharmacotherapy, lab work, case 
management, psycho-education, and psychotherapy. We may also provide 
services via telehealth.
    VA, we have the opportunity and the responsibility, to anticipate 
the needs of returning Veterans. As they reintegrate into their 
communities, we must ensure that all Veterans have access to quality 
mental health care. To serve the growing number of Veterans seeking 
mental health care, VA has deployed significant resources and increased 
its staff for mental health services. The number of Veterans receiving 
specialized mental health treatment from VA has risen each year, from 
over 900,000 in FY 2006, to more than 1.65 million in FY 2016 Executive 
Leadership Board within VISN 10 founded a time-limited workgroup 
entitled: Suicide Prevention--Overdose Prevention (SPODP). The 
workgroup was designed to enhance regional VA capabilities and 
collaboration among State and community partners to improve outcomes 
for Veterans at high risk of death from suicide or accidental opioid 
overdose. Several strong practices have been identified and shared 
throughout the VISN via this group. For example, efforts are underway 
to spread practices such as: Community based outreach workers carrying 
naloxone kits, Community Police training on Veteran issues, and public 
displays focused on suicide prevention (e.g. https://www.facebook.com/
CincinnatiVAMC/photos/pcb.1440977745941595/ 14409756059418 09/
?type=3&theater). Furthermore, all facilities are participating in 
``REACH Vet'' which is designed to identify, and escalate care, for the 
most vulnerable Veterans we serve.
                             mental health
    VA is committed to providing timely access to high-quality; 
recovery-oriented, evidence-based mental health care that anticipates 
and responds to Veterans' needs and supports the reintegration of 
returning Servicemembers into their communities.
    While focusing on suicide prevention, we know that preventing 
suicide for the population we serve does not begin with an intervention 
as someone is about to take an action that could end his or her life. 
Just as we work to prevent fatal heart attacks, we must similarly focus 
on prevention, which includes addressing many factors that contribute 
to someone feeling suicidal. We are aware that access to mental health 
care is one significant part of preventing suicide. VA is determined to 
address systemic problems with access to care in general and to mental 
health care in particular. VA has recommitted to a culture that puts 
the Veteran first. To serve the growing number of Veterans seeking 
mental health care, VA has deployed significant resources and increased 
staff in mental health services. Between 2005 and 2016, the number of 
Veterans who received mental health care from VA grew by more than 80 
percent. This rate of increase is more than three times that seen in 
the overall number of VA users. This reflects VA's concerted efforts to 
engage Veterans who are new to our system and stimulate better access 
to mental health services for Veterans within our system. In addition, 
this reflects VA's efforts to eliminate barriers to receiving mental 
health care, including reducing the stigma associated with receiving 
mental health care.
    Making it easier for Veterans to receive care from mental health 
providers also has allowed more Veterans to receive care. VA is 
leveraging telemental health care by establishing eleven regional 
telemental health hubs across the VA health care system.
    Hubs are located in Seattle, WA; Long Beach, CA; Salt Lake City, 
UT; Harlingen, TX; Charleston, SC; Sioux Falls, SD; Battle Creek, Ml; 
Pittsburgh, PA; Brooklyn, NY; West Haven, CT; and Honolulu, HI. VA 
telemental health provided more than 427,000 encounters to over 133,500 
Veterans in 2016.
    Telemental health reaches Veterans where and when they are best 
served. VA is a leader across the United States and internationally in 
these efforts. VA'swww.MaketheConnection.net, Suicide Prevention 
campaigns, and the PTSD mobile app (which has been downloaded over 
280,000 times) contribute to increasing mental health access and 
utilization. VA has also created a suite of award-winning tools that 
can be utilized as self-help resources or as an adjunct to active 
mental health services.
    Additionally, in 2007, VA began national implementation of 
integrated mental health services in primary care clinics. Primary 
Care-Mental Health Integration (PC-MHI) services include co-located 
collaborative functions and evidence-based care management, as well as 
a telephone-based modality of care. By co-locating mental health 
providers within primary care clinics, VA is able to introduce Veterans 
on the same day to their primary care team and a mental health provider 
in the clinic, thereby reducing wait times and no show rates for mental 
health services. Additionally, integration of mental health providers 
within primary care has been shown to improve the identification of 
mental health disorders and increase the rates of treatment. Several 
studies of the program have also shown that treatment within PC-MHI 
increases the likelihood of attending future mental health appointments 
and engaging in specialty mental health treatment. Finally, the 
integration of primary care and mental health has shown consistent 
improvement of quality of care and outcomes, including patient 
satisfaction. The PC-MHI program continues to expand, and through 
May 2017, VA has provided over 7.2 million PC-MHI clinic encounters, 
serving over 1.6 million individuals since October 1, 2007.
    VA recognizes the importance of the Veterans Crisis Line (VCL) as a 
life-saving resource for our Nation's Veterans who find themselves at 
risk of suicide. Of all the Veterans we serve, we most want those in 
crisis to know that dedicated, expert VA staff, many of whom are 
Veterans themselves, will be there when they are needed. The primary 
mission of VCL is to provide 24/7, world class, suicide prevention and 
crisis intervention services to Veterans, Servicemembers, and their 
family members. However, any person concerned for a Veteran's or 
Servicemember's safety or crisis status may call VCL.
    VCL is the strongest it has been since its inception in 2007. VCL 
staff has forwarded over 504,000 referrals to local Suicide Prevention 
Coordinators on behalf of Veterans to ensure continuity of care with 
their local VA providers. Initially housed in 2007 at the Canandaigua 
VA Medical Center (VAMC) in New York, it began with 14 responders and 
two health care technicians answering four phone lines. Since 2007, VCL 
has answered over 3 million calls and dispatched emergency services to 
callers in crisis more than 84,000 times. Consistent with our mission, 
we have implemented a series of initiatives to provide the best 
customer service for every caller, making notable advances to improve 
access and the quality of crisis care available to our Veterans, such 
as:

     Launching ``Veterans Chat'' in 2009, an online, one-to-one 
chat service for Veterans who prefer reaching out for assistance using 
the Internet. Since its inception, we have answered nearly 359,000 
requests for chat.
     Expanding modalities to our Veteran population by adding 
text services in November 2011, resulting in nearly 78,000 requests for 
text services.
     Opening a second VCL site in Atlanta in October 2016, with 
over 250 crisis responders and support staff.
     Hiring a permanent VCL Director in July 2017, 
psychologist, Dr. Matthew Miller.

    Prior to the opening of our new Atlanta call center in 
October 2016, VCL had a call rollover rate to back-up call centers of 
more than 30 percent. Currently, the average rate is 1.24 percent, with 
calls being answered by the VCL within an average of 8 seconds. 
Overall, VCL performance is above the National Emergency Number 
Association service level standard of answering greater than 95 percent 
of calls in less than 20 seconds; specifically, the VCL's average 
service level exceeds 98 percent.
    VCL continues to exceed these metrics, despite overall call volume 
continuing to rise. Overall call volume has increased 12 percent since 
April 2017, and increased 15 percent over the course of the 2 weeks 
marked by notable adverse weather events earlier this month.
    Today, the combined VCL facilities employ more than 500 
professionals, and VA is hiring more to handle the growing volume of 
calls. VA will also be opening a third VCL site in Topeka, Kansas, 
which will give VCL the additional capacity needed as we expand the 
'automatic transfer' function, Press 7, to all of its community-based 
outpatient clinics (CBOC) and Vet Centers. Despite all of these 
accomplishments and plans, there still is more that we can do.
    The No Veterans Crisis Line Call Should Go Unanswered Act (Public 
Law 114-247) directed VA to develop a quality assurance document to use 
in carrying out VCL. It also required VA to develop a plan to ensure 
that each telephone call, text message, and other communication 
received by VCL, including at a backup call center, is answered in a 
timely manner by a person. This is consistent with the guidance 
established by the American Association of Suicidology. In addition to 
adhering to the requirements of the law, VCL has enhanced the workforce 
with qualified responders to eliminate routine rollover of calls to the 
contracted backup center. VA also implemented a quality management 
system, to monitor the effectiveness of the services provided by VCL. 
This will enable VA to identify opportunities for continued 
improvement. As required by law, VA submitted a report containing this 
document and the required plan to the House and Senate Veterans' 
Affairs Committees on May 23, 2017. The Veterans Crisis line can be 
reached by dialing 1-800-273-8255, Press 1.
    VA's Office of Readjustment Counseling Service (RCS) operates VA 
Vet Centers (www.vetcenter.va.gov), which are welcoming community-based 
counseling centers situated apart from larger VA medical facilities and 
placed in convenient, easily accessible locations. Based on the Veteran 
peer model, clinical staff at these Centers provide confidential 
professional mental health services and psychosocial counseling 
services as needed to help assist Veterans and active duty 
Servicemembers (ADSM) (including members of the National Guard and 
Reserve components) who served in a combat-theater or area of 
hostilities achieve a successful readjustment to civilian life. 
Readjustment counseling services and other services (e.g., 
consultation, counseling, training, and mental health services) are 
available to their family members if essential to the effective 
treatment and readjustment of the Veteran or ADSM. Readjustment 
counseling services include, but are not limited to, individual 
counseling, group counseling, marital and family counseling for 
military-related readjustment issues. Use of non-professional Veteran 
peer counselors at the Vet Centers also helps contribute to the RCS 
mission. Readjustment counseling services are provided through 300 Vet 
Centers, 80 Mobile Vet Centers, and the Vet Center Call Center. In FY 
2016, Vet Centers provided over 258,000 Veterans, ADSMs, and their 
families with 1,797,000 visits.
    In addition, Vet Center staff facilitates community outreach and 
the brokering of services with community agencies that link Veterans 
and ADSMs with other VA and non-VA services that can help with their 
successful readjustment to civilian life. One of the Vet Center core 
values is reducing barriers to access to readjustment counseling 
services. To this end, all Vet Centers offer services during non-
traditional times such as early mornings, evenings, and weekends. 
Barriers to access based on distance (i.e., communities distant from 
the 300 ``brick and mortar'' Vet Centers) are ameliorated by having Vet 
Center staff regularly deliver readjustment counseling services in Vet 
Center Community Access Points (CAP). Generally speaking, CAPs are 
established when community partners, pursuant to a no-cost arrangement, 
permit Vet Center counselors to provide readjustment counseling 
services on their premises on a regular recurring schedule (ranging 
from service provision once a month to several times a week). CAPs 
allow Vet Center clinicians to provide services at a level that is in 
line with the fluid readjustment demands and needs of that community. 
Currently, Vet Center staff operates over 820 CAPs. In FY 2016, Vet 
Center CAPs provided 236, 435 readjustment counseling visits, a 6% 
increase over FY 2015.
    RCS leadership is also working in close collaboration with the 
Veterans Health Administration's Office of Mental Health and Suicide 
Prevention to implement improved collaboration to better improve 
coordination and referral between Vet Centers and VA medical 
facilities. A memorandum of understanding was signed in August 2017 to 
formalize this relationship and outline improved communication 
processes, training, collaboration, and access to important suicide 
predictive data to help decrease suicide within the Veteran population. 
Vet Center counselors are trained, as part of assessment, to identify 
Veterans or ADSMs who are at high risk of harm or suicide. They refer 
these clients to their treating mental health providers (or for 
emergency services, if appropriate). And if a Veteran client is getting 
his/her care through VA, Vet Center staff refers the shared Veteran 
client to the local VAMC and the Vet Center counselor also contacts the 
facility's Suicide Prevention Coordinator to ensure that enhanced care 
delivery procedures for suicide prevention are in effect.
    In 2017, VISN 10, whose average was 2.62 percent, exceeded national 
averages of 1.9 percent in the provision of Evidence-Based 
Psychotherapy to Veterans suffering from PTSD, Depression, and Serious 
Mental Illness.
                             community care
    VA is extremely grateful the House and Senate Committees on 
Veterans' Affairs are actively working on legislation concerning the 
future of VA's community care program. We appreciate the Committees 
willingness to meet with VA and discuss the various proposals, 
including the Department's Veteran CARE Act, and look forward to seeing 
the swift enactment of legislation to this effect. While progress has 
been made, there is still more work to be done to serve our Nation's 
Veterans. VA needs a different approach to ensure we can fully care for 
Veterans. We believe that a redesigned community care program will not 
only improve access and provider greater convenience for Veterans, but 
will also transform how VA delivers care within our facilities.
    This redesigned program must have several key elements. First, we 
need to move from a system where eligibility for community care is 
based on wait times and geography to one focused on clinical need and 
quality of care. This will give Veterans real choice in getting the 
care they need and ensure it is of the highest quality. At a minimum, 
where VA does not offer a service, Veterans will have the choice to 
receive care in their communities. Second, we need to make it easier 
for Veterans to access convenient care services when they need it. This 
will ensure that Veterans will always have a choice and pathway to get 
more immediate needs addressed. Third, the new program must maintain a 
high performing integrated network that includes VA, Federal partners, 
academic affiliates, and community providers. We need to ensure that VA 
is partnering with the best providers across the country to take care 
of our Nation's Veterans. Fourth, it must assist in coordination of 
care for Veterans served by multiple providers. Finally, we must apply 
industry standards for quality, patient satisfaction, payment models, 
health care outcomes, and exchange of health information. By doing so, 
Veterans can make informed decisions about their care and VA can have 
the tools to better compete within communities.
    We believe redesigning community care will result in a strong VA 
that can meet the special needs of our Veteran population. Where VA 
excels, we want to make sure that the tools exist to continue 
performing well in those areas. Veterans need the VA and for that 
reason, community care access must be guided by principles based on 
clinical need and quality. VA needs the support of Congress to level 
the playing field with industry by making it easier to modernize our 
infrastructure, leverage IT technologies, hire the best talent, and 
operate more like the private sector. A good example is management of 
our real property and infrastructure portfolio, where numerous barriers 
prevent VA from being agile in response to Veterans health care needs 
in different geographic areas. We want to work with Congress to discuss 
the best ways to bring common sense to this area.
    VA also needs tools to improve our recruitment, hiring and 
retention of the best professionals to serve our Veterans. These tools 
could include improvements to hiring and pay authorities to better 
address vacancies in our medical center and VISN director positions, to 
help at least in part address disparities with the private sector. As a 
final example, there is Federal law that requires VA facilities to have 
a smoking area. We all know the impact on health from smoking, and 
smoking cessation is the most immediate and dramatic step a Veteran, or 
anyone, can take to improve their health. VA strongly supports H.R. 
1662 which would repeal this requirement. Action in these areas will 
make VA more modern, and be an enabler for our dedicated workforce to 
be more effective in their service to Veterans.
    VA is committed to moving care into the community where it makes 
sense for the Veteran. Finally, I want to make sure that everyone 
understands that making better use of community care must be done in a 
fiscally responsible way. We cannot continue to grow our funding in the 
same way we have done over this past decade. And, I want to be clear 
that I am committed to strengthening the VA system and will not support 
efforts to privatize this much needed and essential system. The 
ultimate judge of our success will be our Veterans. With your help, VA 
can continue to improve Veteran's care, in both VA and the community.
    VA continued to maintain exceptional management in the area of 
Community Care throughout the fiscal year despite many program 
challenges and system wide changes to program model. These challenges 
coupled with re-work challenges due to contractor inefficiencies; have 
had great impact on expediency of care coordination for Veterans.
    Despite these challenges, VISN 10 has performed well; specifically 
leveraging our internally created network of community providers 
through our robust use of provider agreements. VA is able to quickly 
coordinate care through this network when our contractor support fails 
to make the Veteran's appointment. In FY 2017, VISN 10 coordinated the 
care of over 34,000 Veterans using our robust community provider 
network of over 1,600 providers in the VISN; second in the Nation in 
terms of volume and third in use.
    In addition, VA has formed a robust partnership with our DOD 
sharing partner, Wright Patterson Air Force Base; establishing a 
consortium designed and developed to standardize business processes to 
increase the quality of care for Veterans, reduce the overall cost of 
care, expedite Veteran access to care, and support Air Force combat 
preparedness. VISN 10 has successfully referred over 4,600 Veterans to 
Wright Patterson over the last 2 years from VA facilities in 
Cincinnati, Dayton, Chillicothe and Columbus. VA has realized 
substantial cost avoidance using VA/DOD partnership over traditional 
NVCC -Saving realized over $3M through July 2017.
    There are also weekly community care huddles to share strong 
practices, implement changes and provide VISN level support to each 
VISN 10 facility to support our Veterans. VISN 10 strongly supports 
learning, sharing, and growing together to support Veterans in the 
delivery of their care needs.
    In 2017 the VA Central Office made a change in the distribution and 
participation in the formulation of policies, memorandums and handbooks 
which have greatly enhanced field staff ownership and accountability. 
These documents are distributed for field input and subsequently 
finalized and distributed. VISN program leads share and discuss the 
direction and subsequently cascade it down to the field for 
implementation.
                               conclusion
    VA remains focused on providing the highest quality care our 
Veterans have earned and deserve and which our Nation trusts us to 
provide. VA appreciates the support of Congress and look forward to 
responding to any questions you may have.

    Senator Brown. Thank you, Mr. Burke.
    You said in your testimony Ohio averages 97 days to decide 
a claim. Twenty-two percent of Ohioans wait at least 125 days. 
Walk through the claims process. It is pretty hard to 
understand why we cannot do better.
    A veteran walks in and what happens?
    Mr. Burke. There are actually five distinct points in our 
claims process, Senator, that transpire.
    The first is actually putting the veteran's claim under 
control and initiating the first phase of development. This is 
where we start to go out to private treatment facilities, 
obtain records, or even in some cases request a VA examination.
    The second step in our process is the largest part of our 
overall inventory. It is also the most time-consuming. About 85 
percent of our 125-day window takes place is step two. This is 
where we continue to develop evidence. We go out to obtain 
every piece of information, whether it is private records, VA 
exam results, clarification of medical opinions, et cetera, 
before we make a claim what we call ready for decision.
    Once a claim gets to step three out of five, that is the 
ready for decision, we can actually move those claims from 
start to finish in less than 30 days.
    To that end, VA just kicked off a campaign we call 
decision-ready claims. That decision-ready claim initiative is 
designed to bypass the first two steps in the claims process.
    We are celebrating progress. We have not celebrated 
completion because 97 days, we are not content with that.
    Senator Brown. How long should it take?
    Mr. Burke. There are some claims, Senator, that we would 
disadvantage a veteran if we rushed to a decision in less than 
125 days. There are some complex claims. There are those that 
we need verification from other agencies, other entities, that 
do require longer than 125 days.
    Senator Brown. Is there anything like an ordinary, routine 
claim? I guess nothing fits exactly if it is you, right? But, 
how long should it take in a case like that?
    Mr. Burke. If we can change the dynamics of claim filing to 
where the claim comes into VA fully developed with all the 
evidence there at that third step, our guarantee on decision- 
ready claims is that we will render that start to finish in 
less than 30 days.
    Senator Brown. How long should it take for an appeal?
    Mr. Burke. Our goal under the new appeals framework, if you 
take the higher level review path or the supplemental claim 
path, is to have that done on an average of 125 days, and for 
claims going to the Board of Veterans Appeals in under a year.
    Senator Brown. Your comments about suicide are troubling, 
as all comments about veteran suicide are troubling. My 
understanding is that a veteran in Ohio is twice as likely to 
commit suicide as a nonveteran. Ohio's numbers are slightly 
better maybe than the national average, but every suicide, as 
you say, is a tragedy.
    What can this Committee do to help?
    Mr. Burke. I think I would like to engage my partners from 
VHA, as they are the experts in VA's efforts on suicide 
prevention. So, if anyone from VHA would like to chime in, that 
would be great.
    Mr. McDivitt. Sure. Thank you, Mr. Worley and Senator.
    The tragedy of veteran suicide, as you know, is one of 
Secretary Shulkin's five priorities. His only clinical priority 
is to prevent veteran suicide.
    There are a lot of initiatives going on in the State of 
Ohio, as you indicated. For those of us in the Veterans Health 
Administration, we are part of the #BeThere initiative to make 
sure that both our staff, our community members, our partners 
are aware of the symptoms of suicide, are aware of what to look 
for, are aware of the questions that they should be asking 
veterans.
    We do save training of all our staff and of community 
partners. We utilize the REACH-VET tool to identify veterans at 
high-risk and provide special support to them.
    We have the veterans' crisis line, 1-800-273-TALK, where we 
encourage any veteran in crisis, family members, or others to 
call. The next day after the crisis is resolved, they are 
connected with a suicide prevention coordinator at one of our 
VA medical centers.
    We have initiated a program----
    Senator Brown. Let me interrupt.
    Mr. McDivitt. Yes. Go ahead, Senator.
    Senator Brown. I appreciate that litany, and that is 
important.
    Mr. McDivitt. Sure.
    Senator Brown. When Mr. Powers talked about his attempted 
suicide, would anybody at the VA have known that that happened? 
I do not mean him personally, but if someone attempts suicide, 
something like his situation happened, there is a good chance 
the VA would not know that happened, I assume? I am not 
pointing fingers here.
    Mr. McDivitt. Yes, it is certainly possible. It depends. As 
I said, we have veterans who are on the suicide watch list. We 
have veterans who are part of the REACH program. We try to 
connect----
    Senator Brown. He might have been on the watchlist? It is 
possible?
    Mr. McDivitt. I do not know that.
    Senator Brown. He might have been.
    One thing that really stood out as I prepared for this 
hearing, and just what I have learned being on this Committee 
for a decade, is that my understanding is that most of the 
suicides that happen, when veterans commit suicide, most of 
them have not had contact with the VA in a couple years. 
Correct?
    Mr. McDivitt. Of the 20 veterans who commit suicide a day, 
only six are part of the Veterans Health Administration.
    Senator Brown. So, isn't the most important thing for all 
of you is to find those 14?
    Mr. McDivitt. Right. That is a key part of our initiative. 
We have a pilot program in this vision, which rolled out in the 
Toledo area to connect with churches. We are working with over 
100 churches in Northwest Ohio to, again, make members of the 
church aware of what they should be looking for in terms of 
veteran suicide, aware of VA resources that are available, and 
to make those connections.
    We are doing it across-the-board, whether it be working 
with Mr. Tansill and the Ohio Department of Veteran Services, 
with the service organizations who are represented here, with 
many, many community health care partners. We do mental health 
forums at our all our facilities and oftentimes have 100 
partners come, and at every one of those, we talk about suicide 
prevention and how we can better connect with the community.
    Senator Brown. Dr. Matthews, obviously, you know this 
country well and you know the VA from the inside well. You 
probably know that Ohio has more opioid deaths than any State 
in the country. We are not the highest per capita, but we are 
pretty damn high, and we literally had the most 2 years in a 
row. I assume that means we have some of the highest opioid 
addiction among veterans.
    Can you teach sort of civilian Ohio what works? When you 
answer the question of what is unique or interesting or 
particularly successful things that the VA is doing on opioid 
addiction, understanding the State Legislature has pretty much 
been absent on scaling up opioid treatments in this State, 
understanding Congress makes good speeches but does not really 
fund scaling up opioid treatment programs.
    Right now, in Ohio, literally in Ohio, 200,000 Ohioans 
right now are getting opioid treatment because they have 
insurance from the Affordable Care Act. I understand that 
component.
    What can you tell me the VA is doing well? What are your 
plans in the future? And, how can civilian Ohio learn from what 
you are doing in the VA?
    Dr. Matthews. Sure. Thank you so much, Senator. It is an 
excellent question.
    I am actually a primary care physician as well who actually 
does opioid treatment. I am very familiar with this, even 
during my time prior to the VA.
    I can definitely say up front that no State has this right 
yet, but one thing that I am quite proud of within the VA is 
that we have jumped leaps and bounds ahead of a lot of larger 
health systems in the private industry with our opioid safety 
initiative. We have really added processes and performance 
metrics to what is otherwise becoming the standard of care 
within health care, which is based on the CDC guidelines for 
approaching opioid prescribing.
    We are monitoring our veterans. We are monitoring the 
prescribing practices of our providers. We are approaching it 
from a clinical perspective, as far as history-taking and 
actually dealing with pain as a larger concept, as opposed to 
just throwing a medication at it, but dealing with causes of 
it, looking at non-pharmacological approaches to actually 
treating pain.
    We are actually quite advanced and actually do have a lower 
rate of prescription for opioid than most of the private 
industry. What we are now trying to do----
    Senator Brown. Is that long term? There is a book that I 
recommend to anybody here. It is much about Ohio, 
unfortunately, from Portsmouth to Columbus especially, called 
Dreamland. Much of the opioid addiction in this country sort of 
began--the writer really does kind of tag Portsmouth, OH--I do 
not think that is entirely fair--as the beginning over 30 
years, 20 years, I guess.
    Is that a long-term thing that? Clearly, the drug companies 
are guilty as hell in this in how they peddled these drugs, 
saying they were not addictive, OxyContin, oxycodone, Vicodin, 
other drugs, Percocet and all. Doctors overprescribe. We can 
point fingers. We are all guilty, I guess.
    Have you sort of set examples, in terms of prescribing, in 
terms of this?
    Dr. Matthews. Yes.
    Senator Brown. Tell me how that has worked.
    Dr. Matthews. It has actually worked quite well. One of our 
expectations for VA prescribers and soon-to-be, hopefully, in 
our community network as we work with other States, is the 
checking of State prescription drug monitoring programs. This 
is for all controlled substances typically, so more than even 
just opioids, are actually in a State-level registry, so that 
providers can look to see when the last time prescriptions were 
written in a specific veteran's name, can have information so 
that they know that perhaps there might be potential for any 
overprescription or just acknowledgment that treatment is 
already in place, perhaps with another provider, so that a new 
prescription is not necessary.
    Our pharmacy records now feed into these State programs, so 
that even outside providers can see that the VA prescribers now 
have opioid prescriptions in a specific veteran's name.
    Senator Brown. Is there a uniform policy on not 
overprescribing?
    Dr. Matthews. Yes.
    Senator Brown. It would be every bit as good in Ann Arbor, 
or it would be pretty similar in Ann Arbor to Chillicothe to 
Dayton to Cincinnati?
    Dr. Matthews. We have a national clinical guideline on 
opioid treatment that is expected across the Nation. It is 
really equivalent to a lot of the standards of care that other 
health systems--in fact, in Ann Arbor, the University of 
Michigan has a similar set of pain policies that other private 
health systems adopt as well.
    Yes, our expectation is that VA providers are following 
those guidelines, that our pharmacy records are looking into 
any prescriptions that are coming in from community providers 
that may be seeing our veterans, so that we can attack the 
issue proactively.
    Senator Brown. Thank you for that, Dr. Matthews.
    Mr. McDivitt, talk about VA hiring and how you anticipate 
staffing shortages. One of the things that this Committee has 
taught me is to stay in touch closely not just with directors 
in Chillicothe or Dayton or Cincinnati or Wade Park, or even 
the community-based clinics in Springfield and Mansfield and 
Zanesville and all, but also to stay in touch with the work 
staff, the medical personnel and the personnel that are not as 
well-paid and perhaps not as highly skilled as Dr. Matthews.
    One of the things we see is medical staff shortages 
sometimes are not filled quickly enough. What you do in 
Cleveland or what you do in Dayton to anticipate medical staff 
shortages so the wait times for people coming into the VA do 
not get longer because there are not enough medical personnel? 
How do you anticipate that? How do you fill those jobs more 
quickly?
    Mr. McDivitt. Sure. Absolutely. Thank you, Senator.
    Senator Brown. I know it is a huge system, and it is 
difficult.
    Mr. McDivitt. In our VISN, the three-State area, we have 
around 30,000 employees. Yet, I think as you said, it really 
goes to the frontline. We hire directors, and we have three of 
our directors here, Ms. Hepker from Columbus, Mr. Murdoch from 
Chillicothe, and Ms. Hudson from Cincinnati.
    We hire directors who do not spend all their time in the 
board room. They spend a lot of time out in the clinic or on 
the frontlines talking to staff, as you do when you do town 
halls, seeing where the pressure points are in the 
organization.
    We do have an overall human resource strategy. We have 
professions that are challenging to recruit. We try to make 
sure that we are ahead of the game on that, whether it be ICU 
nurses, some medical specialty areas.
    In the last year, I am pleased to report, that in the State 
of Ohio, we added over 380 full-time equivalent employees from 
the beginning of fiscal year 2017 to the end, and pretty much 
across-the-board. Here in Columbus, Cleveland, Cincinnati, and 
Dayton.
    We try not to be a market-leader in our hiring process, but 
we try to be competitive across-the-board.
    I would also say, with Dr. Matthews here, on occasions when 
we have short-term vacancies, and we had a short-term vacancy 
for orthopedic surgeons here in Columbus, we can turn to 
community care now. Community care can fill a gap while we are 
recruiting in the VA.
    Senator Brown. Pay, I assume, the same job at every VA I 
assume does not pay the most. Dayton's cost-of-living is less 
than San Francisco's. Do they get paid more for those jobs in 
San Francisco because the cost-of-living is higher?
    Mr. McDivitt. There are geographic adjustments for larger 
markets in places like New York City and San Francisco and so 
on. However, our physician pay package has two components. One 
is a base pay, and the second is a market pay, knowing that the 
salaries for certain physicians--it may be more challenging to 
recruit someone in Toledo as opposed to Columbus or 
Chillicothe. We try to make adjustments, so we can compete in 
that market.
    Senator Brown. This is not typical in a congressional 
hearing, but would you introduce the directors you mentioned so 
people can see them?
    Mr. McDivitt. Of course. Wendy Hepker, Vivian Hudson, and 
Mark Murdoch are directors here representing the VAs in Ohio. 
[Applause.]
    Both Mark and Vivian are military retirees. Mark retired 
from the Air Force. Vivian just retired last year from the U.S. 
Army.
    Senator Brown. Thank you. Two of you, thank you for 
welcoming both me and my staff to your hospitals and for the 
work you do.
    We have seen major progress in all three of those 
hospitals. It is always a challenge. Thank you for your 
service.
    Thanks for taking that question.
    Let me shift to something very different, Mr. Worley. This 
will be mostly for you, but may be Mr. Burke, too.
    I am concerned that the VA was seeking blanket waivers to 
conflict-of-interest rules that would allow VA employees to 
benefit financially from for-profit colleges and universities. 
I was glad that Secretary Shulkin listened to veterans and VSOs 
and educators and policymakers who opposed this decision.
    Why was VA interested in waiving this requirement?
    Mr. Worley. Senator, I think as was stated in the Federal 
Register notice originally, we believe that the statute had 
unintended and illogical consequences in its full application, 
meaning someone who had a job at a hospital that had entirely 
nothing to do with educational benefits going to a for-profit 
school would have to be fired, or waived under this provision, 
for attending a for-profit school where the G.I. Bill was being 
used.
    I think it was in that context. That I think was a large 
part of the motivation.
    Senator Brown. Did this waiver request come out of the 
White House?
    Mr. Worley. I cannot speak to that, Senator. I don't know.
    Senator Brown. You do not know or you cannot speak to it?
    Mr. Worley. I do not know.
    Senator Brown. Mr. Burke, do you know?
    Mr. Worley. This was handled primarily out of our----
    Mr. Burke. I do not know, sir.
    Senator Brown. There has been, as more and more veterans 
have been cheated by some of these for-profit colleges and 
universities--and ``cheated'' is the right word, not just 
veterans but lots and lots of people have been cheated. These 
for-profit schools spend lots of money recruiting, lots of 
money helping you find financial aid. Then they spend almost no 
money helping you find a job.
    When these for-profit colleges go out of business, or even 
if they do not go out of business, people rack up huge student 
debt, and the diploma is not worth as much.
    There is some political movement in this country to and in 
Washington to protect these for-profit colleges and to protect 
their profits. I am just always concerned, as concerned as I am 
about the VAs.
    You begin to hear more and more on the news that some 
people inside the government want to privatize the VA. I do not 
know exactly what direction that is and what that means, but 
you always hear those warning bells come from my office and 
from a lot of us in Congress, and I hope in both parties.
    Thank you for that answer.
    I want to talk about the 90/10 loophole used to crack down 
on for-profit colleges and universities that use abusive, 
deceptive practices to recruit veterans, servicemembers, and 
their families. As you know, veterans especially, they have 
gamed the loophole to count veterans in that number, which I 
find pretty despicable. That is why I have reintroduced the 
Military and Veterans Education Protection Act.
    My question to both of you, are there other improvements in 
the G.I. Bill not included in the Forever G.I. that would help 
the VA better serve veterans pursuing higher education?
    Mr. Worley?
    Mr. Worley. First of all, I would thank you and the 
Committee for all the incredible improvements that have been 
made just in my time in this job, which has been about 5 years. 
We have seen the educational provisions out of the Choice Act 
of 2014, the Blumenthal-Miller Benefits Improvement Act had 15 
provisions, and, of course, the Forever G.I. Bill. These are 
huge improvements to so many of our beneficiaries and have 
really addressed numerous of VA's legislative proposals as well 
as, of course, numerous VSOs.
    I think there are a few things left to do, as I think you 
are no doubt aware. I think it is called the Valor Act that was 
recently passed, which will help us with apprenticeships.
    Off the top my head, I would have to go back to our 2018 
budget proposal where we had various legislative proposals. 
But, there are fewer of those out there because the Forever 
G.I. Bill covered so many of them.
    Senator Brown. Thanks.
    Do you want to add anything, Mr. Burke?
    Mr. Burke. No, sir. Nothing else to add. I think Mr. Worley 
is the expert with the G.I. bill.
    I would like to echo the appreciation for the support in 
getting the large overhaul done that Rob mentioned. Thank you.
    Senator Brown. My last question of the hearing, and if any 
of you want to add anything else, I am certainly open to that. 
One of the real successes--I think hearings like this and 
reading newspapers and going online, we hear only about the 
problems and the waiting lists and the people who fell through 
the cracks, or when government does not do a good job.
    Well, some years ago, the VA--I believe it was Secretary 
Shinseki; it may have been Principi, I am not sure--set a goal 
on homelessness to eliminate homelessness among vets, 
understanding actually getting it to zero was virtually 
impossible.
    Since 2010, we have reduced veterans' homelessness by 47 
percent. The HUD-VASH voucher program has been instrumental in 
making this progress. It helps veterans. We know, as I said 
before, and Shinseki actually told me this when he was 
Secretary of the VA, that Chillicothe may be the single best 
homelessness program center of any of the VA hospitals 
anywhere.
    Unfortunately, in September, the VA decided to take 
dedicated HUD-VASH supported services funds and combine them 
with other funding needs in general purpose funds, which meant 
housing and veterans' service organizations in our State--I 
think our directors could probably speak to that--and across 
the country are concerned that this decision will undermine the 
success of the HUD-VASH program and set back our efforts as we 
have made measurable, significant progress in reducing the 
homeless veteran population since 2010.
    Is there any chance, Mr. Burke, the VA would reconsider 
this decision? If not, how do you plan to ensure that they are 
going to remain steady to support the struggling veterans 
across Ohio that are on the edge of homelessness?
    Mr. Burke. Sir, that is a great question. I am going to ask 
my colleagues from VHA to chime in as well.
    I will say, we have not given up the fight on trying to 
eradicate veterans' homelessness. In fact, we are using tools 
and technology, such as our National Work Queue, to move those 
veterans with pending claims that we know are homeless kind of 
to the front of the line to expedite decisions on that.
    Mr. McDivitt, if you want to add anything?
    Mr. McDivitt. Sure. Thank you, Mr. Burke.
    This is a very important issue to us, Senator, as you know. 
The decision you talked about is actually on hold right now. I 
think the Committee had asked that it be reconsidered, so it is 
on hold.
    Regardless of how it plays out----
    Senator Brown. The decision to move the funds out of the 
VA----
    Mr. McDivitt. The decision to move the money from special-
purpose into the general purpose fund.
    Regardless of how----
    Senator Brown. I am sorry to interrupt. How do we get that 
from putting it on hold to putting it in the trash, for want of 
a better term? You said that decision is on hold to make the 
move. How do we get that decision to be permanently on hold?
    Mr. McDivitt. There is an active debate with the CFO in the 
Veterans Health Administration about that. My network director 
colleagues and I had a chance to talk with him last week.
    I would say, ultimately, whether the money comes as special 
purpose or it comes as part of the overall appropriation, it 
will come here to Ohio, and it will be part of our overall 
homeless program. Dr. Jessie Burgard, our mental health lead 
for the division, oversees those programs. We have a 
coordinator for the State of Ohio, Jim Kennelly. We have 
homeless veteran coordinators at all our facilities.
    The HUD-VASH funding will continue to come here. It may not 
come as what we call special-purpose dollars, but it would come 
as part of the overall general appropriation. The commitment to 
homeless veterans continues to be very strong here in Ohio.
    Senator Brown. I think about two things that have been 
brought up here. Congresswoman Beatty in her opening statement 
said something very passionately, that it is our duty to serve 
those who served us. I do not know if that is a slogan at the 
VA, but it should be.
    I know that all four of you have dedicated a big part of 
your lives to serving veterans. I know on our previous panel 
that every witness had served this country and was now serving 
veterans either in a voluntary or a paid capacity.
    When you think of two things, in particular, to measure us 
as a Nation, when you think of the veteran suicide rate and the 
veteran homelessness rate, it really has to be more than a goal 
of our country to eradicate homelessness, of course, for 
everybody, and to eradicate suicide for everybody, but 
especially when we fall short so that the number among veterans 
is higher, it is something that we always need to work to 
ameliorate.
    Thank you for the work that the four of you are doing.
    Thank you all for joining us today. Anybody that has 
comments, certainly, outside the process of this Committee, 
come to Brown.Senate.gov and give any comments you have, any 
questions, any of you as veterans. Those of you who represent 
other veterans, if you are from the local DAV or Polish 
American Veterans or VFW or American Legion or any other 
veterans group, or if you are in a Veterans Services commission 
office in a county, certainly feed any information directly to 
Jonathan or Anna in my office, or Amber in the back, or 
directly to me. That is my job to represent you in that way.
    I so appreciate all of you who came. The three directors, 
thank you for joining us. The four of you up here, thank you so 
much.
    The Committee is adjourned.
    [Whereupon, at 3:20 p.m., the hearing was adjourned.]
                                ------                                

    [Responses to posthearing questions follow:]
 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
 Ronald Burke, Assistant Deputy Under Secretary for Field Operations, 
 Veterans Benefits Administration, U.S. Department of Veterans Affairs
    Despite progress in recent years, the suicides among veterans 
remain a critical issue. In the testimony, you note that the suicide 
rate among Ohio veterans specifically is nearly double that national 
rate. I hear from the families of Ohio veterans who have committed 
suicide far too often.
    Their heartbreaking stories vary but each is tragic. You note that 
a majority of the 20 veterans on average that we lose to suicide each 
day have not received care from VA in at least two years.
    This is evidence that VA care contributes to a decreased risk of 
suicide and I commend the employees--often veterans themselves--who are 
on the front lines working every day to support veterans in crisis. 
However, there have to be ways for the Department to do better.
    Mr. Burke, you've highlighted improvements VA has made in its 
approach to suicide prevention.

    Question 1. What specific weaknesses remain and what steps are 
being taken to mitigate those shortfalls?
    Department of Veterans Affairs (VA) Response: Approximately 70 
percent of Veteran suicides are among Veterans who have not been 
recently engaged in our healthcare system. The Veterans Health 
Administration (VHA) provides excellent care to Veterans at risk for 
suicide through enhanced care from facility Suicide Prevention 
Coordinators, and predictive risk programs like REACH VET; however, 
Veterans who do not receive care at VA cannot avail themselves of these 
programs. We are committed to building a national network of 
partnerships to ensure that all Veterans have the care and support they 
have earned, whether or not they are enrolled in VA healthcare. Solving 
Veteran suicide will take a community based approach across the Nation. 
One example of that approach is VA's work with the Substance Abuse and 
Mental Health Services Administration (SAMHSA) on a Mayor's Challenge 
in 7 communities, in order to enable that each of these communities to 
identify unique local solutions to Veteran suicide. That is the type of 
approach we think is necessary to reduce suicide rates for all 
Veterans.

    Question 2. How can this Committee help?
    Response. We ask for Senate Veteran Affairs' Committee support in 
engaging communities to address Veteran suicide through expansion of 
the Mayor's Challenge program to include grant making authority.

    Question 3. Mr. Burke, the first panel of witnesses discussed the 
barriers veterans and their families face transitioning to civilian 
life and accessing the benefits they earned and deserve.
    What are your goals for VBA's distribution of education benefits 
and how will you measure success?
    Response. The Department is working to exceed our timeliness goals 
of 28 days for original claims and 14 days for supplemental claims, and 
to automate original claims as part of the Colmery Act implementation. 
Veterans Benefits Administration (VBA) works to ensure beneficiaries 
make informed decisions concerning their education and training 
benefits, and to protect GI Bill beneficiaries in other ways. VBA's 
Education Service is collaborating with the Veterans Experience Office 
to utilize a new Customer Experience Management System to collect 
Veteran feedback via surveys and electronic comment cards, and to use 
the latest data to identify emerging patterns to improve value to 
Veterans. This will help VBA modernize, prioritize, and focus on issues 
impacting Veterans' experience. Additionally, our academic progress 
measures are being developed and will report on a more complete picture 
of an individual's use of the GI Bill and their outcome (in line with 
Public Law 114-315, Section 404-7). These, combined efforts will allow 
VBA's Education Service to make data-driven decisions to achieve 
program and policy successes, while providing avenues for stakeholder 
engagement.

    Question 4. From a veterans and military family education and work-
readiness perspective, how can this Committee work with the Department 
to meet the needs of those who served and their loved ones?
    Response. Recent legislation introduced by the Committee and signed 
into law by the President significantly improves educational and work-
readiness opportunities for Veterans and their loved ones. 
Specifically, on August 16, 2017, the President signed the Harry W. 
Colmery Veterans Educational Assistance Act of 2017, also referred to 
as the ``Forever GI Bill.'' This law contains 34 new provisions, the 
vast majority of which will enhance or expand education benefits for 
Veterans, Servicemembers, Families and Survivors. On November 21, 2017, 
the President signed H.R. 3949, the Veterans Apprenticeship and Labor 
Opportunity Reform Act (VALOR Act), into law. This law will make it 
easier for multi-state companies and organizations (that operate 
apprenticeship programs) to provide veteran apprentices with access to 
their earned GI bill benefits. VA is working hard to successfully 
implement both laws and remains committed to working closely with the 
Committee as we deliver the accurate and timely educational benefits 
our Veterans have earned.

    Question 5. Mr. Burke, I have heard from many veterans who are 
ineligible for VA-provided healthcare because their income is 
considered too high. Additionally, former reserve component members 
whose service did not involve combat deployments and did not retire, 
medically or otherwise, have noted their ineligibility because their 
service does not meet VA's stated criteria for Veteran status.
    Please take a moment to explain how VA considers eligibility and 
how it relates to income, time in service, and deployments. And, how 
will veteran status relate to eligibility for the Department's eventual 
roll-out of a veteran's ID card program?
    Response. For the purposes of VA health benefits and services, a 
person who served in the active military service and was discharged or 
released under conditions other than dishonorable is considered a 
Veteran and may quality for VA health care benefits. Current and former 
members of the Reserves or National Guard who were called to active 
duty by a Federal order and completed the full period for which they 
were called or ordered to active duty may be eligible for VA health 
benefits as well. Reserves or National Guard members with active duty 
for training purposes only do not meet the basic eligibility 
requirements.
    NOTE: Most Veterans who enlisted after September 7, 1980, or 
entered active duty after October 16, 1981, must have served 24 
continuous months or the full period for which they were called to 
active duty in order to be eligible. This minimum duty requirement may 
not apply to Veterans who were discharged for a disability incurred or 
aggravated in the line of duty, for a hardship or ``early out,'' or 
those who served prior to September 7, 1980. Since there are a number 
of other exceptions to the minimum duty requirements, VA encourages all 
Veterans to apply so that we may determine their enrollment 
eligibility.
    Veterans who do not have a VA-rated service-connected disability 
and who do not receive a VA pension payment or have a special 
eligibility, such as a recently discharged Combat Veteran or a Purple 
Heart recipient, may also receive VA health care if their income is 
below VA's National Income or Geographical-Adjusted Thresholds. To see 
if they qualify, Veterans must provide their gross household income 
(which includes spouse/partner and dependent children, if applicable) 
for the previous year when applying for enrollment for VA health care. 
This part of the application process is called an ``income assessment 
or financial assessment'' (also formerly called a means test) and is 
used to determine if these Veterans are eligible for enrollment and 
whether or not they have to pay copays for their health care or 
prescription medication. Additional information regarding healthcare 
eligibility is available online at: https://www.va.gov/HEALTHBENEFITS/
index.asp.
    For the Veteran ID card, only those Veterans with honorable service 
will be able to apply. The Veteran ID card provides proof of military 
service, and may be accepted by retailers in lieu of the standard 
military discharge documents (DD214) to obtain promotional discounts 
and other services.

    Question 6. Mr. Burke, you heard from the previous panel about 
their experience with VA regarding debt collection. I have heard from 
many Ohio veterans about this, and subsequently sent a letter to 
Secretary Shulkin. Can you answer the following questions for me:

    How does VA ensure that veterans are receiving an accurate 
determination of benefits, and what processes and safeguards are in 
place to mitigate the risk of overpayment and subsequent debt 
collection?
    Response. VA makes every attempt to accurately and expeditiously 
process benefit payments to Veterans and their Survivors. VA 
authorization experts review all monetary awards before approving 
decisions. National quality experts routinely assess the accuracy of 
regional office (RO) actions while local quality experts review the 
actions of individual adjudicators. Regular enforcements, such as 
mandatory training, consistency studies, and Systematic Analyses of 
Operations by management, also help ensure timeliness and accuracy of 
decisions. VA has also deployed the National Work Queue to manage 
workload nationally and take full advantage of RO capacity.

    Question 7. Has VA identified any circumstances or sources that 
account for the sharp increase in the rate of overpayment notices in 
the last few years?
    Response. Department of Defense (DOD) drill pay to Veterans has 
substantially contributed to the number of VA overpayments in VA's 
disability compensation program. By law, Veterans may not receive both 
drill pay and disability or the same periods. Prior to February 25, 
2016, when VBA processed drill pay adjustments, the adjustments were 
applied to future disability payments. This caused the Veteran's future 
payments to be reduced or stopped for a period of time and may have 
caused financial hardship to the Veteran. Accomplishing drill pay 
adjustments from this perspective, only allowed the Veteran to request 
relief from the repayment by requesting a hardship waiver. Effective 
February 25, 2016, VBA changed its policies and began processing drill 
pay adjustments retroactively verses prospectively. This process 
created a debt in VA systems but allowed Veterans additional options to 
repay the overpayment based on their financial situation. Veterans with 
overpayments related to drill pay adjustments are automatically placed 
on a 12-month repayment plan. Other options available once overpayments 
are established, include:

     Request a waiver for the overpayment due to financial 
hardship;
     Request a payment plan for the overpayment;
     Request a compromise of the overpayment due to financial 
hardship;
     Have the amount repaid with future disability payments; or
     Pay the full amount of the overpayment and continue 
receiving their disability payments.

    The success of the Rules-Based Processing System, which 
automatically processes dependency claims without user intervention, as 
well as increased automation of drill-pay adjustments, have helped 
increase overpayments because VA is completing these types of claims, 
which can generate overpayments, in greater numbers.
    Additionally, VBA is working collaboratively with DOD to receive 
drill pay information monthly so we can process these drill pay 
adjustments more frequently resulting in Veterans receiving this 
information in a timelier manner. Currently, VBA receives this data 
annually through an electronic data sharing agreement with the DOD. 
However, VBA's ability to process these monthly adjustments is 
dependent upon a regulation change that would allow an upfront issuance 
of due process for military payment adjustments. The regulation change 
is currently undergoing legal review as part of VA's internal 
concurrence process. We do not have an anticipated date of publication 
at this time.

    Question 8. What is VA doing to ensure that veterans know their 
responsibilities in reporting a change to their status, especially in 
complicated circumstance when benefits overlap with other departments, 
such as DOD?
    Response. A number of measures alert Veterans to report 
circumstances that may affect their VA benefits. Benefit decision 
letters include paragraphs about the need for beneficiaries to 
immediately inform VA of specific situations that could impact their 
monthly payments. In December 2017, VA clarified these conditions that 
may affect Veterans' rights to continued payment. VA also informs 
Veterans of conditions impacting benefits using such forms as VA Form 
8764, Disability Compensation Award Attachment Important Information, 
and cost-of-living adjustment letters.
    In addition, VA has data matching agreements with the Social 
Security Administration, Federal Bureau of Prisons, and other Federal 
agencies to reduce both the number of individuals receiving dual 
benefits contrary to law and the time during which they receive such 
benefits. VA also works with these agencies to ensure VA receives 
critical data, such as dates of death, dates of incarceration, etc., as 
timely and efficiently as possible.
    Finally, VA is deploying technological solutions and leveraging 
automation to reduce overpayments. For example, in 2016 VA worked with 
DOD to automate notifications required when Guardsmen and Reservists 
receive both VA compensation and DOD drill pay. This new automation 
process improves VA's management of drill pay adjustments.

    Question 9. Mr. Burke, The HUD-VASH voucher program helps veterans 
escape homelessness through a combination of HUD-funded housing 
vouchers and VA supportive services and case management. Since 2010, we 
have reduced veterans' homelessness by 47 percent and HUD-VASH has been 
instrumental in that progress. In September, the VA decided to take 
dedicated HUD-VASH supportive services funds and combine them with 
other funding needs in a General Purpose Fund. Housing and veterans' 
services organizations in Ohio and across the country are concerned 
that this administrative decision will undermine the success of the 
coordinated HUD-VASH model and set back our efforts to end veteran 
homelessness.
    Will the VA reconsider this decision? How do you plan to ensure 
that VA will remain ready to support struggling veterans across Ohio?
    Response. As of December 7, 2017, the decision to move Special 
Purpose Funds to the General Purpose budget is on hold for this fiscal 
year (FY). All Special Purpose funding will go through the Veterans 
Integrated Services Network (VISN) as previously allocated. VISN 10's 
commitment to homeless Veterans in Ohio, and in the other states we 
serve will remain strong.

    Question 10. Mr. Burke, the Department of Veterans Affairs recently 
released its first ``WARNO'' or ``warning order'' jointly with the 
Consumer Financial Protection Bureau to notify veterans about VA 
mortgage refinance scams. Illegal and misleading advertising for these 
products includes claims of lower interest rates or thousands of 
dollars in cash back. In reality, borrowers have received much less 
cash than they were promised, or the overall balance of their loan has 
gone up. According to the CFPB, mortgage refinances accounts for as 
much as 14 percent of the complaints submitted to the Bureau by 
servicemembers and veterans.
    Why is it common for predatory financial firms like these to target 
veterans and servicemembers?
    Response. Based upon our knowledge concerning advertisements 
referred to us by Veterans and Veteran employees, VA believes the 
number of lenders engaging in questionable or misleading advertising 
practices is small, relative to the total number of lenders approved to 
make VA loans. This small group of lenders may view the recent boom in 
VA-guaranteed home loans as an opportunity to expand their refinance 
lending businesses through solicitation of Veteran borrowers with print 
ads. Consequently, these lenders may have targeted Veterans with 
mortgages without clear and transparent terms.
    VA plans to address churning practices by issuing a proposed 
rulemaking. In determining what policy actions to take, VA is 
evaluating a range of possible measures--such as net tangible benefit 
tests, seasoning requirements, recoupment requirements, and others--and 
the effects that the measures might have on Servicemembers' or 
Veterans' access to their earned benefits, as well as, the impact on 
lenders, servicers, and mortgage investors.
    In addition to longer-term measures like regulatory action, VA has 
also focused attention on policy changes that can be implemented rather 
quickly. On October 12, 2017, Government National Mortgage Association 
(GNMA) and VA released a joint statement that addresses lenders whose 
patterns of behavior are potentially harming Veterans and/or increasing 
risks and costs to our programs. VA and GNMA meet regularly to discuss 
areas of concern and potential next steps. GNMA issued additional 
guidance on December 7, 2017, to strengthen the seasoning requirements 
for GNMA pool mortgage-back securities. In addition, on February 1, 
2018, VA issued policy guidance regarding initial and closing 
disclosures for IRRRLs to provide Veteran advance notification of the 
terms of the refinance. On February 8, 2018, GNMA issued a statement 
and worked with VA to release letters to nine lenders who are outliers 
among market participants regarding prepayment speeds, and are seeking 
corrective action plans from those lenders. (https://www.ginniemae.gov/
newsroom/Pages/PressReleaseDispPage.aspx? ParamID=129).

    Question 11. While this is the first ``WARNO,'' has the VA worked 
with the CFPB to provide other consumer education and assistance to 
veterans?
    Response. VA's Loan Guaranty Service (LGY) partners with 
stakeholders both inside government and in the private sector to ensure 
that Veterans are getting access to the benefits they have earned 
through their service to our country. VA's LGY and the Consumer 
Financial Protection Bureau (CFPB) collaborate frequently to ensure 
Veterans are well-served when shopping for or obtaining a home loan. 
Examples of that collaboration is the sharing of data on complaints 
received. VA and CFPB are looking at additional messaging through 
social media and through their websites.

    Question 12. Does the VA work with the CFPB to make sure Ohio 
veterans get responses from their banks or lenders if they believe 
they've been harmed in some way?
    Response. VA does provide information, such as misleading 
advertisements, to the CFPB Office of Enforcement and encourages VA 
Loan Specialists to refer Veterans to the CFPB complaint line and/or 
website. VA works with CFPB on a wide range of issues important to 
borrowers using their VA home loan benefit. VA has met with CFPB 
officials to discuss topics such as refinancing, lender refinancing 
marketing policies and laws, and tools available through CFPB to help 
Veteran borrowers determine their financial health and ability to take 
out a loan for a home.

    Question 13. How does the VA ensure that important consumer 
education resources like this are made available to veterans in Ohio? 
Have you worked with the Office of Servicemember Affairs directly?
    Response. VA has a forward facing website which contains 
information about the VA Home Loan Guaranty program. As with the recent 
warning order (WARNO), in addition to the CFPB distribution, VA 
distributed this document to 1.8 million Servicemembers and Veterans 
through a listserv e-mail distribution. VA has 8 Regional Loan Centers 
and Loan Guaranty personnel in Honolulu, Hawaii to provide Veterans and 
Servicemembers with verbal and written correspondence on how to obtain, 
retain, and adapt a home through VA's Home Loan program.
    VA collaborated with the Division of Servicemember Affairs on the 
CFPB WARNO message. In 2012, VA established a relationship with the 
CFPB Division of Servicemember Affairs, which resulted in consistent 
communication between the agencies. In 2017, a new Director was 
appointed for Servicemembers Affairs and VA renewed its engagement with 
the Division and presently meets on a monthly basis.

    Question 14. Does the VA have the capacity to make sure veterans 
have access to financial education and that their consumer rights are 
being protected, or do you think it has been helpful to have the CFPB 
dedicated to that task?
    Response. VA currently relies on entities such as the CFPB and the 
Department of Housing and Urban Development to deliver financial 
education and protect consumer rights regarding homeownership. It has 
been a tremendous help to have CFPB dedicated to this task with regards 
to our Veteran borrowers. The CFPB ``Know Before You Owe'' campaign is 
beneficial to all potential homeowners, including Veterans.

    Question 15. Mr. Burke, your testimony mentions a social media 
campaign to inform individuals of the changes in the Forever GI [sic].
    What kind of communication has VA had with defrauded veterans who 
attended ITT Tech and Corinthian Colleges regarding the restoration of 
benefits since the Forever GI Bill passed?
    Response. VA notified approximately 8,000 individuals regarding 
their potential eligibility for entitlement restoration, of which, 
nearly 6,000 were ITT Tech or Corinthian students. The notification 
included an application form to seek restoration of entitlement. As of 
December 16, 2017, approximately 400 applications for restoration have 
been received, of which 209 have been approved for a total of 1,800 
months. In circumstances where VA does not have a beneficiary's email 
or an email is undeliverable, VA is sending notifications through 
direct mail.
    VA created a dedicated webpage (https://benefits.va.gov/gibill/
fgib/ restoration.asp) that speaks specifically to Restoration of 
Entitlement. It includes the form that beneficiaries can use to apply 
for benefit restoration, and VA is using social media including 
Facebook and Twitter to let beneficiaries know that VA can now restore 
entitlement and encourage those potentially eligible to apply.

    Question 16. Has that included direct email and mail in addition to 
social media?
    Response. In circumstances, where VA does not have a beneficiary's 
email or an email is undeliverable, VA sends notifications through 
direct mail.

    Question 17. What is the projected timeline for future 
communication regarding restoration and when can these veterans expect 
to have their GI Bill benefits restored?
    Response. This communication effort will remain ongoing as VA is 
committed to restoring entitlement to all eligible beneficiaries. VA 
will continue to leverage social media platforms and its website to 
encourage and instruct those potentially eligible to apply.

    Question 18. Dr. Matthews, I have heard from several veterans about 
the onerous referral and authorization process for the Veterans Choice 
Program. Some veterans saying that it take weeks or months to receive 
authorization for an appointment.
    Can you walk me through why it might take this long?
    Response. After a Veteran has been referred for community care 
under the Veterans Choice Program (VCP), the VA staff must ensure the 
Veteran understands the process. VA staff members discuss VCP with the 
Veteran and offer the option for the Veteran to Opt In. Once a Veteran 
has opted in, the referral and supporting medical documentation is 
uploaded to the contractor's portal electronically. The contracting 
partner then contacts the Veteran to discuss scheduling with the 
Veteran, after they have accepted the referral which can take up to two 
days after the referral has been uploaded. The contracting partner will 
then work with a network provider to obtain an appointment. In certain 
circumstances the provider will request to review supporting medical 
documentation before an appointment can be given. After an appointment 
has been given, the Veteran is notified. This process takes on average 
27.2 days from consult to authorization, which is below the 30-day 
target.

    Question 19. What is VA doing to ensure that the TPAs- Healthnet in 
Ohio- don't become a bottleneck in the process?
    Response. VHA has taken additional steps to show how the Veteran 
experience has improved through streamlined processes. VHA has 
implemented 22 total processes and procedures since FY 2015. These have 
significantly streamlined or otherwiseimproved processes, and reduced 
the burden on Veterans when requesting, scheduling, and receiving care. 
VHA links the improvements to the five fundamentals supporting VA care: 
Eligibility, Referral and Authorizations, Care Coordination, Community 
Care Network, and Provider Payment.
    VA nationally deployed a new Operating Model on October 17, 2017. 
The model is a key component to the delivery of VA's goal for community 
care. It is a standardized model for how resources (people, process, 
technology, and data) should be organized within local VA Community 
Care departments to enable access and the future state community care 
vision. The model clarifies eligibility requirements, builds on 
existing infrastructure to develop a high-performing network, 
streamlines clinical and administrative processes, and implements a 
continuum of care coordination services. The Operating Model is 
comprised of the foundational elements of clear roles and 
responsibilities, consistent processes, active partnerships, 
standardized care coordination, and responsive customer service.

    Question 20. Dr. Matthews, Southern Ohio is ground zero in the 
opioid epidemic.
    How does VA currently educate community providers about VA policy 
regarding opioid prescribing and documentation? I have a fear that with 
veterans using both VA and community providers there could be a lack of 
consistency and accountability in how our veterans are treated within 
the system and beyond.
    Response. The VA Office of Community Care has developed a training 
module for community providers in an online educational system that 
provides evidence-based guidelines for prescribing opioids as outlined 
in the VA Opioid Safety Initiative (OSI). The module and additional 
information are being distributed by thes VA's third party 
administrators (TPA) as well as to providers who have contracted 
directly with a VA Medical Center (e.g., sharing agreements, affiliate 
agreements, and direct contracts). VHA Office of Community Care will 
also ensure availability of evidence-based guidelines as outlined in 
the Opioid Safety Initiative through online access.

    Question 21. Dr. Matthews, building on that last question,
    Are there things that you think the VA has done particularly well 
in addressing the opioid epidemic that we could replicate across other 
programs to address the epidemic more broadly?
    Response. OSI by the Department of Veterans Affairs (VA) aims to 
reduce over-reliance on opioid analgesics for pain management and to 
promote safe and effective use of opioid therapy when clinically 
indicated.
          OSI was implemented nationwide in August 2013, and is 
        producing the intended results. The basis for the OSI is to 
        make the totality of opioid use visible at all levels in the 
        organization. The OSI includes key clinical indicators such as 
        the number of VA pharmacy users dispensed an opioid, the number 
        of VA pharmacy users receiving long-term opioids who also 
        receive a urine drug screen, the number of VA pharmacy users 
        receiving an opioid and a benzodiazepine (which puts them at a 
        higher risk of adverse events) and the average morphine 
        equivalent daily dose (MEDD) of opioids. Overall, VA has seen a 
        41 percent reduction in the number of Veterans who have 
        received opioids for greater than or equal to 90 days.
          In order to assist community providers in replicating our 
        successes through OSI, VA has released a STOP PAIN tool kit 
        described below.
          STOP PAIN stands for:

     Stepped Care Model--Adapted from the National Institutes 
of Health, this model encourages a continuum of care with effective 
monitoring and management of the condition from onset through 
treatment. It incorporates self-management through participation in 
such groups as Narcotics or Alcoholics Anonymous; counseling; treatment 
programs; involvement of primary care; and other medical specialists.
     Treatment alternatives/complementary care--Complementary 
and Integrative health expands the availability of provider options 
beyond the use of standard care in the treatment of chronic pain. 
Complementary Health may include such evidence-based treatments as 
acupuncture, yoga, and progressive relaxation.
     Ongoing monitoring of usage, which relies on multiple 
tools for tracking and monitoring individual usage of and risk of 
opioid therapy.
     Practice Guidelines--Key Clinical Practice Guidelines 
updated and utilized in VA for combating the opioid epidemic include 
both the VA/DOD Clinical Practice Guidelines for Management of 
Substance Use Disorder (SUD) and the VA/DOD Clinical Practical 
Guidelines for Management of Opioid Therapy for Chronic Pain. These 
guidelines provide clear and comprehensive evidence-based 
recommendations for practitioners to minimize harm and increase patient 
safety in patients requiring SUD treatment and opioid therapy. They can 
be found online at https://www.healthquality.va.gov/guidelines/MH/sud/
and https://www.healthquality.va.gov/guidelines/Pain/cot/. Prescription 
monitoring--VA has a number of data sources to allow it to monitor 
opioid use to target specific education in real time. The practice 
patterns of providers differ, along with the case mixes, so a provider 
with relatively high opioid prescribing may have an appropriate 
practice, or be someone who could benefit from education. These tools 
allow the VA to drill down to the patient level to evaluate use. Other 
tools can evaluate the treatment of patient panels and the Veterans 
risk of potential abuse. Together, these allow identification of 
potential problems, educational targeting, and tracking of progress.
     Academic Detailing--The academic detailing program is a 
one-to-one peer education program targeted to front line providers. It 
gives specific information on practice alternative and resources, 
opioid safety, and can compare the practice of the provider to that of 
their peers. Veterans have improved pain control as a result of it. 
Information about this may be found at: https://www.pbm.va.gov/PBM/
academic detailingservicehome.asp and https://www.pbm.va.gov/PBM/
academicdetailingservice /Pain_and_Opioid_Safety.asp.
     Informed consent for patients--VA requires an informed 
consent process prior to long-term opioid therapy. This process 
includes the risks of opioid therapy, discusses opioid interactions 
with other medicines, and reviews safe prescribing practices such as 
urine drug screens.
     Naloxone distribution--The Opioid Overdose Education & 
Naloxone Distribution, has focused on education of providers on 
Naloxone distribution to Veterans on long-term opioid therapy.

    Question 22. Does VA need any additional authority from Congress to 
play a larger role to address this epidemic among veterans?
    Response. VA is in constant collaboration with public and private 
health care entities to explore and investigate all opportunities to 
improve our practices and where applicable apply them to our own 
programs. A key example of this is our work on Clinical Practice 
Guidelines. VHA, in collaborations with DOD and other leading 
professional organizations, has been developing clinical practice 
guidelines since the early 1990s. In 2010, the Institute of Medicine 
identified VA/DOD as leaders in clinical practice guideline 
development.
    Implementation of evidence-based clinical practice guidelines is 
one strategy VHA has embraced to improve care by reducing variation in 
practice and systematizing ``best practices.'' Guidelines address 
patient cohorts, serve to reduce errors, and provide consistent quality 
of care and utilization of resources throughout and between the VA and 
DOD health care systems. Guidelines are also cornerstones for 
accountability and facilitate learning and the conduct of research.

    Question 23. Mr. McDivitt, a common issue I hear from veterans is 
the inconsistent information and quality of care they receive from 
different VA medical facilities.
    How do you ensure consistent, quality care and services across VSN 
10 facilities?
    Response. As a healthcare enterprise, we work from all points of 
patient care and services to the VISN office to ensure the delivery of 
the highest quality care to Veterans. Components include, but are not 
limited to the following:

     Quality Management Systems and Internal Controls
     Continuous improvement, redesign, systems engineering and 
efficiency management
     Patient Safety
     Internal and External Reviews
     Utilization Management
     Risk Management
     Performance Measurement and Evaluation
     Veteran and family engagement, activation, satisfaction 
and transparency
     Credentialing and Privileging
     Environment of Care Safety and Engineering

    Each of these components is operationalized at the facility and 
VISN levels to maximize outcomes for Veterans. As a VA health care 
system, ``VA hospitals had better outcomes than non-VA hospitals for 6 
of 9 patient safety indicators. There were no significant differences 
for the other three indicators. In addition, VA hospitals had better 
outcomes for all mortality and readmission metrics.'' (Atkins, David, 
Clancy, Carolyn, Advancing High Performance in Veterans Affairs Health 
Care. JAMA, Nov 2017. Volume 318, Number 19, 1927, 1928P). VISN 10 has 
a robust system of continuous improvement efforts monitored locally, 
regionally and nationally.
    We are considered a 5 Star VISN (on a 5 Star system called SAIL, a 
compendium of patient outcome measures) which is the highest rating 
obtainable. We excel in the following outcomes: patient safety (low 
rate of complications), standardized mortality rate, mental health 
population coverage. The Joint Commission performance outcomes, 
Registered Nurse turnover and call responsiveness. We work at all 
levels of the organization to ensure consistency; compliance and 
excellence; and have robust systems in place to monitor and support 
staff to achieve the best outcomes for Veterans. We seek Veteran input 
and use it to improve quality of care and Veteran outcomes throughout 
the VISN. VISN 10 has a Veteran representative on the Executive 
Leadership Board who is active, engaged and passionate about improving 
outcomes to Veterans.

    Question 24. What is your process for identifying and expanding 
best practices from one facility to others?
    Response. Fortunately, the VISN 10 network has a strong, well-
established system of sharing and spreading strong practices. We 
sponsor workgroups where outstanding outcomes are highlighted and 
shared openly, as well as committees that spread strong practices 
throughout the system. We openly share best practices at the Executive 
Leadership Board that are subsequently spread throughout the system. A 
recent example of shared strong practices includes our medication 
reconciliation process. Additionally, we have a strong mentoring 
process that allows leaders to openly share their experiences with 
newer facility leaders

    Question 25. Mr. McDivitt, veterans have brought to me their 
concerns over VA hiring practices, specifically the medical staff 
shortages.
    What methods do you use to anticipate employee shortages?
    Response. Each facility has a resource management forum that 
includes executive leadership and service chiefs. All resources are 
discussed in the context of immediate critical, clinical needs, future 
vacancies, and supply and demand for resources, new development, 
retention and attrition. Critical, clinical needs are highly 
prioritized and strategies to recruit and retain these positions are 
developed and executed. We have had some issues in rural areas of the 
VISN, as well as some medical sub-specialty areas, and as such have 
aggressively implemented telehealth strategies throughout the network. 
Additionally, when the demand for services exceeds our capacity we have 
coordinated care in the community for Veterans in need. Methods to 
recruit and retain staff include, but are not limited to, recruitment 
and retention bonuses, education payback and incentives, active, 
engaged workforce and environment and a shared governance model. Our 
dedicated staff is passionate and committed to the mission, often 
attracting and recruiting their peers and colleagues from outside of 
the VA health care system.

    Question 26. Have these strategies proven to be accurate when 
forecasting vacancies for critical positions across the VISN?
    Response. The process is generally accurate for forecasting 
vacancies, but does not resolve the issues related to the scarcity of 
providers, specifically certain specialties in some areas of the VISN. 
Operating as a large network with telehealth capacities has helped with 
the supply and demand issues raised by a scarcity of candidates. The VA 
is not allowed to be the highest payor, but offers a highly competitive 
salary and benefits package which can be enticing to potential 
candidates.

    Question 27. How do you ensure that VA remains a competitive work 
environment that retains talented medical professionals? The last thing 
we want to do for our veterans is to push bright, accomplished workers 
out of the agency meant to help vets the most.
    Response. Retention is critical to the maintenance of a dedicated, 
passionate workforce. Numerous mechanisms are in place to foster 
retention including retention incentives, repayment of educational 
debts, and an engaged workforce using a shared governance model.
    In the event an employee chooses to leave VA, we conduct a 
comprehensive exit interview. These interviews track and trend reasons 
for employees leaving and help us strengthen our resources and 
commitment to each and every employee.
    There are many educational and advancement opportunities within the 
VA. Many leaders within the VA started at entry-level positions and 
through education and experiences have become service, facility, and 
network level leaders.

    Question 28. How many Ohio vets will have their GI Bill benefits 
restored as a result of the Forever GI bill? Please provide my office 
with updated numbers, disaggregated by institution, of veterans and 
their families from Ohio who will be eligible for GI Bill benefits 
restoration in light of the Forever GI bill.
    Response. For the Special Application provision VA has identified 
three Ohio schools where students are eligible for restoration as 
follows:

 
------------------------------------------------------------------------
                                                               Number of
                       Name of School                          students
------------------------------------------------------------------------
Brown Mackie College-North Canton...........................      12
Miami-Jacobs Career College-Sharonville.....................       1
Sanford Brown College.......................................       3
------------------------------------------------------------------------

    This number does not include beneficiaries who may have resided in 
Ohio, and attended a school that closed out of state or online.

    Question 29. Mr. Worley, Forever GI Bill will allow the restoration 
of Post-9/11 GI Bill benefits to veterans who were impacted by schools 
that closed from 2015 until the date of enactment.
    What will happen to veterans' GI Bill benefits if vets are using 
their benefits and their school closes suddenly in the future?
    Response. The Forever GI Bill provisions in Section 109 allow 
restoration of entitlement for VA students if a school closes from date 
of enactment (August 16, 2017) and continues into the future. This 
means that VA will not make a charge against a student's entitlement 
for the portion of the period that the student did not receive credit 
toward a program (or lost training time toward the completion of a 
program). For example, if a student was enrolled in a semester full-
time, and the school closed 60 days after the semester started, the 
student would have used two months of their entitlement. VA will 
restore those two months allowing the student to use them at another 
time.
    Additionally, for school closings on or after August 16, 2017, VA 
may continue the housing allowance for Post-9/11 GI Bill students 
beyond the date of closure up to the end of the term, quarter or 
semester, not to exceed 120 days. The law requires VA begin making 
housing allowance payments on August 1, 2018. No charge to a student's 
entitlement will be made for the extended period of eligibility for 
housing allowance.

    Question 30. Are they currently eligible for benefits restoration?
    Response. Yes, the restoration of entitlement provisions in the 
Forever GI Bill took effect 90 days after the date of the enactment 
(August 16, 2017), and apply retroactively to school closures on or 
after January 1, 2015.

    Question 31. Mr. Worley, the Forever GI Bill allows for additional 
funding for State Approving Agencies and instructs SAAs to include 
risk-based surveys in their oversight tasks.
    How can strong oversight from SAAs protect veterans pursuing their 
education?
    Response. Strong oversight by the State Approving Agencies (SAAs) 
helps protect Veterans in several ways. First, oversight ensures 
approved programs meet all statutory approval criteria in 38 U.S.C. 
chapter 36, as well as any individual state requirements the SAAs used 
in their assessment to initially approve a course for Veteran's 
training.
    Second, SAAs are familiar with the responsibilities of School 
Certifying Officials (SCO's). SCOs certify students' enrollments to VA 
to ensure proper payment of benefits. Through oversight, SAAs can 
identify out of line situations that require additional training that 
VA or SAAs can provide, ensuring VA students are certified properly for 
payment, are in courses necessary for completion of their program, and 
that appropriate credit has been granted for their prior training. In 
that oversight review, the SAA may identify violations that could 
result in disapproved programs.
    Finally, using information VA obtains from students through VA's GI 
Bill complaint system, SAAs can conduct an immediate risk-based 
unscheduled school visit to resolve issues, or assess potential 
violations that may require program disapproval or suspension of VA 
student enrollment. The following are areas of focus in the complaint 
system:

 
------------------------------------------------------------------------
      Recruiting/Marketing Practices            Quality of Education
------------------------------------------------------------------------
Accreditation.............................  Grade Policy
Financial Issues (e.g. Tuition/Fee          Release of transcripts
 charges).
Student Loans.............................  Transfer of Credits
Post-Job Opportunities....................  Other (as identified by
                                             student)
------------------------------------------------------------------------

    The SAAs assisting in oversight visits for approval compliance, 
reviews of SCO reporting, and conducting risk based surveys helps 
ensure VA students are in proper programs for their educational 
objective, and receive proper payment. The SAAs strong oversight also 
assists by identifying and resolving issues. The VA's GI Bill complaint 
system is an important tool for early detection of potential problems.

    Question 32. Mr. Worley, I know I would like to see the 90/10 
loophole closed to crack down on for-profit colleges and universities 
using abusive and deceptive practices to recruit veterans, 
servicemembers, and their families. That is why I reintroduced the 
Military and Veterans Education Protection Act this year.
    Are there other improvements to the GI Bill, not included in the 
Forever GI that would help VA better serve veterans pursuing higher 
education?
    Response. While VA defers to the Department of Education on the 90/
10 rule, the FY 2019 President's Budget contains two proposals that 
would help VA better serve Veterans pursuing higher education. The 
first proposal would amend title 38 U.S.C. section 3313(c) and add a 
new section (j) to impose tuition and fee payment caps at institutions 
of higher learning offering flight training programs and establish a 
maximum allowable fee structure for all VA-funded flight programs. 
Savings for this proposal are estimated to be $43 million in 2019, $230 
million over five years, and $540 million over ten years. The second 
proposal would amend 38 U.S.C. section 3002(3)(B), to add a preparatory 
course for a test that is required to enter into, maintain, or advance 
in a given vocation or profession. Costs are estimated to be $1 million 
in 2019, $7 million over five years, and $16 million over 10 years.

    Question 33. What kind of oversight efforts has VA anticipated 
needing to ensure that new offerings from Forever GI, including the 
STEM Scholarship and the High Tech pilot program, are actually serving 
veterans?
    Response. The Department is actively reviewing, planning, and 
preparing for implementation of these two Colmery Act sections in 2019. 
This includes hiring additional temporary full-time employees to 
support standing these initiatives up, processing related claims, and 
providing the necessary oversight to ensure statutory requirements are 
met.

                            A P P E N D I X

                              ----------                              


    Prepared Statement of Benjamin Fitzgerald, Veteran, Westlake, OH
    I truly appreciate Senator Brown for inviting me to talk on behalf 
of veterans, like myself, about topics of discussion concerning Veteran 
Affairs.
    Today I want to highlight some of the questions and concerns that I 
have heard while working as a VA Work/Study at Cuyahoga Community 
College, and through Team RWB Cleveland, Akron, and Columbus Chapters.
    One of the biggest concerns is the transition from military to 
civilian lifestyle. When processing out there is so much on your mind, 
and there are only a few hours that you have learning about benefits, 
and addressing concerns, during this transition. It can become quite 
confusing, stressful, and exciting all at the same time. Knowing this, 
when we return home, you forget what was available to you . . . and it 
happens very easily. I will say however, that Team RWB, a nonprofit 
veterans organization, whose mission is to enrich the lives of Veterans 
through Exercise, Volunteer work, and social interaction, has been the 
greatest thing I have the pleasure to be a part of since coming out of 
service 9 years ago.
    I joined the Cleveland Team about a year and a half ago now, and 
I've never felt more at home. The Team greeted me with open arms, and 
as fellow veterans, that comradery and sense of understanding made me 
feel at home. What's even better, is the team consist of civilian 
members as well, and with their help, we are able to bridge that gap 
between those who serve, have served, and the civilian population. The 
problem is, I didn't even know about Team RWB until 7.5 years after I 
had already got out. In fact, other than the GI Bill, which we 
appreciate Senator Brown making the Forever GI Bill, I had no idea so 
much was available for veterans and their families.
    Next, and quickly, I want to see if there is a solution where our 
medical records aren't taking up to a year to get from our perspective 
Regional Center's?
    Though there are more questions and concerns, which I hope will be 
brought up, I truly appreciate your time, and allowing me to speak on 
behalf of my brothers, sisters, and myself. Thank you!

      

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