[Senate Hearing 115-631]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 115-631

                  THE STATE OF THE VA: A 60-DAY REPORT

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 26, 2018

                               __________

       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

                    Robert J. Henke, Staff Director
                Tony McClain, Democratic Staff Director

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

                      Minority Professional Staff
                            Dahlia Melendrez
                            Cassandra Byerly
                                Jon Coen
                              Steve Colley
                               Simon Coon
                           Michelle Dominguez
                               Amy Smith


                            C O N T E N T S

                              ----------                              

                           September 26, 2018
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     3
Moran, Hon. Jerry, U.S. Senator from Kansas......................    17
Heller, Hon. Dean, U.S. Senator from Nevada......................    21
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    23
    Reports for the record.......................................    24
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    26
Murray, Hon. Patty, U.S. Senator from Washington.................    28
Boozman, Hon. John, U.S. Senator from Arkansas...................    30
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    32
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    34
Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    36
Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    38
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    42

                               WITNESSES

Wilkie, Hon. Robert L., Secretary, U.S. Department of Veterans 
  Affairs........................................................     6
    Prepared statement...........................................    10
    Response to request arising during the hearing by:
      Hon. Patty Murray.......................................... 29,30
      Hon. Joe Manchin III.......................................    37
    Response to posthearing questions submitted by:
      Hon. Jon Tester............................................    45
      Hon. Jerry Moran...........................................    48
      Hon. Dean Heller...........................................    48
      Hon. Patty Murray..........................................    49
      Hon. Bernie Sanders........................................    61
      Hon. Sherrod Brown.........................................    64
      Hon. Mazie K. Hirono.......................................    66
      Hon. Joe Manchin III.......................................    68

                                APPENDIX

Stier, Max, President and CEO, Partnership for Public Service; 
  prepared statement.............................................    73

 
                  THE STATE OF THE VA: A 60-DAY REPORT

                              ----------                              


                     WEDNESDAY, SEPTEMBER 26, 2018

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3 p.m., in room 
418, Russell Senate Office Building, Hon. Johnny Isakson, 
Chairman of the Committee, presiding.
    Present: Senators Isakson, Moran, Boozman, Heller, Cassidy, 
Tillis, Sullivan, Tester, Murray, Brown, Blumenthal, Hirono, 
and Manchin.

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

    Chairman Isakson. I call the Veterans' Affairs Committee of 
the U.S. Senate to order and thank everybody for being here 
today, particularly Secretary Wilkie, who hit the ground 
running a few weeks ago and has not stopped. We slowed him down 
enough to come in today to testify.
    We really appreciate your being here today----
    Secretary Wilkie. Thank you, sir.
    Chairman Isakson [continuing]. And the other Members of the 
VA staff that are here and our friends in the VSOs and everyone 
else that is here. We are going to have good attendance from 
our Members. Do not let the poor numbers right now throw you 
because there are a lot of them working on stuff they are going 
to come in and ask the Secretary about because they have been 
asking me about it.
    But, I do want to set the table for 1 second. I want 
everybody to listen very closely so you can tell the other 
Members who are not here yet that I covered this already.
    The biggest issue for 3 or 4 years has been can we get the 
VA functional. We have put up with front-page stories where 
they lost stuff, veterans could not get services, everything 
known to man.
    We have done a great job and the VA has done a great job of 
addressing that. When you hear the Secretary talk today, he 
will talk about his four key priorities for the VA. Customer 
service is number 1.
    I have gotten letters from my district, unsolicited, 
veterans who used to write me about why we were not worth 
anything because we could not get anything done to thanking me 
for the efficient way the operation works now.
    We are not perfect, and I do not want the Secretary to rest 
on his laurels and think the hard part is over. The hard part 
has just started, but no journey starts without the first 
steps. That is an old Chinese proverb. We took the first step 
with Secretary Wilkie, and he has taken the step of making 
customer care and veterans care and the importance to the 
veteran the number 1 priority of his administration at the VA.
    So, we have got a long way to go on that. We have got 
Cerner software to get installed. We have got lots of changes 
to make. We have got lots of things to come to reality, and we 
are working on them.
    But, if you ask anybody that is sitting here in this room 
in this audience if there is another problem that needs to be 
addressed, they would tell you it is Blue Water Navy.
    I spend a lot of my time sitting with a lot of you, some of 
you in the VSOs and some of the other activist organizations 
and some of the loved ones' parents and the like that are 
veterans. They said, ``You guys need to fix that.''
    Well, I have been working on it, and I want to commend the 
Committee, every Member, Republican and Democrat, because at 
one time or another I have talked to each one of them about 
this, and I think I know where every one of them stands. Every 
one of them has been supportive to find a way to do it. Also, I 
have tried to talk to, beginning with the Secretary whom I 
started talking to a month ago; I have started bouncing various 
ideas off of him to see where we could come to some kind of 
solution.
    The Secretary is right--and the reasons he has been 
opposed--to just doing Blue Water Navy, period, but he is not 
wrong about how we get to it. We need to get to it with you, 
together as a Committee, and the VA Secretary is a principal 
member of the VA.
    The veterans who think they deserve that benefit ought to 
get it. We ought to realize that we do not need to run a 
Veterans Administration that does not have standards in terms 
of new benefits that come along. This is not a new benefit. It 
is a new benefit to some because they never heard of it before, 
but this is a benefit that existed until 1999. Then with an 
administrative change, the eligibility was taken away for 
certain veterans.
    So, you have got the situation if you are on the ground, 
you are inone category; if you are on the water, you are in 
another category. If you are this, you are one category; if you 
are that, you are another category.
    We do not have scientific conclusive proof, which you 
seldom do in a scientific discussion, as to exactly what the 
solution is or what the problem is, but we do know there is a 
problem. We know that non-Hodgkin's lymphoma and certain other 
diseases with presumptive eligibility in other cases is 
something we have to address.
    We need to look at the facts and let us see where they lead 
us, and we need to look at being right and fair to the 
veterans. We should not have two classes of veterans who 
fought, just because one of them was on water and one of them 
was on land, if it was the same conflict, the same exposures, 
then the same difficulties.
    But, we should not also hand out benefits just because we 
think we ought to. We ought to hand them out because it is the 
right thing to do for the veterans; we do it in the right way. 
We set a template for what is going to happen in the future. If 
another situation comes up, we have to evaluate it.
    That is not just me talking; that is all the Members of the 
Committee I have talked to. They feel the same way. They want 
to get this problem solved, but they also do not want to create 
a problem. That is why working with the Secretary to find a 
solution, rather than the Secretary just saying no or me just 
saying no or me saying, ``Yes, we are going to do it.'' We are 
not going to act that way.
    We are going to work together as a team. We are going to 
decide what we need to do. We are going to decide where we need 
to go, and we are going to get this problem solved. I have told 
you all in every beginning year or ending of the 2-year cycles 
that we have gone through that we had goals to accomplish, and 
my goals were Caregivers. My goals were getting the MISSION Act 
done. My goals were doing a lot of things. I know what Jerry's 
goals have been. I know what Jon's goals have been. I do not 
think anybody has been excluded. Everybody on the Committee has 
gotten ideas into the law, but we have now got to deal with 
this problem.
    I do not need to try to cajole you or put it off and not 
deal with it. I need to do everything I can to see that it gets 
done.
    So, I want to just set the table at this hearing with the 
Secretary present to thank him for giving me the time he has 
given me in the last month to talk about this. I appreciate 
what his attitude is about customer service being the principal 
foundation of his administration in VA.
    And, for all of you in the VSOs and all of you of various 
interests--Blue Water Navy or any other benefit anywhere--know 
this is a Committee and a VA that will tackle your problems and 
try to do it as fairly and equitably and as right for everybody 
as we can. However, we are not going to get bulldozed into a 
corner, and we are not going to bulldoze somebody into the 
corner either. I want to bring that up because that is going to 
take care of a lot of questions. I hope it does.
    Again, I want to thank the Secretary for the time he has 
given me and the time we are going to be sharing together in 
the weeks ahead. I now turn it over to the Ranking Member for 
any comments he might have.

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

    Senator Tester. Well, thank you, Mr. Chairman. Thank you 
for your comments, and I want to thank Secretary Wilkie for 
being here today. Welcome.
    I have intentionally stayed away from your office as much 
as possible to be able to give you time to get oriented and get 
your team together and move the VA in a direction I think we 
all want to see it go.
    In your written testimony, you shared five real-life 
stories of individuals in the VA who are really making a 
difference. We do not hear enough about the good things the 
agency does day in and day out, so thank you. There is a reason 
why an overwhelming number of veterans prefer the health care 
that the VA delivers, and there is a reason why thousands of 
men and women across this country work tirelessly every single 
day to provide veterans with the care and benefits that they 
have earned.
    I am talking about the physician assistant in Montana, the 
claims processor in Georgia, the cemetery taker in North 
Carolina, and countless others.
    The VA means a great deal to these folks, and it means a 
great deal to this country. So, today, I am hopeful we can talk 
about what is right with the VA, while I am also hopeful that 
we can address the challenges that the VA has and what needs to 
be done to improve it.
    Mr. Chairman, in terms of numbers and scopes of bills we 
signed into law, this Committee has been under your leadership, 
historicly, but there is much more to do.
    We do need to pass a Blue Water Navy Veterans Act. We need 
to move on a number of other critical bills, and I know you 
addressed that in your opening statement.
    I will tell you that I remember having the conversation 
with you when Patty Murray brought in the caregivers bill, and 
you said, ``I made a promise to get this done, and I am going 
to get it done,'' which you did.
    The challenge we have here is the House is leaving town 
tomorrow, and the Blue Water Navy folks are out there. I trust 
you unequivocally to get this done, but we do need to get it 
done. We have been talking about it for far too long.
    Just as important, we need to ensure that the reforms of 
the previous 2 years are implemented appropriately by the VA as 
Congress intended, as the veterans deserve.
    Mr. Secretary, as you highlighted in your testimony, this 
is not business as usual. This is a fundamental transformation 
not seen in the VA since just after World War II.
    Because the stakes are so high, collaboration and 
partnerships are more critical than ever. Collaboration and 
partnerships are more critical than ever. Whether it is the VA 
and the VSOs working together, whether it is Congress and the 
VA and the VSOs working together, or whether it is Congress and 
the VA working together. That triangle needs to have good, 
solid communication.
    Unfortunately, in my opinion, it looks as if the VA may be 
headed in the opposite direction--disengaging with veteran 
stakeholder groups when it should be more engaged than ever 
with this transformation and becoming less transparent when it 
needs to be more transparent. I hope that I am wrong.
    Let me tell you why I believe what I just said. When the 
negotiation process for the MISSION Act started nearly 2 years 
ago, this Committee worked in good faith with the VA to develop 
legislation that made the most sense for the veterans, 
community providers, and the taxpayers--veterans, community 
providers, and the taxpayers.
    I cannot overstate the amount of collaboration that went on 
between Congress and the VA to get that bill across the finish 
line.
    Now 3 months have passed since that bill has become law, 
and the most that we have received is a 40,000-foot view of the 
offices responsible for implementing the program, really 
nothing of substance.
    It took a letter signed by the leadership of the Senate and 
House Veterans' Affairs Committees after a planned briefing was 
unilaterally canceled by the VA to start getting some answers. 
In my opinion, that is a problem. It is not the way we have 
done business in the past, and it should not be the way we do 
business in the future.
    With that in mind, Mr. Secretary, there were a couple of 
lines toward the conclusion of your written statement that gave 
me some serious pause. You state that the VA cannot stop 
everything that it is doing to provide updates or respond to 
inquiries if we are serious about getting to our destination. 
Providing updates and responding to inquiries about 
implementation of the laws that we fought hard as hell to pass 
may not always be convenient, and it may not always be 
pleasant, but it is really how the democracy works.
    As a longtime congressional staffer, you have been on this 
side of the dais. You know that the only way we get information 
is we have to do our job; we have to get information. That job 
is to provide oversight of the second largest agency in the 
Federal Government, an agency that will spend more than $200 
billion next year during what we both agreed are 
transformational times.
    I strongly believe in your nomination. I continue to 
believe that you are the right person for this job. Our 
Nation's veterans are counting on you. I sincerely--and I mean 
this--I want you to succeed, man. I really want you to succeed.
    After your confirmation, you deserve some space to get your 
bearings, and you need to get your team in place. You need to 
bring some stability to the agency. It has been 60 days, and I 
think we can all acknowledge that the honeymoon is over.
    Moving forward, I am hopeful that the VA can be more 
transparent, engage more constructively with the stakeholders, 
and work more collaboratively on critical issues for veterans. 
For me, medical workforce vacancies, workforce vacancies are at 
the top of the list.
    I know the shortage of medical personnel is a national 
problem, and it is just not a VA problem. It is truly a 
national problem, but I also know that the Secretary before you 
and the one before him and the one before him all sat in that 
chair and asked this Committee for new authorities and 
additional resources to better recruit and retain folks needed 
by the VA to serve our veterans. You know what? Congress 
delivered every single time, including the additional funding 
in next year's appropriations bill and the newest authorities 
that you now have in the VA MISSION Act.
    Mr. Secretary, today you will be receiving a letter from me 
that requests more information about how the VA is utilizing 
those additional authorities. It is not an exercise to create 
additional paperwork. It is so that this Committee, both sides 
of the aisle, can have a better idea of what is working and 
what is not so that we can focus our efforts. It is critically 
important.
    Since vacancies continue to be the biggest barrier to 
primary, specialty, and mental health care for veterans across 
this country, I think it is a very reasonable request. I hope 
that we can work closely together moving forward on this issue.
    We have got a lot of ground to cover. I look forward to 
getting started.
    Mr. Secretary, I want to thank you for being here today. I 
have been looking forward to this hearing, I am going to tell 
you, for a long time.
    Mr. Chairman, I would like to include a written statement 
for the Partnership for Public Service in the record today, 
with your permission.
    Chairman Isakson. Without objection.

    [The statement can be found in the Appendix.]

    Senator Tester. Their statement underscores the need for 
the VA to maintain a collaborative relationship with Congress, 
this Committee, and highlight the importance of employee 
engagement within the VA.
    With that, Mr. Chairman, I appreciate your leadership and 
look forward to this hearing.
    Chairman Isakson. Thank you, Senator Tester. I appreciate 
your comments. I have two things to say before we turn it over 
to the Secretary.
    One is I would like Mr. Brett Reistad to stand up. He is 
the new American Legion National Commander.
    Brett, will you stand up, please? Give him a round of 
applause. [Applause.]
    What is your State, sir?
    Mr. Reistad. Virginia, sir.
    Chairman Isakson. Virginia. Well, you are close to home, so 
that is good. We are glad to have you and appreciate The 
American Legion and all they do.
    Mr. Reistad. Thank you for having us, sir.
    Chairman Isakson. Who in my Committee is in charge of the 
air conditioning? [Laughter.]
    Anybody in this room who is going to admit to that?
    OK. You go find them and tell them it is hot in here.
    We want to cool this place off a little bit. We want to 
make it right and comfortable.
    Senator Moran. It is Tester's fault.
    Chairman Isakson. Tester's fault. That is right.
    Senator Tester. We do not want this to be a heated hearing. 
[Laughter.]
    Chairman Isakson. Secretary Wilkie, we appreciate you being 
here today. We appreciate the access you have given us in the 
past and look forward to working together and appreciate you 
being here today.

        STATEMENT OF HON. ROBERT L. WILKIE, SECRETARY, 
              U.S. DEPARTMENT OF VETERANS AFFAIRS

    Secretary Wilkie. Well, thank you very much, Mr. Chairman 
and Senator Tester and distinguished Members of the Committee. 
I want to thank you for this first opportunity to discuss the 
state of the Department of Veterans Affairs and for the many 
courtesies that you have shown me in the last few months, my 
first iteration as the Acting Secretary and now 7 weeks into 
the term as the confirmed Secretary.
    I am happy to tell you that the state of the VA is better, 
and it is better, as Senator Tester said, because of the work 
of this Committee and the attention paid to our Department by 
the administration.
    It is also better because, a Senator Tester pointed out in 
conversations with me, we now have a fully-experienced 
leadership team in place at all levels. It is better because we 
have a workforce dedicated to the care of veterans, their 
families, caregivers, and survivors. I will say better because 
the turmoil of the first half of 2018 is now in the rearview 
mirror.
    What this means in terms of leadership is that our new team 
is on the same page, speaking with one unified voice on behalf 
of veterans, moving out and delivering the mandate of this 
Committee.
    I also want to thank the Veterans' Affairs Committee for 
its quick movement on our nominees for leadership in the Office 
of Accountability and Whistleblower Protection as well as the 
CIO.
    Mr. Chairman, you and I have discussed that there are two 
Departments in the Federal Government that must always be above 
partisan politics. I have been fortunate to serve in both--the 
Department of Defense and the Department of Veterans Affairs--
and this Committee proves that postulate.
    Now more than ever, we are seeing the need for DOD and VA 
to work together to provide quality care for our Nation's 
servicemembers and veterans, and now more than ever, we are 
seeing the benefit of strong bipartisan support for our DOD/VA 
partnership in the many major acts of Congress passed in the 
last few years.
    Mr. Chairman, you and the ranking member have equipped the 
Department with a $200 billion budget. You have passed the 
Accountability Act to shake up complacency, and you have passed 
the MISSION Act to strengthen our ability to ensure that 
veterans have access to the best care available when and where 
they need it.
    As Secretary Mattis said when the Congress passed his 
budget, there are no more excuses. The future now is up to the 
Department. I look forward to working with the Committee and 
the Congress to carry forward the work of that transformation, 
and I pledge to you to make efforts as transparent as possible 
to give you and the veterans of our Nation the best service 
possible.
    In the past 6 weeks, I have met personally with the leaders 
of nine veterans service organizations, attended several 
conventions, and visited 12 VA hospitals from Boston to Las 
Vegas plus two claims processing centers, two national 
cemeteries, and a veterans treatment court in Maryland. From 
what I have seen and heard, it is clear to me that the veterans 
population and their needs are changing faster than we even 
realize.
    For the first time in 40 years, half of our veterans are 
now under the age of 65. Of our 20 million veterans, 10 percent 
are now women, and the number of women veterans receiving VA 
care has tripled since 2000.
    The new generation of veterans is computer-savvy and 
demands 21st century service, service that is easy to access, 
efficiently delivered, and available where needed. For the VA 
to thrive as an integrated benefits and health care delivery 
system, it must be agile and adaptive.
    I have also seen the wonderful examples of VA 
accomplishments that Senator Tester pointed out. They deserve 
more attention than they have received. We are on the cutting 
edge of medical care and rehabilitative services, prosthetics, 
Traumatic Brain Injury, spinal cord treatment, opioid and 
mental health, telehealth, and community care, where one-third 
of our appointments reside.
    The VA health care system continues to outperform the 
private sector in the quality of care and patient safety for 
our veterans.
    Our National Cemetery Administration has dedicated its 
136th cemetery in Colorado Springs.
    Fifty-two State veterans' homes received construction and 
renovation funds this year, and for the first time in many 
years, our overall VA customer satisfaction rate is steadily on 
the rise.
    Thanks to the unprecedented series of legislative actions 
aimed at reforming the Department and improving care and 
benefits for our heroes, we are now tackling issues that have 
vexed VA for decades: giving veterans more choice in their 
health care decisions with the passage of MISSION; increasing 
accountability for misbehaving employees and protecting 
whistleblowers with our Office of Accountability and 
Whistleblower Production; improving transparency by becoming 
the first hospital system in the Nation to post online wait 
times, opioid prescription rates, accountability, settlement 
information, and chief executive travel.
    We are adopting the same electronic health record at DOD, 
so there is a seamless transfer of medical information for 
veterans leaving the service and are implementing the Appeals 
Modernization Act while reducing wait times for those with 
appeals already pending.
    As the Ranking Member said, we are on the cusp of the most 
important era in the history of the Department. This is not 
business as usual. This is fundamental transformation not seen 
since World War II when Omar Bradley headed the Veterans 
Administration.
    As you said, Mr. Chairman, my number 1 priority is customer 
service. When an American veteran comes to VA, it is not up to 
the veteran to employ a team of lawyers to get VA to say yes. 
It is up to VA to train and equip its employees to get that 
veteran to yes, and that is customer service.
    Second, we will implement the MISSION Act, a landmark 
achievement of this Congress that will fundamentally transform 
health care by consolidating all of VA's community care efforts 
into a single program that is much easier to navigate for 
veterans, families, VA employees, and community providers. As 
Senator Murray worked so hard for, this Act also expands VA's 
family giver programs, caregiver programs, to provide much 
needed assistance to the people who care for our most needy 
veterans day in and day out.
    Third, we will replace our aging electronic health record 
system with the system in use by the Department of Defense to 
modernize our appointment system, automate our disability 
claims and payment claims systems, and connect VA to DOD, 
private health care providers, and private pharmacies, finally 
creating a continuum of care organized around the veterans' 
needs.
    What I see in the future is that we will never have a 
veteran, as my father was, carrying around an 800-page paper 
record. The new system will allow for best practices to be 
shared and implemented across the network and empowering us to 
turn the corner, hopefully, on opioid abuse and suicide 
prevention. Implementation of this system will be ongoing and 
iterative, and I look forward to working with the Members of 
this Committee throughout the process.
    Fourth, we must transform our business systems processes to 
modernize our management of human resources, finance, and just 
as important, our supply chain. This means giving people more 
leeway to manage their budgets and recruit, retain, and 
relocate the staff they need to serve veterans in their areas. 
It also means entering into more robust partnerships with our 
State and local communities to address veterans' homelessness 
and suicide prevention.
    At the same time, we will continue our recent progress on 
many other important issues. For example, to accommodate the 
rapid growth in America's women in the service, VA has expanded 
services and sites of care across the country. We now have at 
least one women's health primary care provider at all of VA's 
health care systems.
    In addition, 90 percent of the community-based outpatient 
clinics have a women's health primary care provider in place. 
Gynecologists are on-site at 133 facilities, and mammography is 
on-site at 60. VHA is in the process of training additional 
providers so every woman veteran has an opportunity to receive 
her primary care at VA.
    We are also working to fill the gaps in our ranks. VA has 
had a net gain of 7,423 employees in fiscal year 2017, and so 
far in fiscal year 2018, we have seen a net increase of more 
than 9,500, including 3,600 in the mission-critical position 
Senator Tester mentioned. Our average annual turnover rate is 
9.2 percent, which beats the 11 percent average of Cabinet-
level agencies in the last 2 years as well as the 20 to 30 
percent turnover rate in the health care industry in America.
    We are providing more health care appointments than ever 
before, having authorized 32.7 million appointments in 2017, 
which was nearly 2 million more than in the previous year.
    All VA health care facilities now provide same-day primary 
and mental health care services for veterans in urgent need.
    Finally, Mr. Chairman, I want to bring to your attention 
something that was very important to me, and I think I am 
speaking for my former boss, Senator Tillis. I want to thank 
the Department of Veterans Affairs for the round-the-clock 
efforts that they provided to serve and protect our veterans 
across the Carolinas. Without a hitch, we were able to evacuate 
patients in the danger zone and provide fuel, food, and oxygen 
to hospitals we had to keep open, in spite of deteriorating 
conditions and the communities they served being cut off from 
the rest of the country.
    What is not known to many of our fellow citizens and some 
in our own Department, we were the foundational emergency 
responders for our foundational emergency Federal response. We 
were the part of the Government providing incident command 
centers, sending doctors, nurses, and engineers plus mobile 
pharmacies, clinics, and nutrition centers into the hardest-hit 
areas. America should be proud of their citizens at VA.
    So, as I said, we are embarking on the most comprehensive 
improvements to veterans' care and benefits since World War II. 
We have more work to do, and thanks to you and the Members of 
this Committee, we now have the resources to complete the work.
    Mr. Chairman, again, I thank you for your many courtesies 
to me and I look forward to working with this Committee as we 
work for the betterment of veterans across the country. I thank 
you for your courtesy.
    [The prepared statement of Secretary Wilkie follows:]
         Prepared Statement of Hon. Robert Wilkie, Secretary, 
                  U.S. Department of Veterans Affairs
    Chairman Isakson, Senator Tester, distinguished Members of the 
Committee: Thank you for my first opportunity to discuss the current 
state of the Department of Veterans Affairs (VA) and my vision for the 
future of America's Veterans.
    I am happy to say that the state of the VA is better--better 
because of the work of this Committee; better because of the attention 
paid to Veterans Affairs by the President; better because we have a 
functioning, experienced leadership team in place at all levels; better 
because we have a workforce dedicated to the care of warriors; and 
better because the turmoil of the first seven months of 2018 is in the 
rearview mirror.
    Mr. Chairman, while all executive branch departments and agencies 
must carry out their missions without consideration or influence of 
partisan politics, I have said in my visits across the department--
visits that in the last five weeks cover ten VA hospitals from Boston 
to Las Vegas--that there are two departments of the Federal Government 
that must be especially careful to rise above partisan politics: the 
Department of Defense (DOD) and the Department of Veterans Affairs--
this Committee is proof of that postulate.
    Now more than ever we are seeing the need for DOD and VA to work 
together to provide quality care for the Nation's Servicemembers and 
Veterans. And now more than ever we also are seeing the benefit of 
strong bipartisan support for our DOD/VA partnership in the many major 
acts of Congress passed in the recent years. Mr. Chairman, Congress has 
infused VA with a $200 billion budget. You have passed the 
Accountability Act to shake up complacency, and you have passed the 
MISSION Act to strengthen VA's ability to ensure Veterans have access 
to the best care available when and where they need it. As Secretary 
Mattis said when this Congress passed a $700 billion defense budget, 
there are no more excuses. The future now is up to the department. I 
look forward to working with the Committee and Congress to carry 
forward that work of transformation, and I pledge to make our efforts 
as transparent as possible to you, to Veterans, and to the American 
people.
    Mr. Chairman, I would also be remiss if I did not mention the round 
the clock efforts of our VA employees to serve and protect our veterans 
during this great time of need across the Carolinas. Without a hitch, 
we were able to evacuate patients in the danger zone; provide fuel, 
food and oxygen to hospitals we had to keep open in spite of 
deteriorating conditions in the communities they serve; and what is not 
known to many of our fellow citizens and some in this Congress--we were 
the foundational emergency responders for our government providing 
incident command centers and sending doctors, nurses and engineers plus 
mobile pharmacies, clinics and nutrition centers into the hardest hit 
areas. America should be proud of their fellow citizens.
                           initial assessment
    As Acting Secretary and Secretary of Veterans Affairs, I met 
personally with the leaders of nine Veterans Service Organizations 
(VSOs), spoke at four VSO events, hosted two VSO breakfasts, and 
attended one White House VSO meeting. I have met with the combined 
leadership of VA's three administrations--Benefits, Health, and 
Memorial Affairs--and I have visited 14 VA medical facilities, two 
claims processing centers, and two national cemeteries, as well as a 
Maryland Veterans Treatment Court. From what I have seen and from what 
I have been told by Veterans' advocates, it is clear to me that the 
Veteran population is changing faster than we realize. For the first 
time in over 40 years, half of our Veterans are now under the age of 
65. Of America's 20 million Veterans, 10 percent are now women. We face 
some persistent problems: increasing demand for care, vacancies in 
critical specialties, aging facilities, antiquated management systems, 
and a new generation of computer-savvy Veterans who expect and deserve 
21st-century service--service that is quick, diverse, and close to 
home.
    I have also seen wonderful examples of VA accomplishments that 
deserve more attention than they get. Many of them are the result of 
collaborations with our public and private sector partners, such as our 
consultation with the National Football League on Traumatic Brain 
Injury. And I've seen VA making groundbreaking progress, particularly 
in the areas of accountability, transparency, and efficiency, thanks to 
an unprecedented series of legislative actions aimed at reforming the 
department and improving care and benefits for our Nation's heroes.
    Most inspiring to me have been the many exceptionally competent and 
caring VA employees I have met who truly live by VA's core ``I CARE'' 
values: Integrity, Commitment, Advocacy, Respect, and Excellence:

           Not long after I rejoined VA, The Washington Post 
        ran a story about the people who answer phones for the White 
        House VA Hotline. I was touched by the patience and compassion 
        of one of the call takers--an Army widow named Mary Hendricks--
        that I called to thank her and her co-workers for the work they 
        do.
           Then there were the four employees of the Phoenix VA 
        medical center who talked a homeless man out of committing 
        suicide. They were on their way to work when they saw him about 
        to jump from an I-10 overpass. One VA employee did not see the 
        homeless man at first, but he did see his co-workers trying to 
        help the man, so he stopped to help them, and together they 
        saved a life that day.
           Last month, Alethea Varra, a regional director of 
        VA's National Tele-mental Health network, met with Ajit Pai, 
        Chairman of the Federal Communications Commission (FCC), to 
        impress upon him the importance of extending high-speed 
        Internet access to rural Veterans. Varra introduced Pai to a 
        Veteran who lives two hours from the nearest VA clinic but is 
        able to keep weekly appointments with mental health counselors 
        over the Internet. Advocacy is one of our core I-CARE values; 
        Alethea Varra lived up to that value by connecting Pai with 
        Veterans in need.
           There's Dr. Joseph Potkay, a researcher at the 
        University of Michigan who is also a biomedical engineer at the 
        VA in Ann Arbor, and who is working to create a microfluidic 
        artificial lung using a high-resolution 3D printer. If it 
        works, it could revolutionize the treatment of Veterans with 
        lung disease.
           Finally, for the past two years, VA health 
        professionals in West Palm Beach and Miami, Florida, have been 
        treating an Army Veteran with melanoma named John Johnson. This 
        summer--after radiation, surgery, and immunotherapy--Johnson 
        was able to realize his dream of bicycling the mountainous 
        route followed by the Tour de France. He later told us, ``I owe 
        the West Palm Beach VA a huge debt of gratitude for making 
        [this ride] possible. . . . There are great people who work 
        here, and they deserve thanks and attention. They're fantastic, 
        and they should all be told, `You're fantastic.' ''

    These are just a few examples of the people who make me truly 
thrilled to be part of VA at just this time in its history. They are 
exceptionally competent and dedicated people, and with the support of 
the President, the Congress, and our many partners, they are now 
tackling head-on issues that have lingered for years, including:

           Giving Veterans more choice in their healthcare 
        decisions with passage of the historic MISSION Act,
           Increasing accountability for misbehaving employees 
        and protecting whistleblowers with the establishment of the 
        Office of Accountability and Whistleblower Protection,
           Improving transparency by becoming the first 
        hospital system in the Nation to post online our wait times, 
        opioid prescription rates, accountability, settlement 
        information, and chief executive travel,
           Adopting the same electronic health record as DOD so 
        there is a seamless transfer of medical information for 
        Veterans leaving the service, and
           Overhauling our claims and appeals processes to 
        create a simplified system for filing to provide Veterans with 
        clear choices and timely decisions.

    This is not business as usual. This is fundamental transformation, 
not seen at VA since just after World War II, when General Omar Bradley 
headed the VA.
                            my vision for va
    Many of the issues I encountered as Acting Secretary and more 
recently as Secretary were not with the quality of medical care but 
with getting our Veterans through the door to reach that care. Those 
problems are both administrative and bureaucratic. Alexander Hamilton 
said that the true test of a good government is its aptitude and 
tendency to produce a good administration. That is where VA must go.
    Our first challenge is to improve the culture to focus our 
attention and efforts on offering world-class customer service through 
all our operations. Our second challenge is increasing access to care 
and benefits through MISSION Act implementation and business 
transformation, which includes adopting a new electronic health records 
system, implementing a new claims appeals process, and modernizing our 
human resources, financial management, construction program, and supply 
systems.
Priority 1: Customer Service (CX)
    My prime directive is customer service. When a Veteran comes to VA, 
it is not up to him to employ a team of lawyers to get VA to say yes. 
It is up to VA to get the Veteran to yes, and that is customer service.
    VA receives 140 million phone calls a year. Ten million people 
contact VA online each month. We have 348 contact centers, hundreds of 
websites, and dozens of databases. Veterans think of VA as a single 
entity, but we deliver services in silos, forcing the Veteran to figure 
out which VA phone number to call, website to search, or office to 
visit. For many, finding the right office to access the right benefit 
or service is a fractured, frustrating experience.
    Driven by customer feedback, we are integrating VA's digital 
portals, contact centers, and databases so that Veterans easily find 
what they need no matter which channel they choose. We have planned a 
re-launch of our VA.gov website on Veterans Day, and we are unifying 
Veteran data, adding customer preferences for electronic correspondence 
to our new Vet360 database and integrating the Vet360 profile service 
with mobile apps. We are also establishing a governance structure to 
involve senior VA leadership in the customer-service effort.
    Our goal is to make accessing VA services seamless, effective, 
efficient, and emotionally resonant. The delivery of excellent CX is my 
responsibility and the responsibility of all VA employees. When the 
interactions between VA employees and our Veteran customers in these 
areas are positive, our Veterans will trust and Choose VA, for their 
care, benefits, and memorial services across their lifetime.
    Customer service must start with VA employees not talking at each 
other but with each other across all office barriers and across all 
compartments. If we don't listen to each other, we won't be able to 
listen to our Veterans and their families and we won't be able to 
provide the world-class customer service they deserve. We must be a 
bottom-up organization, with energy flowing upward from those who are 
closest to those we are sworn to serve. It is from our dedicated 
employees that the ideas we carry to the Congress, to the Veterans 
Service Organizations, and to America's Veterans will come. Anyone who 
sits in this chair and tells you he or she has the answers is in the 
wrong business.
    To help us become the best customer-service team in Government, and 
earn the trust of our Veterans and their families, caregivers, and 
survivors, I have issued a policy statement outlining how VA will 
achieve this goal along three key pillars: CX Core Capabilities and 
Framework; CX Governance; and CX Accountability. I am holding all VA 
executives, managers, supervisors, and employees accountable to foster 
this climate of excellence in customer service. I have also pledged the 
shared services and support of VA's Veterans Experience Office as a key 
enabler to help us all achieve this climate of customer service for 
both those we serve, and to those we serve alongside.
Priority 2: MISSION Act Implementation
    The MISSION Act is landmark legislation that will fundamentally 
transform VA health care and improve Veterans benefits and services. To 
ensure VA meets all of the provisions within the MISSION Act, we have 
established an enterprise program management office, with integrated 
project teams to implement each specific MISSION Act provisions, led by 
Acting Deputy Secretary Jim Byrne.
            Community Care
    The MISSION Act consolidates all of VA's community care efforts 
into a single program that is much easier to navigate for Veterans, 
families, VA employees and community providers. This will ensure our 
Veterans receive the best healthcare possible, whether delivered in VA 
facilities or in the community. To implement requirements under the 
MISSION Act for the consolidated VA community care program, VA began 
drafting the required regulations immediately. Several significant 
regulations are targeted for publication in the summer of 2019. In the 
meantime, the MISSION Act includes an additional $5.2 billion in 
funding for the Veterans Choice program to continue until June 6, 2019, 
while VA develops the regulations to implement the new consolidated 
community care program.
            Caregivers Expansion
    The MISSION Act also expands eligibility for VA's Program of 
Comprehensive Assistance for Family Caregivers (PCAFC) beyond post-9/11 
Veterans to include eligible Veterans from all eras of service. VA's 
Caregiver Support Program (CSP) will oversee the expansion, which will 
occur in two phases:

           Veterans who incurred or aggravated a serious injury 
        in the line of duty on or before May 7, 1975, will begin 
        integrating into the program first.
           Veterans who incurred or aggravated a serious injury 
        in the line of duty between May 7, 1975 and September 11, 2001, 
        will begin integrating into the program two years later.

    The timeline for incorporating all eligible Veterans is still under 
development. To meet the needs of incoming Veterans, CSP must develop 
and implement a new information technology system to support 
administrative and recordkeeping needs. CSP will soon submit a report 
to Congress with a timeline for implementation.
    VA supports this expansion and recognizes the sacrifice and value 
of Veterans' family caregivers not only through this program but 
through its first Federal Advisory Committee for Veterans Families, 
Caregiver and Survivors and its new Center of Excellence for Veteran 
Caregiver Research. Caregivers and Veterans can learn about the full 
range of available support and programs by visiting 
www.caregiver.va.gov or by contacting the Caregiver the Caregiver 
Support Line toll-free at 1-855-260-3274.
Priority 3: Business Transformation
    Business transformation is essential if we are to move past 
compartmentalization of the past and empower our employees serving 
Veterans in the field to provide world-class customer service. This 
means reforming the systems responsible for claims appeals, GI Bill 
benefits, human resources, financial and acquisition management, supply 
chain management, and construction. Office of Enterprise Integration 
(OEI) is charged with coordination and oversight for these efforts.
            Appeals Modernization
    The Veterans Appeals Improvement and Modernization Act of 2017 was 
signed into law on August 23, 2017, and takes full effect in 
February 2019. VA is on track to implement the law by that timeframe. 
The Appeals Modernization Act transforms VA's complex and lengthy 
appeals process into one that is simple, timely and fair to Veterans. 
The new appeals process will feature three decision-review lanes:

           Higher-Level Review Lane: A senior-level claims 
        processor at a VA regional office will conduct a new look at a 
        previous decision based on the evidence of record. Reviewers 
        can overturn previous decisions based on a difference of 
        opinion, or return a decision for correction.
           Supplemental Claim Lane: Veterans can submit new, 
        relevant evidence to support their claim and a claims processor 
        at a VA regional office will assist in developing evidence.
           Appeal Lane: Veterans will have the option to appeal 
        a decision directly to the Board of Veterans' Appeals (Board).

    The law created the Rapid Appeals Modernization Program (RAMP), 
which allows Veterans with a pending disability compensation appeal to 
participate immediately in the new appeals process. About 48,000 
Veterans with more than 57,000 appeals have opted into RAMP so far, and 
VA has paid over $66 million in retroactive benefits as of August 2018. 
While focusing on the timely implementation of the Appeals 
Modernization Act, the Board has also completed a record number of more 
than 81,000 decisions to Veterans for Fiscal Year 2018. The Board is 
focused on developing and updating information technology systems for 
the new claims and appeals process, developing and refining meaningful 
metrics, providing training across VA for employees, adding appropriate 
resources for deployment and collaborating with stakeholders throughout 
the implementation process.
            Forever GI Bill
    Since the law was signed last August, VA has implemented 28 of the 
law's 34 provisions. Twenty-two of the law's 34 provisions require 
significant changes to VA information technology systems, and VA has 
200 temporary employees in the field to support this additional 
workload. Sections 107 and 501 of the bill change the way VA pays 
monthly housing stipends for GI Bill recipients and VA is committed to 
providing a solution that is reliable, efficient and effective. Further 
system changes and modifications are being made and testing is ongoing 
on the IT solution for Sections 107 and 501. VA will announce a 
deployment date upon completion of testing. Pending the deployment of a 
solution, Veterans and schools will continue to receive GI Bill benefit 
payments as normal.
            Financial Management Systems
    VA's financial management system is 30 years old and continued 
reliance on it presents an enormous risk to VA operations. The 
technical and functional ability to support these legacy applications 
gets more difficult with each passing year. Our Financial Management 
Business Transformation (FMBT) program will replace VA's financial 
management and acquisition system with new systems that will increase 
transparency, accuracy, timeliness, and reliability of financial 
information across VA, improving fiscal accountability to taxpayers and 
enabling VA employees to better care for and serve Veterans. FMBT will 
provide a modern, Integrated Financial and Acquisition Management 
System (iFAMS), an acquisition solution with transformative business 
processes and capabilities that enable VA to meet its goals and 
objectives in compliance with financial management legislation and 
directives.
            Supply Chain Transformation
    Effective management of the supply chain is a major differentiate 
between high- and low-quality healthcare systems, yet the 2016 
Commission on Care concluded that the Veterans Health Administration 
(VHA) could not modernize its supply chain to overcome cost 
inefficiencies because it is burdened with confusing organizational 
structures, lack of expert leadership, antiquated IT systems that 
inhibit automation, bureaucratic purchasing requirements and 
procedures, and an ineffective approach to talent management. In 
response, VHA has embarked on a supply chain transformation program 
designed to build a lean, efficient supply chain that provides timely 
access to meaningful data focused on patient and financial outcomes. To 
date, VHA has established a standardized supply chain organizational 
structure, a robust supply-chain training and development program, an 
integrated data analysis capability, and a comprehensive equipment 
lifecycle management program. VHA is continuing to work on data 
standardization and governance, supply chain innovation center, and a 
clinically driven strategic sourcing program.
Priority 4: VA/DOD Collaboration
            Electronic Health Record Modernization (EHRM)
    VA has made a historic decision to modernize its electronic health 
record (EHR) system to provide our Nation's Veterans with seamless care 
as they transition from military service to Veteran status and whether 
they choose to use VA care or community care. To that end, VA has 
established the Office of Electronic Health Record Modernization 
(OEHRM) to ensure VA successfully prepares for, deploys and maintains 
the new EHR solution and the health IT tools dependent upon it. The 
OEHRM Executive Director is Mr. John Windom, who has been with the 
effort since its inception and has the necessary expertise and 
institutional knowledge to effectively lead this initiative. Prior to 
joining VA, Mr. Windom was a Program Manager for the Program Executive 
Office of the Defense Healthcare Management Systems (DHMS). He led his 
team to acquire, test, integrate and deploy a new EHR system to replace 
DOD's legacy EHR system in support of over 9.6 million military 
servicemembers and other beneficiaries.
    OEHRM is working closely with DOD to ensure we are deploying an EHR 
that is fully interoperable. Veterans Integrated Service Network (VISN) 
20 in the Pacific Northwest has been selected as the first Initial 
Operating Capability (IOC) site to deploy and test VA's new EHR 
solution. Engaging front-line staff and clinicians is a fundamental 
aspect in ensuring we meet the program's goals and we have begun work 
with the leadership teams in place in the Pacific Northwest. OEHRM has 
established clinical councils from the field that will develop national 
workflows and serve as change agents at the local level. The work at 
the IOC sites will help VA identify efficiencies to optimize the 
schedule, hone governance, refine configurations and standardize 
processes for future locations. We are committed to a timeline that 
makes sense and are also working with DOD to understand the challenges 
and obstacles they are encountering, adapt our approach to mitigate 
those issues, and identify efficiencies.
            Suicide Prevention
    Suicide prevention is a top priority for VA. Of the twenty (20) 
Veterans, active-duty Servicemembers and non-activated Guard or Reserve 
members who died by suicide, fourteen (14) have not been in our care. 
That is why we are implementing broad, community-based prevention 
strategies, driven by data, to connect Veterans outside our system with 
care and support. In June, VA published a comprehensive national 
Veteran suicide prevention strategy that encompasses a broad range of 
bundled prevention activities to support the Veterans who receive care 
in the VA healthcare system as well as those who do not come to us for 
care.
    Preventing suicide also requires closer collaboration between VA 
and DOD. To that end, President Trump issued an executive order 
January 9, 2018, to assist Servicemembers and Veterans during their 
transition from uniformed service to civilian life, focusing on the 
first 12 months after separation from service, a critical period marked 
by a high risk for suicide, during which--

           Servicemembers will learn about VA benefits and 
        start enrollment before becoming Veterans.
           Any newly transitioned Veteran can go to a VA 
        medical center or Vet Center and start receiving mental health 
        care right away.
           Former Servicemembers with other than honorable 
        discharges can receive mental health care from VAMCs in the 
        first 12 months after separation.
           Transitioning Servicemembers and Veterans will be 
        able quickly to find information online about their eligibility 
        for VA care.

    Every day, more than 400 Suicide Prevention Coordinators (SPC) and 
their teams--located at every VA medical center--connect Veterans with 
care and educate the community about suicide prevention programs and 
resources. Through innovative screening and assessment programs such as 
REACH VET (Recovery Engagement and Coordination for Health--Veterans 
Enhanced Treatment), VA identifies Veterans who may be at risk for 
suicide and who may benefit from enhanced care, which can include 
follow-ups for missed appointments, safety planning, and care plans.
    VHA has also expanded its Veterans Crisis Line to three call 
centers and increased the number of Veterans served by the Readjustment 
Counseling Service (RCS), which provides services through the 300 Vet 
Centers, 80 Mobile Vet Centers (MVC), 18 Vet Center Out-Stations, over 
990 Community Access Points and the Vet Center Call Center (877-WAR-
VETS). In the last two fiscal years, Veterans benefiting from RCS 
services increased by 31 percent, and Vet Center visits for Veterans, 
Servicemembers, and families increased by 18 percent.
    We are committed to advancing our outreach, prevention, and 
treatment efforts to further restore the trust of our Veterans and 
continue to improve access to care and support inside and outside VA.
Additional Priorities
            Accountability
    Everyone recognizes that VA has struggled in the past to hold 
employees accountable when they violated the public trust and to 
protect whistleblowers from retaliation. That is why last year 
President Trump signed an executive order establishing VA's Office of 
Accountability and Whistleblower Protection (OAWP). The first office of 
its kind in the Federal Government, OAWP has changed dramatically the 
way VA handles accountability and whistleblower issues, ensuring 
adequate investigation and correction of wrongdoing throughout VA while 
also protecting employees who lawfully disclose wrongdoing from 
retaliation.
    OAWP is dedicated and empowered to provide transparency and build 
public trust and confidence in VA. The office improves the performance 
and accountability of VA senior executives and employees through 
thorough, timely, and unbiased investigation of all allegations and 
concerns. When allegations are substantiated, OAWP recommends actions 
to be taken, which can include removal, demotion, or suspension based 
on poor performance or misconduct.
    OAWP has worked a full range of case since its inception, receiving 
2,000 disclosures in its first year. In that year, the average 
investigation cycle time declined from 163 days to 100 days. From 
June 23, 2017, through June 1, 2018, OAWP completed 128 senior-leader 
investigations involving 236 persons; discipline was recommended in 54 
cases involving 58 persons.
            Women's Health
    VA has made significant progress in serving women Veterans in 
recent years and now provides full services to women Veterans, 
including comprehensive primary care, gynecology care, maternity care, 
specialty care, and mental health services. For severely injured 
Veterans, we also now offer in vitro fertilization services through 
care in the community and adoption services.
    The number of women Veterans using VHA services has tripled since 
2000, growing from 159,810 to 484,317. To accommodate the rapid growth, 
VHA has expanded services and sites of care across the country. VA now 
has at least one Women's Heath Primary Care Provider (WH-PCP) at all of 
VA's healthcare systems. In addition, 90 percent of community-based 
outpatient clinics (CBOCs) have a WH-PCP in place. VHA now has 
gynecologists on site at 133 sites and mammography on site at 60 
locations.
    VHA is in the process of training additional providers so that 
every woman Veteran has an opportunity to receive her primary care from 
a WH-PCP. Since 2008, 5,800 providers have been trained in women's 
health. This fiscal year, 756 Primary Care and Emergency Care Providers 
were trained in local and national trainings. VA has also developed a 
mobile women's health training for rural VA sites to better serve rural 
women Veterans, who make up 26 percent of women Veterans.
    VA is at the forefront of information technology for women's health 
and is redesigning its electronic medical record to track breast and 
reproductive health care. Quality measures show that women Veterans who 
receive care from VA are more likely to receive breast cancer and 
cervical cancer screening than women in private sector health care. VA 
also tracks quality by gender and, unlike some other healthcare 
systems, has been able to reduce and eliminate gender disparities in 
important aspects of health screening, prevention, and chronic disease 
management. We are also factoring care for women Veterans into the 
design of new VA facilities and using new technologies, including 
social media, to reach women Veterans and their families. We are proud 
of our care for women Veterans and are working to increase the trust 
and knowledge of VA services of women Veterans so they choose VA for 
benefits and services.
            Community Living Centers (CLC)
    This is the first year VA has compiled ratings for our nursing 
homes using the Center for Medicare and Medicaid Services rating 
system. We are now able to present an apples-to-apples comparison of VA 
homes with private facilities. The data show that, overall, VA's 
nursing home system compares closely with the private sector, even 
though VA cares for sicker patients--with conditions such as prostate 
obstruction, spinal cord injury, mental illness, homelessness, PTSD, 
combat injury, terminal illness--in its homes than do private 
facilities. Private-sector nursing homes also admit patients 
selectively, whereas VA cannot refuse service to any eligible Veteran, 
to the extent resources are available. These factors make achieving 
quality ratings comparable to the private sector more challenging.
            Hiring and Vacancies
    VHA's workforce challenges mirror those of the health care industry 
as a whole. There is a national shortage of healthcare professionals, 
especially for physicians and nurses. VA remains fully engaged in a 
fiercely competitive clinical recruitment market and has increased its 
number of clinical providers including hard-to-recruit-and-retain 
physicians such as psychiatrists. Additionally, VHA is taking a number 
of key steps to attract qualified candidates, including:

           Mental Health and other targeted hiring initiatives
           Leveraging flexible pay ranges resulting in 
        competitive physician salaries
           Utilization of recruitment/relocation and retention 
        (3Rs) incentives and the Education Debt Reduction Program 
        (EDRP)
           Targeted nationwide recruitment advertising and 
        marketing
           The ``Take A Closer Look at VA'' trainee outreach 
        recruitment program
           Expanding opportunities for telemedicine providers
           DOD/VA effort to recruit transitioning 
        servicemembers
           Exhibiting regularly at key health care conferences 
        and job fairs
           Critical Position Hiring and Vacancies

    VA had a net gain of 7,423 employees in FY 2017. So far in FY 2018 
(October 1, 2017 to July 31, 2018), VA has seen a net increase of more 
than 9,500 employees, including 3,600 in mission-critical occupations. 
As of June 30, VA had 45,239 overall vacancies, out of a total of 
419,353 full-time authorized and budgeted positions. From the start of 
fiscal year 2014 to the end of FY 2017, VA achieved a growth rate of 
12.5 percent and an average annual turnover rate of 9.2 percent. VA 
turnover rates compare favorably with other large cabinet-level 
agencies, which averaged 11 percent in FY 2017.
            Wait Times
    VA is providing more healthcare appointments than ever before, 
authorizing 32.7 million appointments in FY 2017, nearly two million 
more than in the previous year. All VA health care facilities now 
provide same-day urgent primary and mental health care services for 
Veterans who need them. In June 2018, VA completed 95.18 percent of 
appointments within 30 days of the clinically indicated or Veteran's 
preferred date; 83.46 percent within 7 days; and 20.29 percent the same 
day. The average time it took to complete an urgent referral to a 
specialist has decreased from 19.3 days in FY 2014 to 3.2 days in FY 
2017 and 2.0 days in FY 2018--this number continues to improve and is 
now down to 1.3 days during July 2018.
            Blue Water Navy
    VA's view is that the commitment to science and an evidence-based 
approach to creating or expanding presumptions should be maintained. 
Presumptions of exposure and/or medical causation should always be 
supported by historical, scientific, and/or medical evidence about the 
specific population of Veterans affected. While VA continues to study 
the science of exposure, we do not believe the available scientific 
evidence currently supports a presumption of service connection in this 
case.
    We are also concerned that congressionally mandated presumptions 
not supported adequately by evidence would erode confidence in the 
soundness and fairness of the Veterans' disability benefits system, 
creating the impression that the system can be gamed by political 
activism. Such statutory presumptions will lead to increased pressure 
on VA to create or expand additional presumptions administratively, 
under a similarly liberal approach favoring less deserving but 
politically demanding Veterans over more deserving Veterans who trust 
VA to do the right thing for all Veterans.
    VA estimates a total cost of $6.7 billion over ten years associated 
with such a presumption, including $5.7 billion for mandatory benefit 
payments, $625 million for health care costs, and $357 million for 
discretionary costs to administer benefit payments. Such a presumption 
would also impact VA's ongoing efforts to reduce the appeals and claims 
processing backlogs. The accomplishments VA has made with Congressional 
assistance will be stymied by VA's requirement to verify and study in 
great detail over 30,000 previously-denied claims in the first year 
alone and adjudicate more than 230,000 claims over 10 years, adding 
time to our 125-day claims processing goal.
                               conclusion
    Mr. Chairman, I would like to again thank Congress for passing VA's 
FY 2019 funding bill. Starting the fiscal year with our full year's 
appropriations in place is extremely important as we implement the laws 
Congress has passed.
    As I mentioned, we have instituted new management processes that 
will facilitate successful implementation of these laws. This will be a 
long journey that will not be accomplished overnight. I am committed to 
providing you with regular updates on our progress and the challenges 
that arise. However, I respectfully ask for time to implement and 
evaluate the programs. We cannot keep changing course, or stop 
everything we are doing to provide updates or respond to inquiries if 
we are serious about getting to our destination. I need your help on 
this.
    As we look to the next few years and full implementation of the new 
Veterans Community Care Program and an expanded Caregivers Program, VA 
will need to resolve the necessary funding requirements to meet 
Congress's intent. We are embarking on the most comprehensive 
improvements to Veterans care and benefits since World War II. We will 
need the resources to complete this work and I look forward to working 
with you on that.
    Mr. Chairman, I look forward to working with you and this Committee 
and appreciate your many courtesies to me. I am also eager to continue 
building on the reform agenda I was privileged to work along with 
Senator Tester and Senator Tillis. The mission of this Committee is 
clear--you help remind all Americans why they sleep soundly at night 
because of those who sacrificed in uniform. There is no more noble 
mission in all of government.
    Thank you.

    Chairman Isakson. Thank you very much, Mr. Secretary.
    What I am going to do on the questions, I am going to 
reserve mine until the end. We have got Members coming, so I am 
going to try to get everybody in. We will take you while you 
are here. If you have got another meeting to go to, we will let 
you go.
    I will start out on our side, and I am going to waive my 
time. I will go to Senator Moran.

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

    Senator Moran. Mr. Chairman, thank you very much for that 
courtesy. Thank you for you and Senator Tester having this 
hearing.
    Mr. Secretary, welcome. Let me also join what the Chairman 
did in welcoming the new American Legion National Commander. 
Let me take that a step further. Thank you for your visit to 
Kansas last week. A significant number of posts across our 
State where you visited I know were well received. I appreciate 
the message you brought to veterans in our State.
    Mr. Secretary, thank you for joining us today. I think you 
would know that one of my biggest priorities of this Congress 
was the MISSION Act and making certain that we achieved 
legislation that was more than just a reauthorization of the 
Choice Program.
    In my view, the MISSION Act or that reauthorization was a 
choice and an opportunity for real reform at the VA, one that 
we could not waste and that we ought to use as a chance to fix 
the very real problems that existed with Choice and reform the 
entire VA health care system to better serve our veterans 
really for decades to come.
    I think that, largely, we were successful in that effort, 
and a number of the reforms that I fought to have included in 
this legislation were put in place. You are now preparing to 
implement them.
    My focus is on implementation, how you are going to do 
that. One of the provisions we fought to have included requires 
the VA to regularly consult with Congress during the 
development of rules and regulations that govern the program, 
particularly with the development of access standards, which 
will largely be used to determine when a veteran is eligible to 
receive community care.
    I am out across my State. We are about to complete our 
105th town hall meeting at the 105 counties in our State. I 
raise this topic, and I want my veterans to know that there was 
a Choice Program that is becoming something different. I need 
to make certain that it does become something different than 
what many of them experienced that did not work for them.
    Next week, October 4, marks the first time the VA is 
required to consult with us, Congress, in developing those 
standards, and I want to make certain that it is a veteran-
centric approach. I want the standards to be easy to understand 
and utilized for all parties involved--the VA, the veterans, 
the community providers--and I am anxious to see what is 
presented next week to see that the VA is on the right track.
    One area that I want to highlight for you, bring to your 
attention, is this definition of ``episode of care.'' It is my 
hope that once a veteran is sent to community care for 
conditions, they are able to see their community provider 
through the entirety of their care for that condition.
    For example, a veteran needs eye surgery. It does not mean 
that you get the eye surgery under the MISSION Act and then you 
are required to come back to the VA for follow-up care and 
treatment.
    Mr. Secretary, my question is, how do you expect that 
complex care that requires numerous appointments for a certain 
condition will be structured?
    Let me highlight this because one of the problems we had 
with Choice is a veteran was referred to community care by the 
VA and then was told once that provider needed a lab test, an 
x-ray, back to the VA for additional authorization. That is a 
component of this, but also the continuum of care that is 
needed for a particular condition.
    Thank you.
    Secretary Wilkie. Well, thank you, sir. I also want to 
thank you for making your staff available, as I have gotten 
into my job for discussions with them.
    My view of Congress' thrust in MISSION is to do exactly 
what you said. It is to give that veteran choice and allow that 
veteran to continue with the choice that he or she is most 
comfortable with.
    I think we have a continuum of issues that will come 
together to provide that--electronic health record, getting our 
access standards, as you said, understandable and available to 
everyone. Particularly, as I have said before, we still do not 
understand the scale of the American West, west of the 
Mississippi. I think our changes when they come for access 
standards will revolutionize veterans care.
    It is my goal to make sure that that veteran will 
experience the continuum of service where he or she desires, 
and I think that is one of the more revolutionary changes that 
comes out of MISSION.
    I will also say in response to your last comment about 
briefing, we will have that 120-day briefing for you tomorrow. 
I think we are a little ahead of schedule. I will take 
responsibility for not coming the last day of August when I 
think the first 60-day period came because I did not get--know 
what was in it, but I can assure you that we will get a very 
comprehensive briefing up here tomorrow. We will meet the first 
hurdle that I am fully responsible for, in response to Senator 
Tester's comments, tomorrow.
    Senator Moran. Mr. Secretary, I thank you, and I look 
forward to further conversations with you. We will talk about 
budgeting and the ability for the VA to predict the costs and 
levels of care required.
    Secretary Wilkie. Thanks.
    Senator Moran. Thank you, Mr. Chairman.
    Chairman Isakson. Senator Tester.
    Senator Tester. Thank you, Mr. Chairman.
    I want to thank you once again for being here, Secretary 
Wilkie.
    Is that your wife behind you?
    Secretary Wilkie. Yes.
    Senator Tester. Welcome, Julia. I do not know that we have 
ever had the Secretary of the VA come with his wife. That is 
pretty sweet. Appreciate you being----
    Secretary Wilkie. We came to see you and not Tillis.
    Senator Tester. Oh, yeah. Right. That is it. [Laughter.]
    So, look, I visit with veterans groups all the time, and 
yesterday was no exception. I visited with a number of them to 
hear their concerns, one of the things they said was VA's 
communication on EHR has gotten better, so thank you. Thank you 
for that.
    I am not going to overstate this because if this changes we 
will not bring this up again. But, overall, they expressed 
alarm with what they perceived as increasing disengagement with 
VSOs in several areas.
    I have said in this Committee meeting many, many times, we 
take our cues from the VSOs and from the veterans. So, as we 
implement the MISSION Act and as these men and women as 
veterans are going to utilize it and they are represented by 
VSOs back here, who need to be a part of the equation, in my 
opinion.
    So, talk to me about the Department's engagement for those 
who really helped frame the community health care bill, the 
VSOs, and tell me what you are doing, what you have done, what 
you intend to do. I know there are a number of them, but I 
think they are critically important to your success.
    Secretary Wilkie. Well, absolutely, which goes back to what 
the Chairman said about customer service. My view of Government 
is that the only way Government can be efficient is if it is 
closer--closest to the people it serves.
    I will take a step back and give you my agenda in the last 
6 weeks. I have gone to the Paralyzed Veterans Health Summit. I 
have addressed The American Legion, AMVETS, Jewish War 
Veterans, other groups. I have been making the rounds, as I 
promised you, to walk the post.
    Friday, we will have our first comprehensive all-day 
briefing for VSO leaderships under my tenure. It will be a 
regular feature of----
    Senator Tester. How regular, if I might ask?
    Secretary Wilkie. I believe it is going to be every 2 
months, but that can be augmented as needed.
    Senator Tester. OK.
    Secretary Wilkie. I will get back on the schedule, a series 
of regular breakfasts that the VSOs were used to two 
Secretaries ago, and I continue to go out and talk to as many 
veterans organizations as I can. That is the promise, and I 
will make sure I inform the Committee that I am keeping that 
promise.
    Senator Tester. OK. I am going to use the next question as 
a recommendation, not a question, because you are a smart man. 
Your confirmation hearing was one of the most impressive things 
I have seen with anybody that we have confirmed in any 
Committee.
    I would hope that your conversations with the VSOs is not 
one way. I hope it is not an information dump. I hope it is a 
consultation, an opportunity to tell them what you are doing 
and hear from them how they see it working.
    Secretary Wilkie. I agree with that completely, and I will 
say that in my presentations across the country, I have pointed 
out that my own military service has been modest.
    I would have been very comfortable sitting in front of 
Senator Tillis' subcommittee on SAS without any notes because 
that was my world. I will be honest and say I am still in the 
process of learning, and part of that education, a large part 
of it, comes from talking to veterans across the country, 
including many that I have grown up around.
    Also, I will just mention this. We may talk about the 
subject of burn pits. I had a conversation with someone I have 
known since I was a child about that, General Petraeus.
    So, I am looking to talk to veterans in the VSOs and 
veterans who just want to offer an opinion.
    Senator Tester. That is good, and I would tell you that the 
burn pit discussion may not be a lot different than the Blue 
Water discussion, so we need to get our arms around that, too.
    I am just going to ask you real quick because I have only 
got 30 seconds left. You come out of the DOD. The EHR is a 
shared effort between the DOD and the VA. Have you or somebody 
within your organization had fairly high-level conversations 
with Secretary Mattis to make sure that DOD is paying 
attention, or would you recommend that we have a joint hearing 
with SAS on this issue?
    Secretary Wilkie. Well, I think that would be valuable in 
the future and hopefully in the near future.
    I am in discussions, the Department is in discussions with 
the Department of Defense. I am waiting for information to come 
back from the latest series of engagements, and then I will 
engage Secretary Mattis.
    At my confirmation hearing, you asked me about that 
symbiotic relationship, and I will say on the electronic health 
record--and there was a lot of criticism in the press about 
being too closely tied to the Department. If we do not get the 
front end of a servicemember's service right with the 
electronic health record, it really does not help us when that 
veteran comes into our system.
    One of my goals is to make sure that the DOD end works. I 
know that is something that Secretary Mattis believes in. I 
have the advantage of having been responsible for that, that 
program, when I was Under Secretary as well.
    Senator Tester. Thank you.
    Thank you, Mr. Chairman.
    Chairman Isakson. I understand Senator Boozman wants to 
switch places with Senator Heller.
    Senator Heller, you are recognized.

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

    Senator Heller. Thank you, Mr. Chairman. I appreciate that, 
and I appreciate my colleague for accommodating.
    Secretary Wilkie, thank you for being here today, and I 
also especially want to thank you for coming out to Las Vegas 
last week.
    Secretary Wilkie. Thanks.
    Senator Heller. I thought that was a great experience, and 
in conversations through your nomination process, I asked you 
to try to get out to Las Vegas, spend some time before the end 
of the year. Just to have you there, it meant a lot to me.
    Secretary Wilkie. Thanks.
    Senator Heller. It meant a lot to our veterans in the 
State.
    Mr. Chairman, the President and Secretary Wilkie came out 
to Las Vegas and signed the appropriations for the VA and the 
military construction. I think it is the first time in history 
that a President has gone to a facility, a VA facility, to 
actually sign the appropriations bill for veterans, and it was 
done with great fanfare and interest. Our veterans very much 
were supportive, and I want to thank you----
    Secretary Wilkie. Thanks.
    Senator Heller [continuing]. For taking that time. It was 
wonderful.
    Like most of us here on this panel, I do a roundtable, and 
I had a veterans roundtable in Reno. Obviously, a lot of 
important issues are raised. We talked about mental health, 
homeless veterans, veterans employment opportunities, and the 
gamut of issues that are important to our men and women.
    But, most of all, I heard about our Blue Water Navy Vietnam 
veterans. There is a gentleman in Nevada from Elko. His name is 
Joe, and he is a Blue Water Navy veteran, who has been 
diagnosed with terminal prostate cancer. It is a disease that 
is associated with Agent Orange, but he is not eligible for 
compensation because he is a Blue Water Navy veteran.
    My concern is I think we are turning our back on Joe, and 
before I go much further, I would like to have you clarify your 
position on compensation for our Blue Water Navy Vietnam 
veterans.
    Secretary Wilkie. Thank you, Senator.
    Let me start from an emotional position. I probably have 
experienced the effects of Vietnam in a way that few people my 
age could. I certainly did not fight there, but I saw my father 
and his comrades fight there. My father was gravely wounded in 
Southeast Asia, and some of my classmates' parents did not 
return. So, I have an emotional attachment to the cause of 
Vietnam veterans that I think is unique at this time.
    I have also said that I do not like the term ``greatest 
generation.'' I think that could have only been said by someone 
who has never put on a uniform because soldiers all have the 
same hopes, dreams, and fears. It does not matter what era they 
fight in. So, that is the emotional premise.
    I agree with Chairman Isakson. I want to make sure that we 
get it right, that we get it right for all of our veterans. I 
pledge to work with the Chairman. We have had many discussions.
    I will say I do want to make clear what is happening in VA. 
There are about 40,000 Vietnam veterans across the country who 
served in the Navy who are eligible for VA benefits. It is not 
as if--Agent Orange-type conditions, I should say--it is not as 
if the VA is turning people around--turning people out. We are 
going to continue to do that.
    My pledge to the Chairman is to work with the Committee to 
ensure that we are just, we are equitable, equitable on both 
ends.
    I think the Committee received a letter from four of the 
largest VSOs supporting the legislation but also saying, ``We 
have a question about the funding mechanism,'' a funding 
mechanism that puts a burden on young active-duty 
servicemembers who are getting their first home. It also puts a 
burden on disabled American veterans who live in higher-cost 
areas like Charlotte or Atlanta. So, we want to look at that, 
too.
    My pledge is to work to make sure that we get it right, and 
that is something I believe in sincerely and emotionally.
    Senator Heller. Let me just ask a quick follow-up because 
my time is almost out, but to get it right, in your opinion, if 
you get it right, will Joe from Elko be compensated?
    Secretary Wilkie. Well, yes. I mean, if we get it right, 
anyone who fought, anyone who was exposed and deserves 
attention from us will get it. That is my pledge to work as 
hard as I can to see that nobody slips through the cracks.
    I will say if your staff wants to get me any information--
--
    Senator Heller. OK.
    Secretary Wilkie [continuing]. On Joe, I will see to it. He 
may even qualify and not know it.
    Senator Heller. Mr. Secretary, thank you, and again, thanks 
for coming to Las Vegas.
    Secretary Wilkie. Thank you. Appreciate it.
    Chairman Isakson. Two things, Senator Heller. First of all, 
do what he just said about giving him a call. There may be a 
way they can help.
    Senator Heller. Good, good.
    Chairman Isakson. You missed my opening statement.
    Senator Heller. I did. I apologize.
    Chairman Isakson. But, you did not miss--no, you do not 
need to apologize. [Laughter.]
    You did not miss the conversation you and I had on the 
floor 2 days ago because you were right there.
    I told this--everybody that is here, all the Members that 
were here, the people in the audience here, the VSOs here--the 
issue of dealing with Blue Water Navy is no longer going to be 
a question. How we do it is the only question.
    I told the Secretary and worked with him in various 
meetings to get us to a position we can do a vehicle of some 
description that is unanimously approved by everybody, to be 
sure the veterans who deserve a benefit, that have been denied 
or could not get it, that we do not open the door or set a 
precedent down the road for something else that would run away.
    I know Sherrod Brown has had conversations with some of the 
Members. I have. Senator Tillis has worked with me on a lot of 
stuff we have done talking about this. Senator Boozman. I have 
talked to Patty Murray about it. Jon and I have talked a lot 
about it. So, it is not a subject we are not dealing with.
    I know other people in the audience that have a very vested 
interest, including yourself and including your veterans.
    So, we set the table this morning in my opening remarks, 
and he just confirmed what I said without me coaching him 
because he is down there and I am up here. He has agreed to 
work with us to make that happen. So, we are going to do it.
    Senator Heller. Thank you. I appreciate that. The veterans 
appreciate that.
    Chairman Isakson. You betcha.

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

    Senator Brown. Thank you, Mr. Chairman.
    I thank you, Secretary Wilkie.
    Chairman Isakson. Indians finally won a game.
    Senator Brown. They did. They did. Won one. Thank you for 
pointing that out. [Laughter.]
    When the Indians beat the Braves in the World Series, you 
will think a little differently. Thank you. Being a Cleveland 
sports fan is tough business.
    Thank you, Mr. Secretary, and thank you for not starting 
the clock yet either, Mr. Chairman.
    I want to follow Senator Heller's remarks and the 
Chairman's and the Secretary's. I do not blame anybody 
personally. I do not take any of this personally, but I want to 
keep the pressure on the Blue Water Navy issue because I know 
that--I think I mentioned to the Secretary in my office that I 
knew a gentleman early as a lawyer that fought Agent Orange 
cases one by one by one, and veterans from Vietnam died while 
they were being litigated. Then, the bitterness grew, which 
Congress understood that later, rather than sooner, but 
admirably, it was a victory for Government doing the right 
thing with the VA and on behalf of these veterans. You can 
always do it faster.
    Veterans are dying, as Senator Heller said, while we--we 
are not fiddling while Rome burns. Again, I know that the 
Secretary wants to do the right thing. I know the Chairman and 
I have had a number of conversations on the floor and in this 
Committee, formally and informally about this. I just want to 
keep the pressure on.
    To a lot of Blue Water Navy veterans, it sounds like the VA 
is standing in the way of our efforts to pass this legislation. 
I do not think you see it that way. I am not sure I see it that 
way, but I want to again emphasize the importance of this.
    The Blue Water Navy veterans in my State--I have, like so 
many of you, done a number of roundtables, and my staff has 
done a number. We have done close to a dozen in the last 
several months. Blue Water Navy veterans comes up in every 
single one of these in every part of my State.
    They have read the Institute of Medicine reports. They know 
the science inside and out. They see the VA, in their minds, 
turning their back on them. Again, I know that is not your 
intent, yet, I think to them, it looks that way.
    I wonder, Mr. Chairman, if I can enter the IOM reports into 
the record?
    Chairman Isakson. Without objection.

    [The submitted reports, due to their volume, are not being 
reproduced here, but can be accessed at http://nap.edu/13026 
and http://nap.edu/12662.]

    Senator Brown. Thank you.
    I know the letter, the September letter that you sent to 
the Chairman, there is inconsistent evidence that Blue Water 
Navy veterans were at higher or lower risk than shore-based 
veterans. Mention the presumption of exposure of military 
personnel serving in those vessels is not unreasonable. I know 
about the 12-mile limit. I know that is an issue here.
    I also know the battles that on presumptive eligibility, 
not just the beginning, but every time with Secretary Shulkin 
and his predecessors, your predecessors, we added to the 
presumption eligibility list.
    I know that most of us around this diaz will not let this 
drop; we will keep the pressure on you. It is part of your job 
as a public official. You used to keep the pressure on the VA 
when you sat here with Senator Tillis and prior to that in your 
job. I think that there are a few things this Committee can do 
that are more important than that.
    I appreciate Senator Tester's guidance on this and his 
relentlessness also, so thank you for that.
    In the last couple of minutes, I want to--on a different 
topic, Mr. Chairman--raise my concern about--and I mentioned 
this in my office too--how the VA has implemented the 
Accountability and Whistleblower Act. We moved this legislation 
last year. We intended for VA to use the authority to 
discipline employees who had egregious offenses, as VA should.
    I have some concerns that VA has used this new authority to 
fire low-level employees with marginal offenses, not the senior 
managers who have had egregious offenses. 2,700 employees have 
been fired since last July. I am not arguing that most of them 
did not deserve it. I am arguing, though, that the focus needs 
to be on the most responsible, committing the most egregious 
offenses, that had the most impact, and that is almost by 
definition, in many cases, the senior members.
    I have heard facilities are no longer using performance 
improvement plans or progressive disciplines. I ask if you 
would commit the VA will once again use these tools to address 
employee performance instead of firing for a single offense.
    Secretary Wilkie. We are going to hold our employees to the 
highest professional standards. I am looking at new ways to 
evaluate performance.
    I do want to say that we are unique--and I apologize for 
taking more time. We are a unique Federal Department. We have 
three offices that are symbiotic, but they all are focused on 
the same thing. We have a general counsel. We have an Inspector 
General, and we have the Office of Accountability and 
Whistleblower Protection that was set up by this 
administration.
    They are all designed to address employee misconduct. They 
are also designed to protect employees from retaliation who 
legitimately blow the whistle on bad acts.
    Let me talk quickly about the Office of Accountability and 
Whistleblower Protection. That is designed to deal with 
employees at the GS-15 level and above.
    Right now, I believe there are about 280 investigations of 
GS-15-level employees and above. I am proud of that because I 
think that also meets the intent of the Congress.
    Last year, about 2,500, as Senator Brown said, 2,500 
employees were dismissed. I will also note that we do have 
different conditions here, and I do not mean to cast aspersions 
on my friends who work at the Department of Labor, the 
Department of Commerce.
    When a junior employee who is responsible for sweeping the 
floors does not sweep the floors or does not sterilize an 
instrument, that is all right at the Department of Labor 
because nobody will notice. If they do not do that in our 
hospitals, the consequences could be catastrophic. So, we have 
to hold employees at that level to the highest professional 
standards.
    That said, I am going to ensure that our Office of 
Accountability and Whistleblower Protection continues to 
evaluate and reevaluate those employees at GS-15 and above. 
That has the double advantage of keeping their feet to the 
fire, but also sending a message down the ranks that there 
are--as we say in the military, ``There are not different 
spanks for different ranks.''
    Senator Brown. Thank you.
    Mr. Chairman, if I could have 20 seconds just to sum up. 
Thank you.
    You know what--it is because you know so much about the VA 
even before you took this job. You know the importance of 
whistleblowers in Cincinnati and Dayton; and those were 
terrible situations. Because the whistleblowers came in and the 
meetings that my office had and those I personally had in hotel 
rooms and in all kinds of places to talk about the problems 
with safety and to talk about the problems of accountability 
made a huge difference.
    The VA was helpful in it, but it was the whistleblowers 
that drove it. They were of all ranks, and protecting them is 
essential. Many of them were veterans, as you know. It really 
did make the VA hospitals in those two cities operate more 
smoothly and more efficiently and more humanely for veterans, 
so thank you.
    Secretary Wilkie. Yes, sir, I agree.
    Chairman Isakson. Senator Tillis.

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

    Senator Tillis. Thank you, Mr. Chair.
    And, Secretary Wilkie--I will refer to Robert Wilkie real 
quick. The fact that your wife is here does not mean this is a 
date. [Laughter.]
    I am sorry I was not here for your opening testimony. I am 
co-chairing a committee hearing on cyber and personnel.
    The one thing I want to say about the discussion on blue 
water, I fully expect the past is prologue, and when you were 
in my office, you were very much a part of the effort to get us 
to the right place on the Camp Lejeune toxic substances. That 
is an area where we were at odds with the VA. That is an area 
where we looked to outside expertise to come up with a rational 
basis for a presumption, and we made progress there. I hope it 
is in that same spirit that you are able to make progress and 
also address the legitimate concerns of some of the VSOs with 
respect to once we identify what the need is and once we start 
expanding presumptions, that we also fund it in a way that is 
not at odds with other promises that we have made that we need 
to fulfill for our veterans.
    Secretary Wilkie. First of all, Senator Tillis, thank you.
    I will add that there was an addendum to that agenda that 
you had. You and Senator Klobuchar were responsible for 
creating the registry for those who were exposed to burn pits 
in Iraq and Afghanistan. We worked across the aisle to set the 
stage for science and funding for those who were exposed to 
that.
    I mentioned, I think before you came in, to Senator Tester 
that I have spoken to General Petraeus about the burn pit 
legislation.
    So, the same standards that you apply, the same standards 
that you had me apply in development of the Camp Lejeune 
situation and the burn pit legislation apply here.
    Senator Tillis. I also want to thank you about Hurricane 
Florence. We received a call, and we were concerned with the 
storm headed toward Wilmington and other areas, like your 
hometown of Fayetteville, with very high veteran populations. 
We were concerned with whether or not those receiving care 
there--dialysis and a number of other things--if we were going 
to have continuity of care, and the Department was well ahead 
of it. I commend you for doing that. That has not always been 
the case in every disaster response.
    One question I would have for you is that after action, if 
you take a look at the areas that are most prone to these sorts 
of storms, they happen to be the States with some of the 
highest concentrations of veterans.
    So, what did you learn from that? Maybe what other things 
should we look at in terms of authorities or things that we can 
do to be as prepared for the next storm as you all were for 
Florence?
    Secretary Wilkie. Well, I do want to say that I was amazed, 
being a North Carolinian, of the response, by the Federal 
Government and the State government. I told Governor Cooper 
that as well.
    I am actually going down to Wilmington on Monday to take a 
look at our clinic. It was under water, and I am going to 
evaluate what the future is there. The same applies to Morehead 
City.
    I think we need to do a close look at where some of our 
facilities are located. We have the benefit in Fayetteville 
when the Cape Fear crested at 63 feet above flood stage, the VA 
hospital was at 142 feet above the river. That does not always 
happen.
    But, I want to take a look at the way we position our 
clinics. That might involve looking more closely at the 
opportunity to lease facilities away from the danger zone, and 
I also want our people to take a close look at our facilities 
and their ability to withstand storms.
    The good news in North Carolina is that other than 
Wilmington, two clinics in Jacksonville, and then one in 
Morehead City, everybody else is up and running.
    We did send three mobile medical units to Wilmington, so 
they are addressing the needs of the veterans there. I am very 
proud of the response VA gave.
    Senator Tillis. Well, thank you for that.
    I also wanted to briefly touch on the electronic health 
record. The governance structure you have here is something 
that I am familiar with. I am glad to see that.
    I think that I would also probably just submit a question 
for the record, or perhaps you and I can just talk. I am also 
interested in the MISSION Act and some of the change management 
initiatives that you have going, separate from the electronic 
health record, but I know you are taking a look at what I think 
are some fundamental changes in organizational structure that 
is going to be helpful for the whole of VA.
    So, tell me a little bit now about the DOD/VA relationship; 
how well that is going. We have got a learning over in DOD from 
the electronic health record. We are going to have an 
opportunity to see a life-cycle view of a soldier to a veteran 
after this gets implemented. Can you give me a little idea of 
how that collaboration is working and how we are for the 
Pacific Northwest VISN 20 implementation?
    Secretary Wilkie. Well, you see, I think this was a chart 
that Senator Cassidy has. You do see that there is now cross-
pollination. We are in the process of formalizing a structure, 
and before we finish formalizing that, I will make sure the 
Committee has insight into that and will be able to review it.
    I said during my confirmation hearing, my instructions 
from--and I will call him General Mattis now--when I left the 
Department was that we needed to be joined at the hip on this. 
General Mattis uses the VA in Washington State, and he has a 
personal commitment to making sure that this works. I do 
envision us being joined together because it will not work if 
one of the two halves inchoate.
    So, I will get back to the Committee. Our two staffs are 
working on this. I will sit down with Secretary Mattis and 
begin the formalization of the structure fairly soon.
    Senator Tillis. Thank you.
    Chairman Isakson. Mrs. Murray.

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

    Senator Murray. Thank you very much, Mr. Chairman.
    Thank you, Mr. Secretary. Thank you for being here.
    Let me just start with a huge frustration of mine, and that 
is with ongoing delays in the construction of new clinics in 
Washington State. It has taken almost 9 years--9 years to get a 
new CBOC opened on the Kitsap Peninsula.
    The needs of community have changed, and the VA now expects 
this facility to be at complete capacity on the day it opens. 
Our veterans have been waiting for years to get this open, and 
they have heard promise after promise after promise from the VA 
over these years.
    Can you personally make sure that this and other facilities 
are completed right away and review the Department's 
performance on this as well? Because we have got to hold people 
accountable for this.
    Secretary Wilkie. Yes, Senator. I am actually headed to 
Washington State in a couple of weeks to look.
    Senator Murray. At the Kitsap Peninsula CBOC in particular?
    Secretary Wilkie. I did not hear the last part.
    Senator Murray. Kitsap Peninsula CBOC in particular?
    Secretary Wilkie. I will be discussing that with the VISN 
leadership.
    Senator Murray. OK.
    Secretary Wilkie. I think that is important because people 
think of the Southeast as the growth sector for VA, but 
Washington State in the Pacific Northwest has a very 
important--and I think unmet--need.
    Walla Walla is a continuing issue. Actually, Walla Walla 
was the reason I said at one of the VA conventions that we have 
to give our directors in the regions more authority to relocate 
and evaluate and then change----
    Senator Murray. OK. Well, on this one in particular, if you 
are going to be out there----
    Secretary Wilkie. Yeah.
    Senator Murray [continuing]. I want to find out what you 
said to them.
    Secretary Wilkie. Yeah, absolutely.
    Senator Murray. I need to get this done.
    OK. Let me ask you about a completely different direction. 
Six weeks ago, I sent you a letter about my concerns over the 
reports of private well-connected individuals known as the 
``Mar-a-Lago crowd,'' who are exercising wildly inappropriate 
influence over the VA.
    It is entirely unacceptable for the VA to put those 
people's interests before what is in the best interest of our 
veterans. I believe that is something you agree with. So, we 
need to see steps taken to correct that right away.
    Plus, the Department has to be transparent about this. So, 
I wanted to ask when I would get a response to my letter.
    Secretary Wilkie. Well, I did not know it was in the works, 
but I will give you my response right now.
    I agree with you about outside influences. I also listen to 
a lot of people with opinions. A lot of those stories took 
place before I became the Secretary.
    Senator Murray. Right. I know.
    Secretary Wilkie. I am also committed to making sure that I 
am the sole person responsible to you.
    Senator Murray. OK. Are there any VA officials consulting 
with the Mar-a-Lago crowd now?
    Secretary Wilkie. Not that----
    Senator Murray. Have you met with them?
    Secretary Wilkie. Not that I know of.
    I have met--I met with them once for an hour when I was at 
Palm Beach, the first week I was Acting. I have had no 
connection with them since then.
    Senator Murray. OK. So, the question is, can you assure 
this Committee that there will be no inappropriate 
interference?
    Secretary Wilkie. Absolutely.
    Senator Murray. OK. That is important to all of us.
    And, if you can respond to my letter----
    Secretary Wilkie. Yes.
    Senator Murray [continuing]. I am looking to the data and 
records on that as well.
Response to Request Arising During the Hearing by Hon. Patty Murray to 
 Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
    Response. Secretary Wilkie's September 14, 2018, response to 
Senator Murray indicated: ``This is in response to your August 17, 
2018, letter to the Department of Veterans Affairs (VA). I want to 
assure you that VA takes very seriously its responsibilities to comply 
with the law and its obligation to respond appropriately to 
Congressional requests for information. The matters about which you 
inquired in your letter are the subject of ongoing litigation alleging 
violations of the Federal Advisory Committee Act and, therefore, not 
appropriate for release at this time.''

    Senator Murray. Let me ask you about homelessness, which I 
know is something you care deeply about, and is a priority for 
you to end veteran homelessness, but I am really concerned 
about the VA's focus on this issue because it has fallen off in 
recent years.
    We have seen the VA now try to divert funding away from 
homeless programs. Program providers actually in my homestate 
are losing funding, and despite some of the VA's promises to 
help target Seattle by surging resources to the area, we are 
not seeing that come through on the ground.
    I was really troubled to learn at many of the facilities in 
Washington are failing to actually use the HUD-VASH vouchers 
often, and they tell me it is because they do not have enough 
case managers.
    So, this has got to change, and I wanted to know when we 
are going to see the plan and resources in particular to 
address Seattle's serious needs and how you are going to make 
sure there are enough case managers.
    Secretary Wilkie. The case managers are part of a larger 
issue that we have in retaining those people particularly in 
the social work field, and that is a target for us when it 
comes to hiring.
    I will tell you that we are going to put the word out that 
we need to make maximum use of those HUD vouchers.
    I have a meeting coming up with Secretary Carson, I 
believe, in the next week or so to discuss that.
    Senator Murray. OK. Can you get back to me on that?
    Secretary Wilkie. Yeah.
    Senator Murray. Because that is critically important, and I 
am deeply concerned that they are not being used. Then, the 
report back is that they do not need them. That is not the 
case. So, we need that rectified.
Response to Request Arising During the Hearing by Hon. Patty Murray to 
 Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
    Response. Please see the answers to Question 1 above, which 
addresses the plan for Seattle as well as for addressing hiring and 
voucher use in HUD-VASH.
    [Specific voucher use figures are in the posthearing responses.]

    Senator Murray. I will also add my concerns about the 
electronic health records. As you know, my State was one of the 
first locations to deploy that with the Department of Defense, 
which was a $4 billion investment. I heard about misdirected 
referrals, long waits, staffs that could not open the programs 
in a timely manner. There was inadequate training. There was 
consideration of taking money out of local budgets to supply 
the implementation training, which was really not done well and 
lives were really put at risk.
    I just want to make sure that the problems at DOD are not 
repeated as you move forward. We are going to be following this 
really closely and expect to be kept up to date on any 
challenges that you have to assist this implement.
    Thank you.
    Secretary Wilkie. Thank you.
    Chairman Isakson. Senator Boozman.

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

    Senator Boozman. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary, for being here. We appreciate 
your continued commitment to serving. I know that you are 
working very, very hard in that direction.
    We have seen reports detailing challenges veterans face 
when using the GI Bill. In some instances, the VA underpaid 
some 340,000 GI Bill beneficiaries for their housing allowance.
    In your testimony, you mentioned that IT challenges 
contributed to the situation, and that there is an ongoing task 
to find a suitable solution. When can we anticipate the 
conclusion of the testing, and how quickly will a solution be 
implemented?
    Also, in the meantime, what is the plan and subsequent 
timeline for compensating those students who are underpaid, and 
will any student who received an overpayment through no fault 
of their own--are we going to go back and are they going to 
face a debt owed to the VA?
    Secretary Wilkie. Senator, the GI Bill issue is an 
important one.
    In the issue of full disclosure, my son uses the post-9/11 
GI Bill.
    Let me tell you what has happened in terms of benefits 
flowing to beneficiaries. The housing payments are still going 
out. What is not going out is the increase, the cost-of-living 
increase, which comes out at about a half of 1 percent. So, the 
GI Bill beneficiaries are being paid their housing allowance, 
but it is on 2017 levels.
    When we get the computer system right, we will repay those 
GI Bill beneficiaries. I think it will come out to about $69 a 
month because it is, as I said, it is zero--it is half of 1 
percent.
    This points to a problem that Senator Tester mentioned at 
the beginning of the hearing. We received the instructions from 
Congress on the Colmery Act, and those instructions were--they 
attempted to implement them on a 50-year-old computer system. 
Even something as simple as changing the percentages broke the 
system. It is part of a larger issue that we have to get right.
    I will also say that one of the benefits of the GI Bill 
that this Committee worked on--and it is a good news story--is 
those veterans, both active and veteran, who are part of a 
college program or a pay-for-fee program that fails, we will 
not penalize them. We will make them whole. They will not lose 
those months. We will make sure that they can get the best 
education that they can, and that is the other part of the 
story that we are working on.
    Senator Boozman. Very good.
    Senator Heller mentioned that the President signed the VA 
MilCon bill. In it was included $1.25 billion more than the VA 
requested for medical services and medical community care.
    The new legislation requires the Department to provide 
monthly reports to the Committees, identifying obligations for 
the medical community care program against available 
appropriations, as well as anticipated funding needs based on 
the developing program structure.
    As you noted, the MISSION Act provided $5.2 billion to 
continue the Choice Program through June 6, 2019. Based on the 
VA's current estimates, is this funding, combined with the 
recent appropriation, sufficient to support medical community 
care through the fiscal year? If not, how does the VA intend to 
address any possible shortfall?
    Secretary Wilkie. Yes, sir. I will tell you I believe it is 
sufficient for this fiscal year.
    When we begin the series of briefings, I believe we will 
begin to talk about all the changes that will come that will 
affect fiscal year 2020 and beyond, but, no, I believe it is 
sufficient right now.
    We have to get a handle on, as Senator Tester sent to me in 
a letter I believe last week, overpayments and underpayments 
which affect community care. That is something I am working on 
now.
    Senator Boozman. Very good.
    Thank you very much. We do appreciate your service.
    Secretary Wilkie. Thank you, sir.
    Chairman Isakson. Senator Hirono.

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

    Senator Hirono. Thank you, Mr. Chairman.
    I realize that the VA continues to be against the Blue 
Water vets being included in the presumptive eligibility list, 
but when Congress enacts such legislation, can we get your 
commitment that you will do everything possible to enable and 
facilitate these veterans to get the care that they need?
    Secretary Wilkie. Well, Senator, I grew up in this 
institution, and you reminded me of that at my confirmation 
hearing. Article I is gospel. What the Congress says, I will 
carry out.
    Senator Hirono. OK, good. A strong yes.
    You were asked by Senator Murray about this, but some of us 
also wrote a letter to the Chairman that we would like to have 
a hearing, an oversight hearing regarding reports of ongoing--
what we would consider inappropriate influence of your 
Department with the few people from Mar-a-Lago.
    So, I am going to take this opportunity to ask you some 
questions about the interactions with Ike Perlmutter, Marc 
Sherman, Bruce Moskowitz.
    You noted that you met with them for 1 hour, but when you 
were confirmed as Secretary, Mr. Sherman was--on the first day 
of your being Acting Secretary, Mr. Sherman was waiting for you 
in your office. Can you tell us what was discussed at that 
meeting with Mr. Sherman?
    Secretary Wilkie. What was discussed was somebody I had 
never met before who was standing there and told me for whom he 
worked, and I listened. I said, ``Thank you.'' I am always 
happy to listen to anyone who wants to talk about veterans.
    I was not familiar with what was going on. Again, it was my 
first day, and in terms of a formal meeting, I believe I spent 
an hour when I was down at the Palm Beach VA at my first week.
    Senator Hirono. So, what was that 1-hour meeting about?
    Secretary Wilkie. That was actually about the electronic 
health records, and if I am going to believe the media stories 
that the folks I talked to were against it, then I went against 
their wishes because I approved it 2 weeks later.
    Senator Hirono. So, was Dr. Moskowitz at that meeting? 
Because he had some interest in the electronic health records. 
That subject must have come up.
    Secretary Wilkie. Yes. There were several--I think there 
was a Marine general and a couple of other veterans there.
    Senator Hirono. So, you are going ahead, obviously, with an 
electronic health records program that is long in coming.
    You just testified right now that you had no further 
interactions with these three people; by the way, when you met 
with any of them, did the subject of privatizing VA come up?
    Secretary Wilkie. No.
    Senator Hirono. Since you yourself have not had any further 
interactions with them, though, have any of your other high-
level decisionmakers at the VA been having meetings with these 
three people?
    Secretary Wilkie. Not that I know of.
    As I mentioned at the beginning, we have a completely new 
leadership team in place; everyone from the chief of staff to 
the Under Secretaries, so a completely new--completely new 
leadership team.
    Senator Hirono. So, as far as you know, none of your high-
level leadership people have been meeting with these folks.
    So, does the type of interactions with members of Mar-a-
Lago reported by ProPublica violate appropriate standards of 
transparency? Because you have testified that transparency is 
very important and accountability at the VA is very important 
to you.
    Secretary Wilkie. Well, that is right, and I believe I have 
laid out everything that went on as a result of my meeting and 
went against what they were advocating.
    Senator Hirono. Well, I hope that is made clear to them 
because it certainly seems as though they just weighed in as 
though they ran the place.
    As Secretary, you are responsible for managing over $1 
billion in funding to assist homeless veterans and their 
families, and we have made progress. But, we are not there yet.
    You did not mention homelessness in your testimony. Could 
you provide to the Committee where this issue of veterans 
homelessness falls on your list of priorities and what your 
plan is to end veteran homelessness and also improve the 
transition process to prevent homelessness of veterans?
    Secretary Wilkie. Well, it is very important, and I 
mentioned earlier that on the issue of Blue Water Navy, our 
veterans homelessness problem impacts a community that I am 
very familiar with and very close to, more than any other, and 
that is Vietnam era.
    We are working with HUD. We are also working with State and 
local communities on the issue of homelessness. We are funding 
homes and projects across the country to get homeless veterans 
off the street.
    In North Carolina Senator Tillis and I worked on the 
creation of a program that gets them off the street and gets 
them sober and with a job.
    Senator Hirono. Can you tell me right now how many homeless 
veterans there are?
    Secretary Wilkie. I cannot tell you that number because it 
changes every day.
    Senator Hirono. I do realize that, but give and take, the 
number?
    Secretary Wilkie. No, I cannot because we do not know. We 
just do not know.
    We have the same problem with homelessness that we have 
with suicide. The tragedy in our Department is that every day 
22 veterans commit suicide, yet 14 of those veterans are 
outside of our purview.
    Senator Hirono. I think that, Mr. Chairman, if you do not 
mind, because this is an area that we really need to provide, 
as far as I am concerned, more focus. Whatever efforts you are 
making to reach out to the veterans, I think that is important. 
I would like to know what you are doing along those lines----
    Secretary Wilkie. Yes.
    Senator Hirono [continuing]. And some numbers----
    Secretary Wilkie. Right.
    Senator Hirono [continuing]. As to how many veterans----
    Secretary Wilkie. I will get you----
    Senator Hirono [continuing]. Are being helped.
    While I am at it, I just would like to have you continue to 
make sure that you implement the VA telehealth bill that 
Senator Joni Ernst and I were really pushing for.
    Secretary Wilkie. Very important for mental health.
    Senator Hirono. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you very much.
    I want to introduce Colonel Sullivan of the U.S. Marine 
Corps who was yesterday promoted in the Mansfield Room. I 
happened to be there, and he looked great in his uniform, with 
all his family. We are proud of you.
    Before you start, I want to get up for a second because I 
have got to make a phone call. So, in case I am not back when 
you finish, Senator Boozman is going to conduct the rest of the 
meeting.

          HON. DAN SULLIVAN, U.S. SENATOR FROM ALASKA

    Senator Sullivan. Well, thank you, Mr. Chairman. I 
appreciate you being there and so many of my other colleagues.
    Mr. Secretary, welcome back. I am glad you are on the job. 
I know it is not an easy job and probably one of the hardest 
jobs in Washington, if not the hardest job in Washington, but 
probably one of the most important jobs. I personally am glad 
you are there.
    I want to talk to you about a couple of specific Alaska 
issues. One of the things that you committed to me on is 
getting up to the State, my State, soon in your tenure. I know 
your staff and my staff have been looking at possibly 
confirming dates for the third week of October, and as luck 
would have it, that is when the Alaska Federation of Natives is 
going to be meeting in Anchorage. So, that is the large--AFN is 
an annual meeting. It has all of our--thousands and thousands 
of Alaska Natives, who constitute almost 20 percent of the 
population in my State, meet together.
    Very importantly from the VA perspective, these are some of 
the most patriotic Americans in the country. They serve at 
higher rates in the military than any other ethnic group, such 
as Native Hawaiians and American Indians. Decade after decade, 
even though, let us face it, after World War II or Korea or 
Vietnam, they came home to a country that did not always treat 
them so well.
    So, I would welcome your commitment to participate in this 
conference, whether by giving a speech, or convening in that 
Native Alaskan veterans roundtable with me, or both. Of course, 
we will coordinate with the executive director of that 
organization, but I think they would be excited, particularly 
given how many veterans you will see. You will have an 
opportunity to meet literally with thousands of Alaska's 
finest, most patriotic citizens.
    Secretary Wilkie. Senator, I am planning to be in Alaska 
for several days, including that conference. I will actually be 
in Anchorage the day before the conference convenes, and I am 
looking forward to that. So, I will be there for a while.
    Senator Sullivan. OK. Well, let us try to work together and 
get--it is a great opportunity, and it is fortuitous timing.
    Let me talk about another issue, both kind of at the 
national level, but again, also an Alaska issue. One of the 
important issue that we addressed in the MISSION Act was prompt 
payment for providers, which has been an issue that has 
bedeviled the VA. As you know, it has a real negative domino 
effect because you have these providers who want to serve 
veterans, and then they are not getting paid on time. They have 
problems meeting their own payrolls, and the next thing you 
know, they are turning away veterans, even though they do not 
want to turn away veterans.
    So, the MISSION Act establishes a prompt payment standard. 
I want to get your views on how you think that is going. 
Granted, we just passed the bill. The President signed it just 
a couple months ago.
    More specifically, I have a constituent, Joyce Abangan, and 
her husband, who is a 21-year veteran, lieutenant colonel, U.S. 
Army, two combat tours. They are small business owners in 
Alaska. They have an operating home health agency that has a 
backlog of pay of over $100,000 with the VA, and they are 
getting ready to do what other providers have to do, which is 
turn away veterans because they are almost--you know, they are 
having a hard time.
    I would like to get your commitment to work with me and my 
staff on that specific one, but more broadly for this hearing 
and the other Senators here, how is that going? It is such an 
important issue. I know you cannot turn on a dime on it, but, 
boy, it is really important. Now, it is in law. I mean, you 
have to do it, so I would like an update on that.
    Secretary Wilkie. Senator, now we are turning. MISSION does 
not work unless we have that relationship with particularly 
small-town providers, small-town community hospitals.
    Senator Tester sent me a letter about Health Net, and I 
think this change answers in part his concerns, which is a 
concern particularly for the West.
    That provider is on the way out. They stopped getting new 
authorizations 2 months ago. VA has had to pick up the slack. A 
few months ago, VA was adjudicating 100,000 of these small 
provider claims. We are now up to 700,000 a month. We are 
working as quickly as we can to do that, and that will 
hopefully accelerate when we get a new vendor on board. But, it 
is a terrible problem, and if it does not work, MISSION does 
not work.
    Senator Sullivan. Well, let me just real quick on that--we 
have TriWest. I do not know if it has the same issues as 
HealthNet, but it is part of the network. If I can get your 
commitment, your staff's commitment to help my staff and I work 
with this one group, it is exactly the kind of people we want 
to keep in the system, not have them walk away. They are 
veterans themselves, and 100 grand for a small business is----
    Secretary Wilkie. It is devastating.
    Senator Sullivan. Yeah, devastating.
    Let me ask just one final question. How is morale overall? 
The one thing I always liked--you come in here a lot of times 
and get the crap kicked out of you and everything, as do the 
other employees. But, the vast majority of the VA, the vast 
majority of the employees who care are focused on vets. I know 
that is the case in Alaska.
    A big part of leadership is morale, so how is it with 
regard to your employees? Because we need to know that, too.
    Secretary Wilkie. I will let others make a more definitive 
statement.
    I will say that VA is calm. A lot of my first objectives 
was to do what Marines do--Air Force guys do not do it as 
much--that is, walk the post. That is why I have been across 
the country, to be seen and to talk to the people who work in 
VA.
    They have gone through a lot. I am going to refer back to 
something Senator Tester said in the debate on my confirmation 
on the floor. Their lives have been upset by an agency that has 
been run by--I think you said anecdote--and the individual 
story that sometimes does not apply across the Department.
    I will continue to walk the post, and when the opportunity 
presents itself, I will tell the good news stories. I will also 
tell the truth. As I said at the beginning, the state of VA is 
better. I did not say good or excellent. It is better, and I do 
think we are headed in the right direction.
    Senator Sullivan. Great. Thank you.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you.

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

    Senator Manchin. Thank you, Mr. Chairman.
    Secretary Wilkie, it is good to have you. I wanted to say 
that my reports have been excellent, the job you are doing, the 
changes you have made, and basically the care that you have 
shown for the Vietnam veterans.
    With that, I just wanted to discuss--a couple of subjects, 
basically. We are all concerned about the Blue Water Navy. We 
all have Vietnam veterans. West Virginia has more, 
unfortunately, veterans on the Vietnam Wall than any State per 
capita. So, we have all given.
    Anyway, I want to talk to you about the number of 
electronic health records, things that we have done over the 
years that have not seemed to work that well. I think you know 
that. They include the joint program of DOD called--the new one 
now called the Integrated EHR to replace the separate EHR 
system with a single shared system.
    On that, the integrated system was abandoned in 2013, and 
the Secretaries of VA and DOD announced that they would not 
continue or develop this joint system.
    Once again, VA has announced its intentions to establish an 
electronic health record system that is interoperable with DOD, 
and that is through a $16 billion contract, as you know, with 
Cerner Corporation. However, the DOD's initial rollout of 
Cerner's system in four medical facilities was plagued with 
significant problems.
    So, with the way that this is rolling out--VA is starting 
with the rollout on the West Coast and moving East. By the time 
it gets to West Virginia, that will be 2023.
    So, we have to work with the system at hand, which is the 
VistA system, and I need to know how are you all working with 
that. Are you able to maintain and keep that system up until 
you integrate the other system?
    Secretary Wilkie. EHRM is an iterative process, and it is 
going to take time to get it online. We will have the other 
systems in place to mitigate.
    Senator Manchin. VistA will stay in place?
    Secretary Wilkie. I believe. I will have to get----
    Senator Manchin. You can get back with me. I know, yeah.
    Secretary Wilkie. Yeah, I will have to get back with you on 
that as to what exactly will happen.
Response to Request Arising During the Hearing by Hon. Joe Manchin III 
   to Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans 
                                Affairs
    Response. Yes, VistA will stay in place until the Cerner rollout is 
completed.

    Secretary Wilkie. I will say something about the failures 
of the testing in the Pacific Northwest. My last job at DOD 
was--I was the head of Secretary Mattis' close combat task 
force, and we were evaluating weapon systems and computer 
systems that we would deploy with Marine infantry, Army 
infantry. We would not give them a weapon or a system unless we 
tested it. And, we tested it for mistakes.
    My understanding of what went on, on the DOD side, is that 
they were testing it for mistakes, and they found them. I would 
rather find them there than down the line after we spent the 
$16 billion that you talked about.
    My pledge is that we are going to be joined with DOD to 
make sure that this works and not just interoperable between 
DOD and VA, but if we are going to make MISSION work, we have 
to make the electronic health record interoperable with private 
pharmacies, small town doctors, hospitals in the community. 
Without that, MISSION does not work. So, we will be giving you 
regular updates.
    Senator Manchin. Let me roll into something else because 
you know my really major concern has been the opioid addiction 
that we have and our veterans have been plagued with. I think 
we all know how some of that has perpetuated.
    A study published August 2018 in the Journal of Health 
Services Research examined the numbers and times of opioid 
prescriptions filled for post-9/11 veterans at VA and non-VA 
pharmacies. They used the ones in the State of Oregon. It was a 
small study, but it was basically a study. It found that 15 
percent of our veterans who filled a prescription for opioids 
at a VA pharmacy had also dually filled a prescription in a 
non-VA, and that is not just veterans. I mean, everyone, when 
they get addicted, they will do whatever it takes.
    The likelihood of having those concurrent opioid 
prescriptions increased if the veteran was enrolled in the 
veterans Choice Program. You are aware of that. OK.
    So, given the expansion of the community care expected with 
the VA MISSION Act, I guess, what does the VA plan to do to 
monitor prescriptions of potentially dangerous drugs?
    Here is the thing that we said. I found out when I went to 
the veterans hospital--we have four in West Virginia--one, in 
particular, I was talking to the head nurse and I said, ``How 
is our problem here?'' and she said, ``It is the same 
everywhere. It is severe.'' She says, ``If you all would quit 
calling and raising Cain about what we do and let us do our 
job, we can cure this a little bit better.''
    So, what happens is an addicted veteran calls a Senator or 
Congressperson raising holy Cain that they are not getting what 
they demand. So, we took that--we have taken that away from 
where we are rating how our VA veteran hospitals are going 
along with our regular hospitals. They get rated on 
reimbursement of Medicaid and Medicare.
    Can you just check on that, sir? I know this is something 
new, but this opioid addiction is affecting our veterans. They 
should never be in this position to where we cannot get them 
back into a useful, productive life.
    Secretary Wilkie. I agree with you.
    Mr. Chairman, may I have a minute or so to fully answer?
    Chairman Isakson. Let me say this. Senator Blumenthal just 
came in.
    Secretary Wilkie. OK.
    Chairman Isakson. He is going to have his chance. Senator 
Cassidy has been waiting a long time, and a lot of people got 
here early and took care of their business. So, let us be as 
quick as our 5 minutes as possible and be respectful for the 
people who have stayed.
    Secretary Wilkie. Yes, sir. I will do it fast.
    That is one of the beauties of electronic health record as 
I see it----
    Senator Manchin. Yes.
    Secretary Wilkie [continuing]. Is that with the 
interoperability, a veteran will no longer be in the position 
of getting opioids from a private doctor or hospital and then 
going to the VA and getting Ambien or another opioid because 
once that happens, a system kicks in, and red flags are raised. 
VA knows that that veteran is now on the spectrum.
    Second part is I am talking to the President's opioid 
conference on Friday. I am going to talk about the good news at 
VA. We are doing groundbreaking work in getting our veterans 
off of opioids using things as simple as aspirin and Advil--
they work just as well--and also rehabilitative therapies, 
orthopedic therapies.
    We are getting the opioid addiction down in the VA system, 
and we still have a lot more work to do.
    Senator Manchin. I appreciate this. This is a serious 
problem.
    Secretary Wilkie. Thank you, sir.
    Chairman Isakson. Thank you, Senator Manchin.
    Senator Cassidy.

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

    Senator Cassidy. Yeah, several things. First, Secretary 
Wilkie, good to see you.
    I thank the Chair for acknowledging the Blue Water issue at 
the outset and look forward to its resolution.
    I also want to thank you. Again, you do take a fair amount 
of fecal material, as Colonel Sullivan said, but----
    Secretary Wilkie. That is how the Air Force would describe 
it. He would say it is something different as a Marine. 
[Laughter.]
    Senator Cassidy. But, again, thanks for your support in the 
Preventing Veterans Death of Despair Act, which I will be 
introducing shortly. Your guys have worked extensively with us; 
it is a common mission, so thank you for collaborating.
    Now, there has been a lot of conversation here on EHR. As a 
doc, of course, I am interested in it. I am just going to touch 
on a couple of things since you and we have all discussed the 
history so much, and then I would like to go a little more 
deeply because part of it involves what we, the Congress, have 
directed, which does not seem to be fulfilled. Not your 
problem--no, not your fault, but now your problem.
    Just a couple things to point out. 2008, the NDAA 
established a joint Interagency Program Office, the IPO, to act 
as a ``single point of accountability for the electronic health 
care exchange efforts.'' Fast forward, we have expanded it over 
time.
    In February 2014, GAO reported that the VA and DOD had not 
addressed management barriers to effective collaboration. The 
IPO lacked effective control over central resources, such as 
funding and staffing, and decisions by both the VA and DOD had 
diffused responsibility for achieving integrating health care 
records, potentially undermining the IPO's role as a single 
point of accountability, so VA and DOD diffusing authority, 
even though Congress said IPO should have that authority.
    Now, in May 2018, OMG, the VA gives Cerner a contract for 
$10 billion within this context of diffused responsibility.
    In September 2018, GAO reported to HVAC that the IPO has 
not been effectively positioned to be the single point of 
accountability as mandated by the NDAA fiscal year 2008.
    Now, their recommendations, the Secretary of Veterans 
Affairs should ensure that the role and responsibilities of the 
Interagency Program Office are clearly defined within the 
governance plans for acquisition of the VA's new electronic 
health care record.
    So, I can now kind of wrap this up and bring it into your 
comments.
    May I see the chart, please?

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Senator Cassidy. This was given to HVAC by the VA, and, Mr. 
Chairman, if you do not have a copy of this--you can see that 
there is a blend here. This is facilitated by the IPO, and this 
is the joint work between the two, the VA and the DOD. There is 
no dotted line going up to the VA executive committee. It is 
operating merely as ``Hey, do you mind giving somebody a 
call?''
    Similarly, the DOD/VA executive committee does not appear 
to have you or your deputy on it. So, this is not within the 
highest reaches at least in the VA regarding responsibility.
    Even like the language ``facilitated by IPO'' is not 
exactly what Congress had in mind. They wanted it to be the 
single point of authority and not a facilitator who I tend to 
think of as lacking authority, except why do we not all do it 
together?
    So, I did not mean to bump you. I am sorry.
    First, what is your response to the GAO's assertion that 
there is a critical need for a single point of accountability 
for VA and DOD's interoperability to be successful?
    Second, why is the VA/DOD executive committee, the highest 
joint committee, not the top leadership of the two Departments? 
This is a $10 billion contract, just for one of them. Best I 
can tell, your office is not on that crew.
    Third, how do you respond to the GAO's assessment that the 
IPO's role and responsibilities is not clearly defined and not 
effectively positioned to be the single point of 
accountability?
    And, last, what are your plans to strengthen IPO's position 
to be that congressionally mandated single point of 
accountability and standardization, et cetera?
    Secretary Wilkie. Senator, when I came to VA, I realized 
that it was, as you said, an organization of dotted lines. An 
organization like that is anathema to someone who has been 
raised in the military.
    My objective----
    Senator Cassidy. The only thing worse than that is no 
dotted line.
    Secretary Wilkie. So, we are in discussions, as we speak, 
with the Department of Defense to hopefully--I cannot be 
definitive right now, but we are working on it--make those 
solid lines and create that one single point of authority.
    As to the issue of the deputy, I was able to get an acting 
deputy just a few weeks ago, put him in charge of our response. 
I have stated that my goal is to take the ideas that our 
working group with DOD is working on and take those to 
Secretary Mattis, so that we come to you with a plan that you 
all will see and hopefully bless because you are absolutely 
right. Dotted lines do not work; no lines, worse. We have to 
have a single point of contact that is responsible to the two 
Secretaries and makes this----
    Senator Cassidy. It is my experience that unless you 
empower that IPO person, she or he will continue to be 
ineffective, and granted, they theoretically would have more 
authority than you. But, practically speaking, it is going to 
be you and Mattis.
    Secretary Wilkie. Right.
    Senator Cassidy. It is going to be, frankly, your 
responsibility to make sure that she or he, when they walk down 
the hall, people give them the right of way because I 
understand that she or he represents you. Does that make sense?
    Secretary Wilkie. Yes, it does. Yes, sir.
    Senator Cassidy. Then, it is fair to say that your 
conversations with Mattis will be along those lines to give 
whomever this is----
    Secretary Wilkie. Yes.
    Senator Cassidy [continuing]. That authority?
    Secretary Wilkie. Yes. I do not know what we are going to 
call it, but it is in line, I believe, with the dictates of 
NDAA from several years ago in that it will have that single 
office with DOD and VA running the show jointly.
    Senator Cassidy. Then just heads-up--and I know you will do 
this, but just to say those will be the kind of subjects of my 
questions going forward.
    Secretary Wilkie. Yes, sir.
    Senator Cassidy. Thank you, sir.
    Secretary Wilkie. Thanks, sir.
    Chairman Isakson. Senator Blumenthal.

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

    Senator Blumenthal. Thanks, Mr. Chairman.
    I know that you talked to Senator Tester briefly about 
vacancies, and he emphasized to you--and I share this view 
strongly--that the VA should use resources given to it by 
Congress to fill those vacancies. Each of us on this Committee 
are aware of really staggering statistics regarding VA 
vacancies, 45,000 of them nationwide, 40,000 within the 
Veterans Health Administration. They are incredibly alarming, 
and they undermine VA care and services. This challenge has 
been longstanding in the VA, not new, and in fact, the numbers 
fail to articulate or portray the real-life impact.
    Recently, a VFW district commander in Connecticut contacted 
me after his counseling session at the Norwich Vet Center. He 
explained that the center was short a director, an office 
manager, an outreach worker, and a counselor, and he said to 
me--and I am quoting--``I feel these staffing shortages 
directly and adversely affect the well-being and delivery of 
veterans counseling services to men and women veterans living 
in this area.''
    I would like you to commit that the Norwich Vet Center will 
be fully staffed and capable to delivering effective and 
efficient counseling services to Connecticut veterans.
    Secretary Wilkie. Yes, sir. Senator, you and I talked about 
Norwich in your office before my confirmation hearing. I do 
intend to get up to Connecticut and take a look. I am not 
familiar with all of the details.
    I will say on the 40,000 number, on its face, is 
staggering.
    I will also say that if we try to fill all 40,000, we would 
never get where we need. The issues that you have just 
highlighted, we have to concentrate on, I think, four areas: 
primary care; internship, internists; mental health workers; 
and women's health.
    The MISSION Act gives us the tools to help that situation--
the repayment of educational debt, our ability to set new 
salary levels that you would not otherwise have to do in the 
other areas of the Federal Government. But, the three R's for 
us are recruit, retain, and relocate. We have to give our 
leadership in VA the authority to relocate to places like 
Norwich. So, it is something I am very concerned about. I agree 
with you.
    Senator Blumenthal. Well, I am going to take that as a yes, 
that you will make that commitment, and I would welcome your 
visit to Connecticut to see the VA; that as a yes that you will 
make that commitment. I would welcome your visiting Connecticut 
to see the VA Center in Norwich but also in West Haven, where 
,as you know--and I thank you--the VA has allocated $17 million 
to invest in new sterilization equipment in the department 
which will help resolve the current challenges--I will put it 
euphemistically--in the sterilizing and surgical commitment due 
to outdated infrastructure.
    I would suggest to you more than just that sort of Band-Aid 
is necessary. There has to be a rebuilding and a refitting. In 
fact, there are many more infrastructure challenges to follow 
at West Haven, and West Haven is only one example of the 
infrastructure challenges faced by the VA.
    As you work with the White House on the President's Budget 
Request for fiscal year 2020, I hope you have a plan and 
specific actions for the next 5 to 10 year to invest. It cannot 
be just 1 year. It has to be a multiyear investment in the 
bricks and mortar of the veterans' health care system.
    Secretary Wilkie. Yes, sir. And, the other thing--I agree 
with that, and I am taking a close look at the Office of 
Construction and Logistics. I have made a commitment during my 
confirmation hearing that I would not produce budget numbers 
that appear to take from places like VHA to pay for other 
things.
    It is going to be a fine balancing act, but I am going to 
do my best to make sure that we are balanced.
    Senator Blumenthal. Let me ask you finally about the Blue 
Water Navy Vietnam Veterans Act. I know that you have discussed 
it with Senators Brown, Heller, Tester, and Tillis.
    In the Institute of Medicine 2008 report, as you know, the 
Committee states, ``Given the available evidence, the Committee 
recommends that members of the Blue Water Navy should not be 
excluded from the set of Vietnam-era veterans with presumed 
herbicide exposure.''
    I want to be clear. You agree with that recommendation, 
correct?
    Secretary Wilkie. I agree that I am going--I am not a 
doctor, and what I have talked with the Chairman about is that 
we are going to do everything we can to make sure that those 
veterans are taken care of with funding and science, and I 
pledge to work with the Committee.
    My concerns were not one of saying absolutely no, because I 
grew up with those folks who fought in Vietnam as certainly 
part of my family. I just want to make sure we get it right 
because we have burn pits that we need to deal with--Camp 
Lejeune--and I pledge to you to give this my best effort.
    Senator Blumenthal. Well, I have to acknowledge that I am 
somewhat disappointed that you cannot give a yes or no.
    Chairman Isakson. Let me help you. Can I help you a little 
bit on this point?
    Senator Blumenthal. Absolutely, Mr. Chairman. I always 
welcome help.
    Chairman Isakson. You and I have had some conversations, 
and I have had conversations with every Member of the 
Committee, I think.
    Senator Blumenthal. I know what the conversations have 
been, Mr. Chairman, and I am really looking for a somewhat less 
equivocal answer.
    Chairman Isakson. Oh, I know, but let me get to where I was 
going.
    In my opening statement today--the Secretary and I have met 
on numerous occasions in the last 6 weeks. I have told him we 
need to fix the Blue Water problem. He has agreed to work with 
us to do that.
    I realize there are scientific questions. There are policy 
questions. There are all kinds of questions, but that is an 
administrative decision the VA made in 1999 and 2002, where 
people who served in Vietnam in certain places got benefits and 
other places did not. We need to fix it so that it is equal for 
everybody, and we are going to do that. He has committed to 
doing that, working with us to do that.
    What I want to do--and I want everybody to hear this loud 
and clear--I want to do something we can do under a unanimous 
consent where nobody objects. I do not want to do something 
that becomes a circus. I do not want to do something that 
forestalls the decision. I want to do right.
    He has agreed to work with us and do that, and I believe 
the Administration will do the same. I am going to see this 
thing through, and I am not trying to cut you off. You missed 
that part of the meeting. I wanted to let you know that was the 
first item of business we talked about.
    Senator Blumenthal. I very much appreciate that point, Mr. 
Chairman, and I would like to join you in working toward that 
end, which also recognizes the need of veterans who suffer from 
other kinds of toxins and poisoning, where, as a matter of 
fact, you and I have worked together on legislation to achieve 
that goal because the modern-day battlefield is filled with 
poisons and toxins and so forth. I recognize that the Blue 
Water Navy Veterans Act--the Vietnam Veterans Act is just the 
tip of the problem. But, I do hope we can make some progress on 
it.
    Chairman Isakson. Well, we are going to do what I said. We 
are going to address the Blue Water Navy, and that is going to 
get done. I am going to see to it. The Secretary is going to 
work with us, and I hope you will help us get there.
    But, I will tell you this. I do not want to open the door 
to a multiplicity of debates over other things that end up 
causing us not to get something done. So, we are going to do 
Blue Water Navy being sympathetic to anything else that is 
going on. We are going to get that finished because that has 
been a drag for some time. The House has acted, and it is time 
we figure out a way that we could work it out so it is the best 
that we can possibly do and get it done.
    Senator Blumenthal. I thank you. By the way, Mr. Chairman, 
I do not think there is such a thing as beating this horse too 
much. I do not think--and I say that for the benefit of my 
friend, Senator Tester, to use the farming analogy.
    Chairman Isakson. Vernacular. I understand.
    Senator Blumenthal. But, I open with a quote to the 
Institute of Medicine, which is a scientific body----
    Chairman Isakson. Right. I realize that.
    Senator Blumenthal [continuing]. To the effect that their 
recommendation is that members of the Blue Water Navy should 
not be excluded from the coverage here.
    Chairman Isakson. I agree with that.
    Senator Blumenthal. I just want to close, Mr. Chairman--
because I am over my time, and you have been very gracious--by 
saying that I hope that data privacy and security against 
foreign influence campaigns is high on your list of priorities, 
Mr. Secretary, because there is certainly evidence that during 
the election, Russia promoted disinformation that specifically 
targeted our military and veterans. As we go into this next 
election, it is highly relevant and important.
    I hope that the VA cooperates with social media and tech 
platforms to address these threats.
    Thank you.
    Secretary Wilkie. Thank you, sir.
    Chairman Isakson. Thank you, Senator Blumenthal.
    Thank you, Mr. Secretary, for your attendance and your 
thoroughness. We appreciate it very much. I look forward to 
working with you ahead on Blue Water Navy and the other things 
we have to do together for the men and women who have served 
and represent so well.
    Is there anything you want to say, Ranking Member?
    Senator Tester. Just one thing, which has to do with the 
MISSION Act implementation and the Under Secretary for VHA. Do 
you have somebody in mind, and when do you anticipate we will 
see them in front of this Committee?
    Secretary Wilkie. I am looking. I am very happy with the 
executive in charge. You all have met Dr. Stone, Army general.
    Senator Tester. Yeah.
    Secretary Wilkie. I have pledged to you that I would get 
somebody in that position as quickly as I could. I did, and now 
we are working on the confirmation.
    Senator Tester. OK. Thank you very much.
    Chairman Isakson. We stand adjourned.
    [Whereupon, at 4:49 p.m., the Committee was adjourned.]
                                ------                                

   Response to Posthearing Questions Submitted by Hon. Jon Tester to 
 Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
    Question 1. VA health care has been on GAO's High Risk List since 
2015 for a variety of reasons, including inadequate oversight and 
accountability, information technology challenges, and ambiguous 
policies and inconsistent processes. In a letter to you in April, when 
you were Acting Secretary, GAO highlighted 26 priority recommendations 
that VA has yet to implement, 17 of which were carried over from 2017.
    Response. VHA is responsible for 14 of the 26 High Priority 
recommendations; 2 are closed, 4 are pending a closure decision from 
GAO, 5 have target completion dates within the next 60 days, 3 have 
target completion dates in the future and are on track for completion.

    Question 2. Since GAO wrote to you in April, VA has only 
implemented 3 of GAO's 26 priority recommendations. These are just the 
priority recommendations. VA also has about 100 other open GAO 
recommendations that remain unaddressed. GAO tells me that VA has yet 
to submit a satisfactory action plan to address its high risk status in 
the almost 4 years that have passed since GAO put them on the list. 
What specific progress has been made during your tenure as Secretary?
    VA Response:

     VA Actions on GAO's high risk listing titled ``Managing 
Risks and Improving Veterans Health Care'':

          - FY 2015: Established VA's GAO High Risk List (HRL) Area 
        Task Force (Task Force) and provided GAO with an initial 
        Strategy for Health Care High Risk Management that linked 
        actions to the MyVA Initiative. Conducted listening sessions to 
        gain field insights and potential solutions. GAO found this 
        information interesting but not sufficient for an action plan.
          - FY 2016: Conducted root cause analyses for each of the five 
        areas of concern and enterprise root causes. GAO found the root 
        cause analyses acceptable and a good start to an action plan.
          - FY 2017: Work groups developed action plans for each of the 
        five risk areas, and continued work to resolve the risk areas.
          - FY 2018: Work groups completed action plans and presented 
        them to GAO on March 15, 2018. GAO considered the action plan 
        to be a good start, and requested more clarification on 
        metrics, and integration with modernization efforts.
          - FY 2019: VHA merged GAO high risk work with its Management 
        Review Service to leverage strong liaison functions with GAO, 
        improve communications, and build routine operations into 
        management of the GAO HRL. VHA partnered with the Office of 
        Strategic Integration to apply robust project management 
        discipline to all GAO HRL projects. VHA partnered with the 
        National Center for Organizational Development to apply robust 
        change management to GAO High Risk List. VHA partnered with 
        Office of Enterprise Integration to incorporate modernization 
        efforts into the GAO High risk plan.

     Status of Open GAO recommendations to VHA:

          - At the close of FY 2018, VHA has 113 open GAO 
        recommendations; 61 are new recommendations made in FY 2018; 47 
        were closed this fiscal year. VHA has completed work on 26 
        recommendations and awaits GAO's decision regarding closure.
          - Over the past 3 years, GAO averaged 50 new recommendations 
        per year and averaged 51 closures per year--essentially no net 
        decrease in recommendations despite constant actions toward 
        completing actions.

    Question 3. At your confirmation hearing, you affirmed the 
statutory independence of the Inspector General, after Acting VA 
leadership claimed that the IG is the Secretary's subordinate. It's 
essential that all VA employees know that you will continue to support 
and uphold this independence. It's also critical for veterans and 
taxpayers to know that an independent body exists to conduct oversight 
and help improve VA. Can you tell the Committee what you have done 
since taking the job to help reinforce and uphold the IG's 
independence?
    Response. As I stated during the hearing, I view the Inspector 
General as a partner and not subordinate to the Secretary. The 
Inspector General works closely with the Office of Accountability and 
Whistleblower Protection and the Veterans Health Administration's 
Office of Medical Inspector to investigate allegations of misconduct or 
other improprieties. In my previous position, I worked with the 
Department of Defense Inspector General and plan to foster that same 
working relationship with Mr. Missal. I was asked during the hearing if 
I would commit to not interfere or hinder the independence of the 
Inspector General and be transparent with requested information. I 
would like to state again that I am committed to that. I have met with 
Mr. Missal as recently as October 5, 2018, and it is my goal to 
regularly meet with him for updates and discussion. I strongly support 
the Inspector General's investigations and mission.

    Question 4. The Committee continues to receive concerns from 
whistleblowers and other employees about the implementation of the 
Accountability Act. Do you find it appropriate that facilities are 
investigating whistleblower complaints against themselves? Do you 
believe this can be done fairly? Do you believe that whistleblowers 
should have access to the findings of the reports and investigations 
conducted into their inquiries? What are the timelines given to OAWP, 
or by OAWP to administrations, within which they need to conduct 
investigations into reports of whistleblowers?
    Response. The Department has developed a robust system of checks 
and balances related to the receipt, review, and reporting regarding 
whistleblower disclosures. The process ensures each disclosure is 
investigated thoroughly, timely, and impartially. The Office of 
Accountability and Whistleblower Protection (OAWP) has received 
approximately 3,100 submissions since its inception on June 23, 2017, 
with the signing of the VA Accountability and Whistleblower Protection 
Act, through October 1, 2018. Upon receipt, each submission is assigned 
to an OAWP Triage Division Case Manager. The Case Manager sends the 
disclosing party (if not submitted anonymously) an acknowledgement 
message that includes the date the submission was received and a 
tracking number. OAWP thoroughly reviews each submission to determine 
if a submission satisfies the Act's definition of a ``whistleblower 
disclosure.'' Of the 3,100 submissions, OAWP determined approximately 
1,000 met the definition of a ``whistleblower disclosure'' for 
referral. Once a submission is determined to be a ``whistleblower 
disclosure'' the disposition of the disclosure depends on its content.
    The definition of ``whistleblower disclosure'' is found in 38 
U.S.C. Sec. 323(c)(1)(G)(3):

          The term `whistleblower disclosure' means any disclosure of 
        information by an employee of the Department or individual 
        applying to become an employee of the Department which the 
        employee or individual reasonably believes evidences:

          (A) a violation of a law, rule, or regulation; or
          (B) gross mismanagement, a gross waste of funds, an abuse of 
        authority, or a substantial and specific danger to public 
        health or safety.

    The VA Accountability and Whistleblower Protection Act requires 
OAWP to refer whistleblower disclosures to the appropriate 
investigative entity. Disclosures involving clinical matters are 
referred to the Office of the Medical Inspector (OMI). Disclosures 
involving potentially criminal conduct are offered to the Office of the 
Inspector General (OIG); however, if the OIG declines the disclosure it 
is returned to OAWP for further disposition. If the disclosure alleges 
misconduct or poor performance by a senior leader, the disclosure is 
referred to OAWP's Investigations Division. If the disclosure involves 
an allegation of whistleblower retaliation by a supervisor, it is 
likewise referred to OAWP's Investigations Division. If the disclosure 
does not fall within any of the aforementioned criteria, it is referred 
to the appropriate Administration or Staff Office for investigation and 
reporting.
    Of the approximately 1,000 whistleblower disclosures received, they 
have been referred for investigation as follows:

     Allegations of misconduct or poor performance by a senior 
leader or whistleblower retaliation by any supervisor investigated by 
OAWP: 354
     Allegations involving potential criminal wrongdoing 
accepted by the OIG: 13
     Allegations involving clinical matters referred to OMI: 8
     All other allegations referred that are not included in 
the above:

          - VHA: 570
          - VBA: 31
          - NCA: 1
          - Staff Offices: 26

    The remainder of this response only addresses those disclosures 
referred to an Administration or Staff Office.
    Each disclosure referred to an Administration or Staff Office is 
referred with an instruction memo describing the requirements and 
standards for review and reporting. The timeframe for a responsive 
report is 30-days, although extensions can be granted with sufficient 
justification. The instructions describe the limitations on who may 
conduct the investigation and the specific items that must be addressed 
in the resulting report. OAWP also sends a template for the required 
report that describes the reporting requirements in detail. Each 
referral includes the prohibition:

        All investigations must be conducted by a neutral party who is 
        not named or involved in any of the disclosures. It is not 
        acceptable to send the referral notice to a party named in a 
        disclosure as part of any investigation method you choose.

    Once the completed report is submitted by the Administration or 
Staff Office to the OAWP Case Manager who reviews the report for 
technical adequacy based on the instruction memo and reasonableness of 
the response. If the Case Manager accepts the report, it is reviewed by 
the Case Manager's supervisor for concurrence and, if satisfactory, the 
disclosure is closed. A closure notice is provided to the disclosing 
party. The notice explains that the disclosure was investigated and is 
now closed. If the disclosing party has further questions, the closure 
notice directs them to the Administration or Staff Office point-of-
contact. If a disclosing party seeks a copy of any of the investigatory 
materials or report, they are referred to the appropriate Freedom of 
Information Act Office.

    Question 5. Please provide the Committee with the PowerPoint Slide 
deck titled, ``Next Steps for Agent Orange Benefits, including Navy 
Veterans in Territorial Water,'' which was produced by VBA on 
November 24, 2017.
    Response. This deck cannot be shared externally as it was used for 
internal deliberate discussions regarding policy choices. The documents 
requested consist of internal policy discussions by and amongst VA 
employees regarding decisions on issuance of grant benefits and/or 
proof presumptions to groups of Veterans, including benefits related to 
Agent Orange and to groups of Veterans who served in waters in the 
vicinity of Vietnam. The confidentiality of these communications is 
critical to VA employees' faith in their ability to hold frank 
discussions regarding highly publicized and controversial issues such 
as these without such communications being disclosed to public.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Jerry Moran to 
 Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
    There's been much discussion about the poor implementation of the 
Choice program in terms of delays in scheduling, lack of robust 
provider network, and inability for participating community providers 
to get paid. In the midst of this bad news, I want to recognize and 
applaud VA's direct contracts with dialysis providers. This is a good 
example of VA's successful engagement of dialysis providers where 
Veterans receive high quality, timely dialysis care and 23 dialysis 
vendors are paid in a timely manner to provide a robust dialysis 
provider network with coast-to- coast coverage.
    The direct dialysis contracts that are in place today are set to 
expire soon. VA has advised this Committee that there will be 6-month 
bridge contract to ensure that there's no disruption in dialysis care 
for Veterans. VA further informed this Committee of their plans to 
recompete the direct dialysis contracts that would be a total of 5 
years in duration.

    Question 6. Does the VA intend to include dialysis in the Community 
Care Network contracts that will be awarded in the coming months, or 
will the VA preserve the direct dialysis contracts as the sole path for 
acquiring dialysis services under the new MISSION Act?
    Response. The new Nationwide Dialysis Services contracts (NDSC) 
will be separate from the Community Care Network contracts. VA issued a 
Request for Proposals (RFP) on October 29, 2018 and estimates award of 
the contracts no later than January 31, 2019.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Dean Heller to 
 Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
    Question 7. Secretary Wilkie--during your confirmation, we talked 
about getting a full-time doctor in a clinic in Pahrump. It was a great 
day two years ago to be there for the opening of this clinic--but we 
need to make sure it has the staff the veterans need. Can you provide a 
status update on getting a full-time doctor out to the Pahrump clinic?
    Response. The last full-time physician who was employed in Pahrump, 
resigned January 31, 2017. Since that time, the position was re-posted 
October 1, 2017 and has remained posted since that date. This posting 
has yielded 1 candidate who was selected, but due to licensure issues, 
was unable to complete the hiring process. Two additional candidates 
were received, however, neither were viable candidates. Recruitment 
continues with the inclusion of recruitment incentives. Physicians 
applying for the position in Pahrump are being offered a higher salary 
than physicians in the Las Vegas metro area.
    The VISN 21 physician recruiter has also been actively seeking 
physicians for Pahrump since January 2017. However, these efforts have 
yielded no viable candidates. VA patients in Pahrump are treated and 
managed through the following methods:

    a. One full-time Nurse Practitioner (Monday through Friday);
    b. One full-time Physician Assistant (Monday through Friday);
    c. VA Southern Nevada Healthcare System Primary Care has 
collaborated with San Francisco's V-IMPACT program to provide one full-
time physician via Telehealth, which started September 4, 2018. This 
program also provides an additional one week of face-to-face physician 
coverage each quarter; and
    d. If San Francisco is unable to see patients due to illness we 
have back up available via telehealth.

    Question 8. Secretary Wilkie--As part of the VA MISSION Act, I 
secured a provision that requires the VA to implement a pilot program 
for the use of medical scribes. I believe Las Vegas would be a great 
location for this pilot program given we have a busy Emergency 
Department where scribes could be very helpful. Do you have a status 
update on when that pilot program will be implemented? Can you provide 
a timeline for implementation?
    Response. Planning for implementation of the medical scribe pilot 
program is currently underway. Section 507 of the VA MISSION Act of 
2018 is fairly prescriptive in the requirements for the program 
concerning such issues as selecting pilot site locations, hiring and 
distributing scribes, reporting, and evaluation. VA's timeline for 
implementation is still in development, but VA plans to complete site 
selection, scribe hiring and training, and to begin implementation over 
the course of FY 2019.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Patty Murray to 
 Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
                              homelessness
HUD-VASH
    Question 9. Data from the Department of Housing and Urban 
Development showed that there was an increase in veteran homelessness 
in 2017, and a significant increase in my home state of Washington. 
Secretary Shulkin stated before the Committee that VA will be 
implementing a new plan to address this issue in Seattle. Please 
provide a full description of what additional resources have been made 
available, any proposed programmatic changes, and a timeline for 
implementation.
    Response. Since the 2017 Point in Time (PIT) Count results showing 
a significant increase in the number of homeless Veterans in 
Washington, and particularly in Seattle/King County, were announced, 
the Homeless Program Office (HPO) has provided targeted resources and 
technical assistance to the area. HPO assigned its National Director of 
Clinical Operations to work with the Director of the Homeless Programs 
at VA Puget Sound to develop strategies and identify resource needs. 
Resources and technical assistance provided over the past year include 
the following:

     New HUD-VA Supportive Housing (HUD-VASH) voucher 
allocations to increase permanent supportive housing resources:

          - FY 2017 award: 362 to Puget Sound (150 to Seattle/King 
        County).
          - FY 2018 award (Round 1): 134 to Puget Sound (69 to Seattle/
        King County).
          - FY 2018 award (Round 2) not yet announced but expected to 
        be: 54 to Puget Sound (44 to Seattle/King County).

     New lease signed for expanded, centrally-located Community 
Resource and Referral Center in Seattle (anticipated opening Spring 
2019), to enhance homeless Veteran access to services.
     Two new Grant Per Diem (GPD) programs (Orting State 
Soldier's Home: 40 beds; expansion of Salvation Army William Booth 
Center by 14 beds).
     Expansion of Health Care for Homeless Veterans (HCHV) 
Contract beds (Seattle/King County) from 20 to 30 beds (Sept. 2018).
     Supportive Services for Veteran Families (SSVF) Rapid 
Resolution/Diversion Pilot (Seattle/King County).
     Continued, innovative collaboration with non-profit, local 
governmental, and Continuum of Care (CoC) partners to streamline 
services for homeless Veterans across the region, including King County 
to ensure a targeted utilization of King County Senior, Veterans, and 
Human Services Levy (VSHSL) funds to complement services provided 
through VA and fill identified gaps in care.
     Close collaboration with all CoCs to create and maintain 
``By Name'' or ``Master Lists'' of homeless Veterans across our region, 
to better ensure that resources are optimally targeted based on need 
and availability.
     To help fill vacant case manager positions, VA assigned 
staff from VA Central Office Workforce Management and Consulting to 
assist in recruitment efforts, reducing the lag time associated with 
filling vacant positions.
     In terms of timeline for implementation, unless otherwise 
indicated, all resources and technical assistance listed above are 
ongoing.
     These efforts resulted in a 31 percent reduction in 
Veteran homelessness as identified by the 2018 PIT Count. This result 
provides concrete evidence of the effectiveness of the resources and 
technical assistance listed above.

    Question 10. Unfilled case manager positions and un-used vouchers 
throughout Washington state continue to hamper efforts to help 
veterans. From discussions with local staff in the VA, housing 
authorities, and non-profit providers, it seems that the hiring process 
remains tedious and inefficient. Also, HUD and VA tracking systems are 
not able to communicate with one another, slowing down the rapid-
rehousing process and potentially resulting in some veterans falling 
through the cracks.
     What will you do to ensure a streamlined hiring process 
and the filling of critical case manager positions?
    Response. As noted above, VA assigned staff from VA Central Office 
Workforce Management and Consulting to assist in recruitment efforts. 
This addition of staff to assist in hiring will reduce the lag time 
associated with filling vacant positions.

    Question 11. What will you do to ensure HUD and VA are able to 
coordinate more effectively?
    Response. HUD and VA have recently implemented a shared data 
dashboard that is presented monthly at the Strategic Decision and 
Consultation Team meeting, a monthly meeting with the US Interagency 
Council on Homelessness (USICH). This process has ensured that HUD and 
VA establish shared data definitions which has enhanced the sharing of 
data at the Headquarters level.
    Over the past two years, VA has also taken many steps to enhance 
the ability to share data across HUD and VA systems at the local level. 
These steps include but are not limited to the following:

     VA adopted HUD's Universal Data Elements into its data 
collection system and matching data elements related to housing 
outcomes wherever possible
     VA established a process by which staff may share 
protected health information across VA and HUD systems through an 
encrypted email system which complies with all privacy and security 
requirements.
     VA released extensive guidance requiring VAMC staff to 
participate in local coordinated entry efforts.

    VA is piloting use of cloud-based software to enhance VA medical 
center (VAMC) staff ability to participate in community data sharing 
efforts using the cloud.

    Question 12. What is the long-term VA plan to get ahead of 
increasing rates of veterans experiencing homelessness in areas with 
fast increasing populations?
    Response. In brief, the long-term plan is to address these areas on 
both the demand and supply side. On the demand side, VA currently does 
and will continue to target resources to the areas that need them most. 
VA uses a sophisticated gap analysis model to predict homeless Veteran 
population growth and uses the results of this model to guide resource 
allocation in many of its key programs, including HUD-VASH, SSVF, and 
GPD. This ensures that resources go where they are needed most. On the 
supply side, VA is working closely with HUD and external partners to 
increase the available housing stock for permanent supportive housing 
and affordable housing. This includes targeted use of Project Based 
Vouchers in HUD-VASH, use of VA property through the Enhanced Use Lease 
(EUL) process, working with cities and counties on methods to incentive 
development of units dedicated to homeless Veterans, and working with 
landlords and developers to promote the need for the same.

    Question 13. Please provide a national by-facility breakdown of:

    i. The number of case managers
    ii. Number of case manager vacancies
    iii. Number of vouchers each case manager is responsible for
    iv. How many vouchers are not in use
    v. How many vouchers expired at the end of fiscal year 2018 and had 
to be reissued
    vi. How many veterans are waiting for vouchers

    Response. Please see the attached spreadsheet and the responses 
below:

    i. The number of case managers:
           Tab 1 (VA Staff) column D of the attachment shows 
        the total number of case manager positions in HUD-VASH.
    ii. Number of case manager vacancies:
           Tab 1 (VA Staff) column C of the attachment shows 
        the total number of case manager vacancies in HUD-VASH. Please 
        note that many of these positions were just created, due to the 
        recent FY 2018 voucher allocations.

    iii. Number of vouchers each case manager is responsible for:
           It is not possible to obtain this number for each 
        case manager, due to the unique make-up of case management 
        teams at each VAMC. Nationally, however, there are 
        approximately 3,100 VA case managers plus 273 contracted case 
        managers, for a total of 3,373 staff providing case management 
        for approximately 85,500 vouchers. This yields a ratio of 
        roughly 25 vouchers for each case manager. The data showing the 
        staffing breakdown by VAMC is in Tab 1 (VA Staff) and Tab 2 
        (Contracted CM) of the attachment.

    iv. How many vouchers are not in use:
           Tab 3 (Voucher Utilization) column C of the 
        attachment shows the number of vouchers not in use (i.e., 
        available for use) by VAMC. Please note that in some cases many 
        of these unused vouchers were just recently allocated by HUD. 
        Negative numbers indicate that VAMCs have admitted more 
        Veterans to HUD-VASH than there are available vouchers. This is 
        a recommended practice to offset expected attrition prior to 
        voucher issuance, similar in concept to airline 
        ``overbooking.''

    v. How many vouchers expired at the end of fiscal year 2018 and had 
to be reissued:
           We do not collect data on this at the VACO level and 
        are thus unable to report it here.

    vi. How many veterans are waiting for vouchers:
           Tab 3 (Voucher Utilization) column D of the 
        attachment shows the number of Veterans awaiting vouchers. This 
        is the number of Veterans who have been referred to the Public 
        Housing Authority (PHA) for a voucher but have not yet received 
        the voucher. This number does not include Veterans admitted to 
        the HUD-VASH program who have not yet been referred to the PHA.

                            VA Staff (Tab 1)
------------------------------------------------------------------------
             Facility                 Filled       Vacant    Grand Total
------------------------------------------------------------------------
(1V01) (402) Togus, ME HCS.......         5           6           11
(1V01) (405) White River                  6           5           11
 Junction, VT HCS................
(1V01) (518) Bedford, MA HCS.....        22           1           23
(1V01) (523) Boston, MA HCS......        41           9           50
(1V01) (608) Manchester, NH HCS..        13           1           14
(1V01) (631) Central Western             21           6           27
 Massachusetts HCS...............
(1V01) (650) Providence, RI HCS..        14           3           17
(1V01) (689) Connecticut HCS.....        24           9           33
(1V02) (526) Bronx, NY HCS.......        31           5           36
(1V02) (528) Western New York HCS        11           -           11
(1V02) (528A5) Canandaigua, NY            8           -            8
 HCS.............................
(1V02) (528A6) Bath, NY HCS......         5           1            6
(1V02) (528A7) Syracuse, NY HCS..        12           2           14
(1V02) (528A8) Albany, NY HCS....        12           4           16
(1V02) (561) New Jersey HCS......        22           5           27
(1V02) (620) Hudson Valley, NY            9           -            9
 HCS.............................
(1V02) (630) New York Harbor HCS.        41           2           43
(1V02) (632) Northport, NY HCS...        16           3           19
(1V04) (460) Wilmington, DE HCS..         9           4           13
(1V04) (503) Altoona, PA HCS.....         2           2            4
(1V04) (529) Butler, PA HCS......         6           -            6
(1V04) (542) Coatesville, PA HCS.        18           1           19
(1V04) (562) Erie, PA HCS........         7           -            7
(1V04) (595) Lebanon, PA HCS.....        14           -           14
(1V04) (642) Philadelphia, PA HCS        24          11           35
(1V04) (646) Pittsburgh, PA HCS..        15           -           15
(1V04) (693) Wilkes-Barre, PA HCS         7           2            9
(1V05) (512) Baltimore, MD HCS...        46           2           48
(1V05) (517) Beckley, WV HCS.....         6           -            6
(1V05) (540) Clarksburg, WV HCS..         2           -            2
(1V05) (581) Huntington, WV HCS..        10           -           10
(1V05) (613) Martinsburg, WV HCS.         6           2            8
(1V05) (688) Washington, DC HCS..        41          12           53
(1V06) (558) Durham, NC HCS......        21           -           21
(1V06) (565) Fayetteville, NC HCS        12           4           16
(1V06) (590) Hampton, VA HCS.....        32           3           35
(1V06) (637) Asheville, NC HCS...        13           1           14
(1V06) (652) Richmond, VA HCS....         9           6           15
(1V06) (658) Salem, VA HCS.......         4           -            4
(1V06) (659) Salisbury, NC HCS...        28           1           29
(2V07) (508) Atlanta, GA HCS.....        75          13           88
(2V07) (509) Augusta, GA HCS.....        10           1           11
(2V07) (521) Birmingham, AL HCS..        24           1           25
(2V07) (534) Charleston, SC HCS..        31           7           38
(2V07) (544) Columbia, SC HCS....        17           6           23
(2V07) (557) Dublin, GA HCS......         8           -            8
(2V07) (619) Central Alabama HCS.        14           2           16
(2V07) (679) Tuscaloosa, AL HCS..        10           1           11
(2V08) (516) Bay Pines, FL HCS...        52           8           60
(2V08) (546) Miami, FL HCS.......        42           -           42
(2V08) (548) West Palm Beach, FL         23           2           25
 HCS.............................
(2V08) (573) Gainesville, FL HCS.        61           9           70
(2V08) (672) San Juan, PR HCS....        11           4           15
(2V08) (673) Tampa, FL HCS.......        38           2           40
(2V08) (675) Orlando, FL HCS.....        56           -           56
(2V09) (596) Lexington, KY HCS...        11           -           11
(2V09) (603) Louisville, KY HCS..        21           -           21
(2V09) (614) Memphis, TN HCS.....        19           1           20
(2V09) (621) Mountain Home, TN           14           2           16
 HCS.............................
(2V09) (626) Middle Tennessee HCS        28           7           35
(3V10) (506) Ann Arbor, MI HCS...        17           5           22
(3V10) (515) Battle Creek, MI HCS        19           5           24
(3V10) (538) Chillicothe, OH HCS.         8           1            9
(3V10) (539) Cincinnati, OH HCS..        23           4           27
(3V10) (541) Cleveland, OH HCS...        41           4           45
(3V10) (552) Dayton, OH HCS......        11           1           12
(3V10) (553) Detroit, MI HCS.....        30           3           33
(3V10) (583) Indianapolis, IN HCS        20           5           25
(3V10) (610) Northern Indiana HCS        16           4           20
(3V10) (655) Saginaw, MI HCS.....         8           2           10
(3V10) (757) Columbus, OH HCS....        13           3           16
(3V12) (537) Chicago, IL HCS.....        50           5           55
(3V12) (550) Danville, IL HCS....         7           1            8
(3V12) (556) North Chicago, IL            7           -            7
 HCS.............................
(3V12) (578) Hines, IL HCS.......        28           -           28
(3V12) (585) Iron Mountain, MI            1           1            2
 HCS.............................
(3V12) (607) Madison, WI HCS.....        15           1           16
(3V12) (676) Tomah, WI HCS.......         7           2            9
(3V12) (695) Milwaukee, WI HCS...        21           2           23
(3V15) (589) Kansas City, MO HCS.        16           4           20
(3V15) (589A4) Columbia, MO HCS..         6           -            6
(3V15) (589A5) Eastern Kansas HCS        16           2           18
(3V15) (589A7) Wichita, KS HCS...        10           1           11
(3V15) (657) St. Louis, MO HCS...        16           1           17
(3V15) (657A4) Poplar Bluff, MO           6           1            7
 HCS.............................
(3V15) (657A5) Marion, IL HCS....         2           1            3
(3V23) (437) Fargo, ND HCS.......        10           -           10
(3V23) (438) Sioux Falls, SD HCS.         5           -            5
(3V23) (568) Black Hills, SD HCS.         9           2           11
(3V23) (618) Minneapolis, MN HCS.        24           6           30
(3V23) (636) Nebraska-W Iowa HCS.        15           2           17
(3V23) (636A6) Central Iowa HCS..         7           2            9
(3V23) (636A8) Iowa City, IA HCS.         6           2            8
(3V23) (656) St. Cloud, MN HCS...         2           2            4
(4V16) (502) Alexandria, LA HCS..        12           1           13
(4V16) (520) Gulf Coast, MS HCS..        29           5           34
(4V16) (564) Fayetteville, AR HCS        14           1           15
(4V16) (580) Houston, TX HCS.....        71          10           81
(4V16) (586) Jackson, MS HCS.....        17           4           21
(4V16) (598) Little Rock, AR HCS.        16           5           21
(4V16) (629) New Orleans, LA HCS.        35           3           38
(4V16) (667) Shreveport, LA HCS..        11           2           13
(4V17) (504) Amarillo, TX HCS....         7           2            9
(4V17) (519) Big Spring, TX HCS..         8           1            9
(4V17) (549) Dallas, TX HCS......        53           6           59
(4V17) (671) San Antonio, TX HCS.        24           1           25
(4V17) (674) Temple, TX HCS......        22           8           30
(4V17) (740) Texas Valley Coastal         9           2           11
 Bend HCS........................
(4V17) (756) El Paso, TX HCS.....        10           3           13
(4V19) (436) Montana HCS.........        12           5           17
(4V19) (442) Cheyenne, WY HCS....         7           3           10
(4V19) (554) Denver, CO HCS......        55           9           64
(4V19) (575) Grand Junction, CO           5           2            7
 HCS.............................
(4V19) (623) Muskogee, OK HCS....        18           -           18
(4V19) (635) Oklahoma City, OK           11           5           16
 HCS.............................
(4V19) (660) Salt Lake City, UT          22           6           28
 HCS.............................
(4V19) (666) Sheridan, WY HCS....         4           2            6
(5V20) (463) Anchorage, AK HCS...        11           2           13
(5V20) (531) Boise, ID HCS.......        10           1           11
(5V20) (648) Portland, OR HCS....        47          17           64
(5V20) (653) Roseburg, OR HCS....        13           7           20
(5V20) (663) Puget Sound, WA HCS.        64          19           83
(5V20) (668) Spokane, WA HCS.....        20           1           21
(5V20) (687) Walla Walla, WA HCS.        12           4           16
(5V20) (692) White City, OR HCS..        12           4           16
(5V21) (459) Honolulu, HI HCS....        37           7           44
(5V21) (570) Fresno, CA HCS......        29           3           32
(5V21) (593) Las Vegas, NV HCS...        57           4           61
(5V21) (612A4) N. California HCS.        56          18           74
(5V21) (640) Palo Alto, CA HCS...        79           7           86
(5V21) (654) Reno, NV HCS........        20           2           22
(5V21) (662) San Francisco, CA           44          22           66
 HCS.............................
(5V22) (501) New Mexico HCS......        22           2           24
(5V22) (600) Long Beach, CA HCS..        34          26           60
(5V22) (605) Loma Linda, CA HCS..        39          14           53
(5V22) (644) Phoenix, AZ HCS.....        40          14           54
(5V22) (649) Northern Arizona HCS        16           1           17
(5V22) (664) San Diego, CA HCS...        58           5           63
(5V22) (678) Southern Arizona HCS        31           4           35
(5V22) (691) Greater Los Angeles,       175         108          283
 CA HCS..........................
                                  --------------------------------------
    Grand Total..................     3,100         632        3,732
------------------------------------------------------------------------


                    Contracted Case Managers (Tab 2)
------------------------------------------------------------------------
                                                             Contracted
                         Facility                               Case
                                                              Managers
------------------------------------------------------------------------
(1V02) (526) Bronx, NY HCS................................        14
(1V02) (561) New Jersey HCS...............................        13
(1V02) (620) Hudson Valley, NY HCS........................         3
(1V02) (630) New York Harbor HCS..........................        14
(1V02) (632) Northport, NY HCS............................         7
(1V04) (503) Altoona, PA HCS..............................         1
(1V05) (688) Washington, DC HCS...........................        13
(5V20) (653) Roseburg, OR HCS.............................         4
(5V20) (663) Puget Sound, WA HCS..........................         6
(5V21) (662) San Francisco, CA HCS........................        13
(5V22) (678) Southern Arizona HCS.........................         1
(5V22) (691) Greater Los Angeles, CA HCS..................       184
                                                           -------------
    Grand Total...........................................       273
------------------------------------------------------------------------


                       Voucher Utilization (Tab 3)
------------------------------------------------------------------------
                                                                Veterans
                                     Vouchers      Vouchers     Waiting
             Facility                Allocated     Available     for a
                                                    for Use     Voucher
------------------------------------------------------------------------
(1V01) (402) Togus, ME HCS.......       216           -19           2
(1V01) (405) White River                204            19           1
 Junction, VT HCS................
(1V01) (518) Bedford, MA HCS.....       544            10           3
(1V01) (523) Boston, MA HCS......       918            82           0
(1V01) (608) Manchester, NH HCS..       281             6           1
(1V01) (631) Central Western            645            35           7
 Massachusetts HCS...............
(1V01) (650) Providence, RI HCS..       376            -5           3
(1V01) (689) Connecticut HCS.....       818            32           4
(1V02) (526) Bronx, NY HCS.......     1,339           -36           3
(1V02) (528) Western New York HCS       323            -3           0
(1V02) (528A5) Canandaigua, NY          201             5           0
 HCS.............................
(1V02) (528A6) Bath, NY HCS......       125             2           5
(1V02) (528A7) Syracuse, NY HCS..       257            18           0
(1V02) (528A8) Albany, NY HCS....       350           -20           6
(1V02) (561) New Jersey HCS......       957             0          20
(1V02) (620) Hudson Valley, NY          349            17           0
 HCS.............................
(1V02) (630) New York Harbor HCS.     1,776           -39          17
(1V02) (632) Northport, NY HCS...       464             2           0
(1V04) (460) Wilmington, DE HCS..       217             6           3
(1V04) (503) Altoona, PA HCS.....        83             7           4
(1V04) (529) Butler, PA HCS......       125             2           0
(1V04) (542) Coatesville, PA HCS.       479            23           0
(1V04) (562) Erie, PA HCS........       121             7           0
(1V04) (595) Lebanon, PA HCS.....       284           -38           0
(1V04) (642) Philadelphia, PA HCS       926            16           0
(1V04) (646) Pittsburgh, PA HCS..       422             5           0
(1V04) (693) Wilkes-Barre, PA HCS       219           -27           6
(1V05) (512) Baltimore, MD HCS...       944           -69          18
(1V05) (517) Beckley, WV HCS.....       143            -6           0
(1V05) (540) Clarksburg, WV HCS..        67            -6           0
(1V05) (581) Huntington, WV HCS..       215            12           1
(1V05) (613) Martinsburg, WV HCS.       172             2           2
(1V05) (688) Washington, DC HCS..     1,495           -14          10
(1V06) (558) Durham, NC HCS......       480             3           0
(1V06) (565) Fayetteville, NC HCS       366            -3           4
(1V06) (590) Hampton, VA HCS.....       747            53           0
(1V06) (637) Asheville, NC HCS...       338           -10           6
(1V06) (652) Richmond, VA HCS....       369            23           1
(1V06) (658) Salem, VA HCS.......        98            -6           0
(1V06) (659) Salisbury, NC HCS...       744            20          33
(2V07) (508) Atlanta, GA HCS.....     1,955           111          48
(2V07) (509) Augusta, GA HCS.....       237           -11           4
(2V07) (521) Birmingham, AL HCS..       606           -19           1
(2V07) (534) Charleston, SC HCS..       649             5           0
(2V07) (544) Columbia, SC HCS....       549           -20          12
(2V07) (557) Dublin, GA HCS......       200             5           2
(2V07) (619) Central Alabama HCS.       306           -10           0
(2V07) (679) Tuscaloosa, AL HCS..       267           -15           5
(2V08) (516) Bay Pines, FL HCS...     1,309            45           6
(2V08) (546) Miami, FL HCS.......     1,038            56          11
(2V08) (548) West Palm Beach, FL        560             1           4
 HCS.............................
(2V08) (573) Gainesville, FL HCS.     1,688           -20          15
(2V08) (672) San Juan, PR HCS....       197            23           0
(2V08) (673) Tampa, FL HCS.......       987           -12          22
(2V08) (675) Orlando, FL HCS.....     1,262            58           0
(2V09) (596) Lexington, KY HCS...       302             2           0
(2V09) (603) Louisville, KY HCS..       475            55           1
(2V09) (614) Memphis, TN HCS.....       492           -46           8
(2V09) (621) Mountain Home, TN          355            37           0
 HCS.............................
(2V09) (626) Middle Tennessee HCS       763           -31          13
(3V10) (506) Ann Arbor, MI HCS...       450            38           2
(3V10) (515) Battle Creek, MI HCS       557            11           5
(3V10) (538) Chillicothe, OH HCS.       228            13           0
(3V10) (539) Cincinnati, OH HCS..       548            -7          12
(3V10) (541) Cleveland, OH HCS...       955            16          12
(3V10) (552) Dayton, OH HCS......       225            13           3
(3V10) (553) Detroit, MI HCS.....       912           113           0
(3V10) (583) Indianapolis, IN HCS       641            45          27
(3V10) (610) Northern Indiana HCS       427            25          12
(3V10) (655) Saginaw, MI HCS.....       219             8           0
(3V10) (757) Columbus, OH HCS....       372           -22           0
(3V12) (537) Chicago, IL HCS.....     1,220            -2           1
(3V12) (550) Danville, IL HCS....       226             9           1
(3V12) (556) North Chicago, IL          194            13           0
 HCS.............................
(3V12) (578) Hines, IL HCS.......       609            17           0
(3V12) (585) Iron Mountain, MI           36            -1           0
 HCS.............................
(3V12) (607) Madison, WI HCS.....       276             8           0
(3V12) (676) Tomah, WI HCS.......       161             2           4
(3V12) (695) Milwaukee, WI HCS...       628            -7           7
(3V15) (589) Kansas City, MO HCS.       397             4           6
(3V15) (589A4) Columbia, MO HCS..       153            30           0
(3V15) (589A5) Eastern Kansas HCS       400            11           4
(3V15) (589A7) Wichita, KS HCS...       238            16           2
(3V15) (657) St. Louis, MO HCS...       370             8           7
(3V15) (657A4) Poplar Bluff, MO         129            -4           0
 HCS.............................
(3V15) (657A5) Marion, IL HCS....        90             8           0
(4V16) (502) Alexandria, LA HCS..       263             9           3
(4V16) (520) Gulf Coast, MS HCS..       652            14           5
(4V16) (564) Fayetteville, AR HCS       241           -15           4
(4V16) (580) Houston, TX HCS.....     1,919            60           7
(4V16) (586) Jackson, MS HCS.....       447            20           3
(4V16) (598) Little Rock, AR HCS.       398            40           1
(4V16) (629) New Orleans, LA HCS.       801            45          10
(4V16) (667) Shreveport, LA HCS..       282            15           0
(4V17) (504) Amarillo, TX HCS....       240             2           0
(4V17) (519) Big Spring, TX HCS..       213             5           6
(4V17) (549) Dallas, TX HCS......     1,330          -113          46
(4V17) (671) San Antonio, TX HCS.       719           -31           8
(4V17) (674) Temple, TX HCS......       779            51           0
(4V17) (740) Texas Valley Coastal       239            -1           2
 Bend HCS........................
(4V17) (756) El Paso, TX HCS.....       294           -15           0
(4V19) (436) Montana HCS.........       410            14           1
(4V19) (442) Cheyenne, WY HCS....       235            15           1
(4V19) (554) Denver, CO HCS......     1,359            62          21
(4V19) (575) Grand Junction, CO         187             6           0
 HCS.............................
(4V19) (623) Muskogee, OK HCS....       336           -10          10
(4V19) (635) Oklahoma City, OK          372             0           2
 HCS.............................
(4V19) (660) Salt Lake City, UT         601            40          17
 HCS.............................
(4V19) (666) Sheridan, WY HCS....       112             8           2
(5V20) (463) Anchorage, AK HCS...       311             4           2
(5V20) (531) Boise, ID HCS.......       221            11           4
(5V20) (648) Portland, OR HCS....     1,210           -90          12
(5V20) (653) Roseburg, OR HCS....       503            40           6
(5V20) (663) Puget Sound, WA HCS.     1,893          -101          44
(5V20) (668) Spokane, WA HCS.....       411           -17           8
(5V20) (687) Walla Walla, WA HCS.       396            -7           9
(5V20) (692) White City, OR HCS..       385            40           5
(5V21) (459) Honolulu, HI HCS....       742            13          27
(5V21) (570) Fresno, CA HCS......       545            29           4
(5V21) (593) Las Vegas, NV HCS...     1,419           159          19
(5V21) (612A4) N. California HCS.     1,465            -9          14
(5V21) (640) Palo Alto, CA HCS...     1,997          -128          72
(5V21) (654) Reno, NV HCS........       483            27           7
(5V21) (662) San Francisco, CA        1,593           -33          20
 HCS.............................
(5V22) (501) New Mexico HCS......       548            17           2
(5V22) (600) Long Beach, CA HCS..     1,508           121          45
(5V22) (605) Loma Linda, CA HCS..     1,082           -16           0
(5V22) (644) Phoenix, AZ HCS.....     1,103           232           6
(5V22) (649) Northern Arizona HCS       327             7           6
(5V22) (664) San Diego, CA HCS...     1,641            68          32
(5V22) (678) Southern Arizona HCS       810            45           7
(5V22) (691) Greater Los Angeles,     6,189           892          36
 CA HCS..........................
(3V23) (437) Fargo, ND HCS.......       244            23           2
(3V23) (438) Sioux Falls, SD HCS.       151             4           0
(3V23) (568) Black Hills, SD HCS.       205            13           2
(3V23) (618) Minneapolis, MN HCS.       651           -24           8
(3V23) (636) Nebraska-W Iowa HCS.       494            38           6
(3V23) (636A6) Central Iowa HCS..       200            -3           0
(3V23) (636A8) Iowa City, IA HCS.       176           -13           2
(3V23) (656) St. Cloud, MN HCS...        74             0           2
                                  --------------------------------------
    Grand Total..................    85,461         3,402         975
------------------------------------------------------------------------

                               facilities
Yakima CBOC
    Question 14. The Yakima CBOC funds were allocated in 2016. After a 
delay on construction due to a contested bid, we do not have a current 
estimate for date of construction beyond a vague assertion of 18 months 
to two years. Please provide a more detailed account of projected 
construction timeline.
    Response. In order to address prior protests associated with what 
has been determined to be a geographic area of consideration that was 
too restrictive, the Yakima lease area of consideration has been 
revised. The updated lease solicitation will be issued no later than 
December 2018 and an award is anticipated by Fall 2019 or earlier. Upon 
award, the new lease may take 18-24 months to be completed for VA 
occupancy. The lessor's construction timeline depends on what type of 
space lessor offers and VA leases, existing space to be renovated or 
new construction.
Bremerton CBOC
    Question 15. The Bremerton CBOC was slated to be updated nine years 
ago. A month ago the notice to proceed was finally obtained and 
construction has begun on a new facility in neighboring Silverdale. The 
timeline for construction is now 18 months. Since the authorization of 
funding, the needs of the community have changed and the slated 
construction of a site that can serve 7,200 veterans will not meet the 
needs of the area given the rate of growth in the veteran population, 
the number of beds being added to the new facility, and the expected 
return of veterans who have gone to the Choice program due to backups 
at the current facility.

      Please provide a full timeline of construction and 
expected end date.
      Please provide details on most recent assessment of 
community capacity and needs.
      Please provide assessment of recently announced Auburn 
and Olympia facilities as well and explain rationale for different 
sizes.
      The Bremerton CBOC still lacks a Women's Care Team 
despite Secretary Shulkin assuring me in 2016 that one would soon be 
there. Please update me on the timeline for this team to be operating 
in the clinic.

    VA Response:

     Please provide a full timeline of construction and 
expected end date. The lease was awarded on July 7, 2017 and in 
August 2018 VA issued the lessor a Notice to Proceed with construction 
per VA approved clinic design. The lessor is currently scheduled to 
complete construction of the building October 2019.
     Please provide details on most recent assessment of 
community capacity and needs. Currently, Market Assessments are being 
planned for all facilities nationwide. A contract was let to accomplish 
this starting this fiscal year. These assessments will analyze both in-
house workload and do a comprehensive review of community capacity and 
needs.
     Please provide assessment of recently announced Auburn and 
Olympia facilities as well and explain rationale for different sizes. 
Newly approved CBOC leases in Auburn and Olympia, Washington are 
similarly sized at approximately 25,272 and 25,179 net usable square 
feet respectively. Both sites intend to provide PACT Primary Care, 
Primary Care Mental Health Integration (PCMHI) and Specialty Mental 
Health services, along with basic laboratory and diagnostic imaging 
services. Differences in programing space can occur based on the number 
of staff, number of rooms or the size of a room.
     The Bremerton CBOC still lacks a Women's Care Team despite 
Secretary Shulkin assuring me in 2016 that one would soon be there. 
Please update me on the timeline for this team to be operating in the 
clinic. The current Bremerton CBOC has four designated Women's Health 
(WH) Providers. Two of them have been WH providers since 2016. The most 
recent ones have been on station since August 2017. The New Silverdale 
CBOC has space designated for WH.
Tonasket Rural Medical Clinic
    Question 16. As of May 2017, the VA intended to close the Tonasket 
Rural Health Clinic, located within the North Valley Hospital, and 
roughly a year ago they did. More than 850 veterans relied on that 
clinic to receive care from the VA. Without the clinic, they are forced 
to travel either two hours each way to Wenatchee, or three hours each 
way to the Mann-Grandstaff VA Medical Center (MGVAMC) in Spokane. The 
medical center has been unable to provide an accurate picture of the 
status of the replacement clinic, and previously told my office an 
award was expected in February 2018. As of last week, medical center 
had no update or information on this extended delay due to a lack of 
transparency in contracting.
    Please provide a full details of current status of Tonasket 
reopening, including a firm date for the clinic to be operational.
    Response. Tonasket Contract Clinic proposals have been received and 
are currently under review. Upon award and notice to proceed, the 
contract clinic is to be operational within 120 days.
Puget Sound VA
    Question 17. During his confirmation hearing in 2017, Secretary 
Shulkin committed to following up on concerns I raised about the 
condition of the VA Puget Sound Health Care System and obstacles 
Washington veterans faced in accessing care. The problem then seemed to 
stem from unfilled management positions and frequent turnover in 
leadership. A management improvement team was sent to the facility, and 
measures have been taken to ensure physician and nurse positions are 
filled, but many problems persist. The problems again seem to center on 
unfilled rolls and overburdened existing staff. I am very concerned 
with low levels of support staffing overall, specifically in the 
maintenance and human resources departments and the effects this 
understaffing is having on patient care.

     I ask that you investigate these issues and take action 
expeditiously to resolve these problems. In particular, if additional 
staff or resources are necessary for patient care or for human 
resources in order to expedite hiring of providers, I ask that you take 
all necessary actions to meet those needs, including temporarily 
detailing staff to the facility.
     I also ask that you undertake a review of the long-term 
feasibility of hiring in this region. With increasing costs of living 
and significant competition for employees among hospitals in the 
Seattle area, VA will have to be sure it can recruit and retain the top 
talent. Please describe whether and how VA can keep pace with the 
market and any additional authorities that are necessary.

    I am also specifically concerned about reports I have received 
about deficiencies in the radiology department, especially in light of 
reports of hundreds of thousands of radiology consults being improperly 
closed, potentially putting veterans at risk. The specific concerns 
raised about Puget Sound include the lack of an efficient scheduling 
system and lack of compliance with scheduling policy, lack of 
sufficient clerical staff, as well as possible mishandling of patient 
images including CDs being stored unsecured or improperly, images not 
being entered into the medical record, or patient images being deleted. 
Please investigate these concerns and take appropriate corrective 
action.
    Response. VA Central Office's H.R. Team is supporting the Puget 
Sound facility with direct impact to hiring is actively filling 
vacancies. Currently, this team has vacancies for two H.R. Specialist 
and one H.R. Assistant which are expected to be filled within the next 
90 days. Additionally, an additional nurse recruiter (part-time) was 
supported for hire in Patient Care Services this year to assist with 
recruitment in this area. The following strategies are being employed:

     Utilization of Recruitment and Retention flexibilities 
(recruitment, relocation and retention incentives, student loan 
repayment, education debt reduction, accelerated leave accrual) for 
hard-to-fill occupations for the facility, including human resources.
     Pay authorities such as above-minimum entry and highest 
previous rate are also applied, as appropriate, to assist in achieving 
and offering salaries commensurate with an applicant's qualifications 
and/or in recognition of prior Federal service.
     Telework options have been leveraged in an effort to 
recruit and retain H.R. staff while maintaining a customer-service 
focus to support medical center operational needs.
     In January 2018, OPM authorized direct hire authority to 
VA for 15 critical occupations to include Human Resources Specialist 
and Human Resources Assistants, which we are actively using as a 
flexibility to hire.
     H.R. consolidation to the VISN is actively moving forward 
to create a more efficient, effective and standardized means to deliver 
H.R. services in VHA.
     Adjusted salary rates or new special salary rates 
established for numerous occupations to create more competitive wages. 
VISN 20's compensation team has been providing assistance in this area 
and will continue to support the facilities, including Puget Sound.
     Utilizing non-competitive hiring authorities available to 
fill positions, appropriately, with qualified quality candidates 
(trainees, VRA, schedule A, 30%+ Veterans)
     Policy changes are creating greater efficiencies and 
flexibilities (i.e. physician market pay review, Title 38 hybrid 
conversions, elimination of professional standards boards, etc.)

Continued Barriers/Challenges:

     The Seattle-Tacoma labor market is unique, since the 
greater Seattle area was minimally affected by the economic downturn 
and the area has been a major hub for growth in both technology and 
healthcare over the last decade. In addition, the minimum wage for the 
Seattle area is $15.00 per hour. This is slightly below the annual rate 
of an employee at GS-4, Step 1 on the Seattle-Tacoma locality scale. 
The local minimum wage has limited our competitiveness, since it 
provides a higher hourly rate than that paid to a GS-3, a grade widely 
used in our hiring for the same region.
     VA Puget Sound, Seattle campus, is in a prime location and 
property with a high growth rate and cost of living. Competition is not 
only with private sector hospitals but also with other Federal agencies 
as the area is saturated with other agencies.
     Available flexibilities are not available to recruit and 
retain personnel at VA, if they are existing Federal employees or 
taking an opportunity with another agency. Limited funding for 
education reimbursement.
     Length of job posting--15 business days as negotiated by 
the union is often too long to leave a position open if you have a 
viable pool of applicants.
     Professional Standards Boarding timeliness presents a 
delay with some Title 38 and Title 38 Hybrid occupations, with emphasis 
on those at a regional or national level.
     Required use of multiple systems for same or similar 
purposes that do not talk to each other causing additional admin work 
for H.R. team and users.
          - Downgrading of positions such as H.R. Specialists, 
        Engineers, Radiation Safety Officer, Credentialing Assistants, 
        Administrative Officers of the Day (AOD), and other 
        occupations.

     While there have been positive regulatory and policy 
changes occurring to support a more effective and efficient hiring 
process, it frequently increases the workload required of the local 
H.R. team members to enact.

    Question 18. I have also received troubling reports about 
insufficient staffing and operations in the emergency department. 
Please provide an update on staffing levels and vacancies, by position 
type, and describe any barriers to achieving full staffing and 
retaining ED staff.
    Response. As of 9/26/18, there are 570.7 approved-budgeted 
vacancies for VA Puget Sound HCS. Of these, there are 185 selections to 
fill positions ranging from administrative support to direct patient 
care, 40% of these selectees have a firm Entry on Duty between October-
December while the others pending are undergoing the pre-employment 
process.
    The ED currently has the following vacancies:

     4 Physicians
     1 Physician Assistant
     1 Advanced Registered Nurse Practitioner
     6 Registered Nurses
     6 Nursing Assistants
     2 Medical Support Assistants

    Question 19. a. Please describe wait times at the ED over the year 
to date, and any instances of bed shortages. b. What impacts are 
projected as flu season begins, and what mitigation steps are being 
taken? (VHA 10NC)
    Response. During FY 2017, VA Puget Sound's average time from the 
decision to admitting the patient was 178 minutes, compared to the 
national average time of 130 minutes at other VA hospitals. The average 
time in FY 2018 is slightly longer at VA Puget Sound at 197 minutes, 
compared to a national average of 131 minutes. Some of the ongoing ways 
we are actively addressing these challenges include patient flow 
assessment projects, daily huddles to optimize available beds, planned 
discharges, admissions, surgeries and staffing, and continuous process 
improvement to enhance quality, efficiency, safety and the overall 
Veteran experience.

    b. What impacts are projected as flu season begins, and what 
mitigation steps are being taken?
    Response. Flu season will increase the volume of Emergency 
Department patient encounters and subsequently the number of inpatient 
admissions, in particular, for vulnerable populations such as the 
elderly and those with chronic disease. Patients with suspected flu 
will need respiratory isolation to prevent the nosocomial spread of 
infection. There will be an increase in staff illness during the flu 
season which will decrease workforce productivity.
    Risk mitigation steps include:

     We have hired additional staff in the Emergency 
Department, with approved and budgeted additional increases in process.
     We have hired additional staff in the inpatient medical 
units, with approved and budgeted additional increases in process.
     We have a contract with a nurse staffing agency for short 
term nurse staffing increases.
     We have improved processes around timely discharges to 
increase available isolation beds for patients with influenza.
     We have designed a process for continual and proactive 
assessment of bed availability that raises awareness and shares 
resources across units at times of high hospital census.
     We have met with local area hospitals (Madigan Army 
Medical Center) to improve collaboration around patient transfer at 
times of high hospital census.
     We have coordinated a robust staff influenza vaccination 
campaign.
                              va programs
IVF
    Question 20. It has been two years since Congress gave VA the 
authority to provide IVF and other necessary fertility treatments for 
ill or injured veterans and their spouses. These treatments can help 
veterans realize their dream of starting a family, but access to this 
care promised to our veterans is still limited. We should not cut 
corners when it comes to our veterans and their families. Consistent 
and nationwide access to this program is essential to meet the 
commitments we have made, and the dreams for which these veterans 
fought so hard.

     Please describe how you are currently working to ensure 
additional providers are enrolled into the program and any other 
necessary steps taken to make sure our veterans have easy access to 
this treatment in the country. What steps can the Department take to 
more quickly enroll providers? Please also discuss how provision of ART 
will be incorporated into the Department's planning and implementation 
of the new Veterans Community Care Program.
     Please describe how VA is ensuring veterans and spouses 
receiving such treatments or about to start such treatments are not 
adversely impacted by repeated changes in non-VA care programs and 
contractors.

    Response. IVF services are a very specialized medical procedure, 
and as such are only provided by a discrete number of clinicians around 
the country. When an IVF provider is needed by a Veteran and/or his or 
her family, VA's third party administrators actively work to bring the 
clinician into the community care network, if they are not already part 
of it. Active outreach is being performed for couples either approved 
for VA IVF health care benefits or those who are eligible for VA IVF 
health care benefits but whom we know are actively receiving IVF care 
outside our health care system. In the latter case, the couples can 
decide if they wish to transfer responsibility for their future/
continuing IVF care and services to a VHA-authorized provider(s). VA 
has developed a mechanism to track these patients to ensure care 
coordination (including identification of preferred providers) for 
these Veterans and their families. Identifying these Veterans as early 
in the process as possible will help ensure more timely access to 
providers and the IVF care. IVF care that cannot be provided in-house 
will continue to be purchased in the community (invoking available 
contract or similar purchase authority.)
Electronic Health Records
    Question 21. According to the reports from this spring, the Defense 
Department's $4.3 billion Cerner medical record system failed to 
achieve many of its initial goals at the first hospitals that went 
online and transition systems seamlessly. Technical problems and poor 
training resulted in numerous errors and reduced the number of patients 
who can be treated, according to interviews with more than 25 military 
and VA health IT specialists and doctors, including six who work at the 
four Pacific Northwest military medical facilities that rolled out the 
software over the last year. Recently, DOD has added a $1.1 billion 
contract to extend Leidos' work order to include EHR standardization 
since the VA had hired Cerner as its prime contractor. This is in 
addition to the original $4.3 billion Leidos- Cerner contract. A recent 
briefing to Congressional staff by VA Puget Sound cited Madigan Army 
Medical Center experiencing a 50 percent drop in clinician productivity 
during the transition. Clearly, already overburdened VA hospitals 
cannot afford to see this same effect.
    a. Please provide a detailed description of the measures you are 
taking to ensure the VA EHR implementation will not fall victim to 
similar problem that the DOD implementation did.
    Response. To mitigate possible impacts to the deployment of VA's 
new EHR in VA hospitals, VA is leveraging DOD's lessons learned from 
their IOC sites. Several examples of efficiencies VA is leveraging 
include: revised contract language to improve trouble ticket resolution 
based on DOD challenges; optimal VA EHRM governance structure; fully 
resourced PMO with highly qualified clinical and technical oversight 
expertise; effective change management strategy; and, utilizing Cerner 
Corporation as a developer and integrator consistent with commercial 
best practices.

    b. Please provide an updated timeline for EHR implementation in VA 
Puget Sound and VA Tacoma.
    Response. By implementing the same electronic health record (EHR) 
solution as the Department of Defense (DOD), the Department of Veterans 
Affairs (VA) is not only taking advantage of a commercial solution and 
industry's best practices, but VA is also able to leverage lessons 
learned from DOD. These lessons learned are tracked to proactively 
reduce and address challenges at VA Initial Operating Capability (IOC) 
sites. As challenges arise throughout the deployment, VA will work 
urgently to mitigate the impact to Veterans health care.
    Furthermore, there have not been any changes made to the deployment 
timeline provided to your staff on October 23, 2018, which includes the 
timeline for EHR implementation in VA Puget Sound and VA Tacoma.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to 
 Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
    Question 22. Mr. Secretary, as you stated in your testimony 
provided ahead of the hearing, one of your priorities is to address the 
45,000 vacancies at the VA. One of the ways I proposed to address this 
issue was to increase the maximum amount the VA will provide to 
participants in the Education Debt Reduction Program, a measure I was 
proud to have included in the VA MISSION Act. Can you expand upon the 
measures you mentioned in your testimony on how you and your staff are 
addressing this crisis, and how you hope to recruit and retain the best 
candidates to these positions?
    Response. The Education Debt Reduction Program (EDRP) is one of 
VHA's most viable tools for recruiting and retaining critically needed 
healthcare providers. VA is looking forward to implementing additional 
flexibilities authorized by the MISSION Act, specifically the increase 
in the maximum EDRP award amount to $200,000 and the establishment of a 
program targeted to recruit recent medical school graduates, residents 
and fellows by repaying student loans in exchange for service at VA. 
VHA will also be expanding the Health Professions Scholarship Program 
to include offers of medical school scholarships for 50 individuals as 
required under the MISSION Act.

    Question 23. Mr. Secretary, I'm sure you know that today, veterans 
with no service-connected disabilities who have higher incomes are not 
able to get care from the VA. My office gets calls from Vermont 
veterans who know they don't qualify for VA health care, but want to 
get their care there. Many have even suggested that they'd be willing 
to pay to access VA health care. I think this idea makes a lot of 
sense. Do you think that all veterans--regardless of income--should be 
able to choose VA if they want? Are you willing to work with me on 
figuring out what it would take to give these veterans the choice of VA 
health care?
    Response. The Veterans' Health Care Eligibility Reform Act of 1996 
(Public Law 104-262) mandated that VA deliver services to Veterans in 
accordance with statutory requirements who have service-connected 
conditions, to Veterans unable to pay for necessary medical care, and 
to specific groups of Veterans, such as former prisoners of war. The 
legislation permitted VA to offer services to all other Veterans to the 
extent that resources and facilities were available; it also required 
VA to develop and implement an enrollment system to facilitate the 
management and delivery of health care services. This has been 
accomplished through the establishment of eight (8) Priority Groups 
with Priority Group 1 (Veterans who are 50 percent or more service-
connected and medal of honor awardees) and Priority Group 8 which 
includes Veterans whose incomes are above certain thresholds.
    In 2003, VA made the difficult decision to stop enrolling new 
Priority Group 8 Veterans in order to ensure the provision of timely 
and quality medical care. However, on June 15, 2009 regulations were 
issued that allowed VA to reopen enrollment for VA health care to 
Veterans whose previous calendar year's household income exceeded the 
current VA national income thresholds or Geographical Means Test 
Thresholds by 10% or less. While this new provision did not remove 
consideration of income, it did increase established income thresholds 
allowing more Veterans to qualify for enrollment in VA's health care 
system. Also, in 2015 VA eliminated the use of net worth as a 
determining factor for both health care programs and copayment 
responsibilities. This change made VA health care benefits more 
accessible to lower-income Veterans

    Question 24. Mr. Secretary, I know we've had a lot of conversations 
around choice and privatization. VA remaining strong is central to the 
whole idea of ``choice''--that veterans should have the choice of where 
they go for care because VA must be one of the choices given to the 
veteran. I am worried, however, that right now--even with the changes 
from the MISSION Act--the VA is set up to fail as an organization, and 
fail our veterans, because of the current bureaucracy we've set up. Let 
me walk you through what I mean by that.
    Take a veteran, who calls the VA CBOC in Burlington, my home town, 
for an appointment--let's say it's a dermatology appointment. The 
veteran is told the next available appointment is in 60 days, making 
her eligible for Choice. So she is referred to the UVM Medical Center, 
where the wait is 12 MONTHS for a new patient. So, two months at VA--12 
months in the community. At that point, the veteran has two choices--
call VA back and say she wants the appointment at the VA CBOC in 60 
days, or make the appointment for community care in a year. There are 
two problems with this: First, we're relying on the veteran to 
understand this nuance--that she still has the choice of VA care--and 
relying on her to take the extra step of calling the VA back and 
setting up the appointment. But here's the second problem: If the 
veteran does that--calls back the VA and sets up the appointment for 
two months from now, that VA appointment ends up making the CBOC's wait 
times look bad, because they're not hitting their wait time goals. That 
leaves the CBOC to decide between either doing what's good for the 
veteran but knowing it will mess up their numbers, or doing the wrong 
thing for the veteran but what looks better administratively for them.
    Mr. Secretary--Do you really think this makes sense? How will you 
make sure that VA medical centers and clinics aren't ultimately hurt 
when they do the right thing for their patient?
    Response. VA is working toward taking back community care 
scheduling and care coordination from contractors. VAMCs will be 
responsible for scheduling and care coordination activities. Owning 
customer service is a top priority for VA and the third-party 
administrator will only assist with these activities when a VA facility 
has requested the support. VA is developing a tool that allows the 
Veteran and VA to see the average wait time for the community care 
appointment. VA's plan is to phase in the use of this tool prior to 
MISSION act implementation so Veterans may make a more informed 
decision on the best location to receive the requested care.

    Question 25. Mr. Secretary, last month VA testified on my 
legislation to expand access to dental care for veterans. I want to 
thank you for supporting the idea of expanding access to veterans for 
dental care. I'm glad this is something the VA supports. Now, I 
understand you're worried about the cost. First, this Committee doesn't 
get to make the decisions about how much money the VA gets--that is the 
job of the appropriations committee. But let me promise you that I will 
do everything I can to make sure the VA gets the money needed to 
accomplish any expansion that this Committee approves. And I hope we 
can work together on that. Will you work with me on that?
    Response. To be clear, VA did not support many of the sections in 
the draft legislation presented at the August 1, 2018, Senate Veterans' 
Affairs Committee hearing, as several were unnecessary given our 
current authority and other provisions either required significant 
additional resources or relied on unproven approaches to treatment. 
With that said, we are always ready to provide technical help. We agree 
the preventive model of dental care is the most cost-effective. Section 
3 of the draft bill would have required VA to assess the feasibility 
and advisability of furnishing dental services and treatments to 
Veterans enrolled in VA health care but who are not eligible for such 
care under other authorities. We note that expansion of dental benefits 
would create a surge of new patients who we believe would have unmet 
dental needs due to their prior lack of dental care. These previous 
unmet needs would be more involved with a higher associated cost to 
treat and take more dentist time. We expect the increased demand and 
time would create access to care hurdles based on our current resource 
allocation. In the short-term, we expect an initial surge in demand for 
dental care and individual costs would stabilize over time. Of the 9.1 
million Veterans enrolled for VA health care, only 1.2 million are 
currently eligible for dental care, and approximately 530,000 of those 
Veterans received dental care through VA in fiscal year 2018. We expect 
that a 758 percent increase in dental eligibility would create a 
significant short-term spike in resources needed to meet the increased 
demand. Following the short-term spike, VA would need a substantial 
increase in resources for the long-term due to the sheer number of 
newly eligible Veterans. There may be opportunities to explore 
expansion of dental benefits to these 8 million Veterans who currently 
are not eligible or have not used dental benefits in the past, in a way 
that is considerate of financial impact in both the short-term and 
long-term, and we would be happy to discuss any such options with you.

    Question 26. Mr. Secretary, to my mind, VA is already spending this 
money on dental care--it's just that you're spending it on the back 
end, when costly health care problems have already occurred rather than 
on the front end, preventing these problems in the first place. Let me 
give you some data, which you might find helpful. UnitedHealthCare--a 
private insurance company, which you probably won't hear me site very 
often--did a study where they found that--and I quote: ``individuals 
with chronic conditions who regularly received recommended dental care 
. . . had medical claims that averaged nearly $1,500 lower annually 
than those with chronic conditions who received . . . no dental care at 
all.'' Given the especially high rates of veterans with chronic 
conditions, I think it's reasonable to assume this same cost savings of 
$1,500 per person would easily translate to the veteran population. 
That is to say, by providing dental care to veterans, we'd actually 
have the opportunity to save money, not spend more. So, Mr. Secretary--
can you tell me that if we can show that providing dental care wouldn't 
actually cost the VA more money, that you'd support it?
    Response. Yes, VA will work closely with Congress to estimate 
utilization and work toward implementing any legislation that is 
approved. The President's FY 2018 budget of $1.2 billion for VA dental 
care covered oral health care services for the 530,000 Veterans that 
were served. The budget is approximately $2,300 per year per Veteran. 
As previously stated, these dental needs will be more complicated with 
a higher associated cost to treat for newly eligible Veterans. Our 
research found no data to estimate utilization of new benefits such as 
those proposed for an additional 7.9M Veterans. Published data on 
dental utilization varies ranging from 35% to 60%. The higher usage is 
associated with those that have third-party dental benefits. If 
eligibility is expanded, the Office of Dentistry will collaborate 
within VHA to works toward the goal of using dental care to improve 
Veterans' overall health care.

    Question 27. Mr. Secretary, I have always believed that the cost of 
war must also include taking care of our veterans when they return 
home. To my mind, this includes providing benefits to those who may 
have been exposed to dangerous chemicals in service to our country, 
such as Agent Orange. While the VA provides benefits to these veterans, 
the burden of proof is much higher for those who served in Vietnam's 
territorial waters compared to their counterparts who served on the 
ground. I have heard from many Vermonters that this increased burden of 
proof has negatively impacted their ability to receive the care they 
need. Mr. Secretary, will you work with me and the overwhelming 
majority of Congress who want to create a more lenient burden of proof 
for our Blue Water Navy veterans, and ensure they receive the care they 
need due to their service?
    Response. VA stands ready to work with Congress to ensure the 
equitable administration of disability compensation for all Veterans 
including Blue Water Navy Veterans. VA's current regulatory definition 
of service in Vietnam excludes service in the offshore waters of 
Vietnam unless the conditions of service involved duty or visitation in 
the Republic of Vietnam. This is because there is not sufficient 
scientific evidence showing that individuals who served in the offshore 
waters risked exposure to Agent Orange. However, VA has developed 
procedures for Veterans who served in the offshore waters to ensure 
that each case is reviewed individually on a facts-found basis. This 
procedure allows adjudicators to grant benefits for presumptive 
service-connected conditions when the evidence demonstrates that a ship 
operating in the offshore waters:

    1) temporarily enters an inland waterway,
    2) docks to a pier or shore, or
    3) sent personnel or supplies ashore.

    VA has established a lenient burden of proof for the latter as a 
statement provided by the Veteran saying he went ashore would be 
sufficient to grant benefits.

    Question 28. Mr. Secretary, as you know, the White River Junction 
VA Medical Center has been without a permanent director for some time 
now. Now that we have a new VISN 1 Director, will you commit to working 
with me and Mr. Lily to quickly fill the White River Junction director 
role with someone who will be there for the foreseeable future?
    Response. We recognize your concerns about filling the Medical 
Center Director position at White River Junction VA Medical Center. 
Strong medical center leadership is critical to maintaining the high 
standards and quality of care of Veterans being served by this system. 
You can be assured that VA is committed to hiring the best qualified 
candidate for the Director position as soon as possible. The position 
was announced on September 12, 2018 and closed on September 26, 2018. 
VA's selection of Senior Executive Service (SES) leaders is a thorough 
and rigorous process. We anticipate completing the hiring process for 
this position as soon as possible.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
 Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
                              agent orange
    Question 29. Your letter to the Committee neglects to mention 
several sections of the ``Blue Water Navy Vietnam Veterans and Agent 
Orange'' report issued by IOM in 2011, which corroborates the 
Australian report finding ``that in experiments simulating the water-
distillation systems used on Navy Ships the systems had the potential 
to enrich TCDD concentrations.'' You also ignore IOM's Veterans and 
Agent Orange 2008 Update, published in 2009 that states, ``a 
presumption of exposure of military personnel serving on those vessels 
is not unreasonable.'' The effort to cherry-pick details from the 
report undercuts your opposition to extending presumption of service 
connection to Blue Water Navy veterans. Does the Department dispute the 
science behind the IOM and Australian studies related to distillation? 
Why does VA refuse to act when IOM presents the Department with 
scientific evidence linking health conditions, such as bladder cancer, 
Parkinson's like conditions, etc. to herbicide exposure, as was clear 
in the 2016 release report?
    Response. Advocates for Blue Water Navy Veterans have framed the 
issue as there being a lack of science from the National Academy of 
Medicine, as well as other sources, to exclude these Veterans from a 
presumption of Agent Orange exposure. However, this is a 
mischaracterization of the standards for determining that exposure 
occurred. When Congress passed the Agent Orange Act, it required that 
there be ``sound medical and scientific evidence'' to support such 
exposures.
    VA has determined that this threshold has not been met. In 2011, 
the Institute of Medicine (IOM), now the National Academy of Medicine, 
reviewed all available scientific evidence and concluded that exposure 
among Blue Water Navy Veterans ``cannot reasonably be determined.'' The 
IOM's report indicated that Agent Orange was destroyed by sunlight 
within hours of application and any that survived would rarely make it 
out to the South China Sea because of the major dilution factor.
    Media and several Veterans Service Organizations supporting the 
legislation have relied on an Australian study from 2002 that was 
designed to mimic Royal Australian Navy distillation policies and 
procedures; however, this study is irrelevant to U.S. Navy policy and 
practice. U.S. Navy ships were required to draw up seawater for 
conversion to shipboard potable water at least 12 miles offshore from 
any river, a distance at sea where the presence of Agent Orange was 
highly unlikely. As points of reference, 12 cubic miles of water is 
equal to 13.2 trillion gallons, and 1 trillion gallons of water flow 
over Niagara Falls in a single month. Thus, the dilution factor would 
have been significant. IOM considered the Australian study in its 2011 
review and stated the significance of the study's findings was highly 
uncertain for U.S. Blue Water Navy ships.
    VA continues to study the science behind this issue. In late 2019, 
VA will publish the peer-reviewed Vietnam Era Health Retrospective 
Observational Study. The study will compare the health and morbidity of 
deployed Vietnam Veterans versus a cohort of non-deployed Veterans and 
similarly-aged U.S. residents who never served in the military. VA 
collected data from nearly 43,000 participants including nearly 1,000 
Blue Water Navy Veterans. VA believes it is necessary to be informed by 
the finding of this study before further action is taken.

    Question 30. What is the timeline for VA and OMB to act on the IOM 
recommendation regarding bladder cancer, Hypothyroidism, Parkinson's-
like conditions, and hypertension?
    Response. The National Academy of Medicine (NAM) issued a 
contracted Veterans & Agent Orange report in March 2016. VA organized 
work groups and deliberated, as it had under the Agent Orange Act. The 
workgroups made recommendations to then-Secretary Shulkin. Secretary 
Wilkie is currently reviewing the recommendations made to Secretary 
Shulkin. A new NAM on Veterans & Agent Orange was issued November 2018 
and is also currently under review. The timeline for this review is 
expected to extend to this summer.
                        electronic health record
    Question 31. a. Please discuss how patient information will be 
housed under the new Electronic Health Record between DOD and VA?
    VA Responses: Patient information for the Department of Defense 
(DOD) and the Department of Veterans Affairs (VA) will be physically 
housed at the Cerner Federal Hosted Enclave, which is comprised of two 
facilities. One facility serves as the failover and continuity of 
operations (COOP) back-up for the other. Data is encrypted at rest and 
in transit, before it leaves the facility. Connectivity between the two 
facilities is achieved via fully redundant with no single points of 
failure high-speed networks.

    b. How will VA ensure that patient data is shared between community 
providers and VA? How will you ensure that the data is protected 
against cyber intrusion?
    VA Responses: VA's new EHR will have the capability to connect and 
securely exchange patient data with community care providers, 
specifically, but not limited to, CommonWell Health Alliance and 
DirectTrust by supporting their specifications, security, and content 
specifications. Once the VA EHR is deployed, the solution will 
participate in a Health Information Network (HIN) or Qualified Health 
Information Network (QHIN) that has agreed to the terms of the Trusted 
Exchange Framework and Common Agreement (TEFCA). Participation is 
defined as being in production with HIN or QHIN, under a participation 
agreement that aligns with the TEFCA.

    c. Do you think that you have the appropriate team in place to 
implement the Cerner contract?
    VA Responses: VA will deploy DOD authorized security boundary 
protections using a combination of Cybersecurity Service Provider 
(CSSP) services and joint Department cybersecurity operations centers 
(CSOC) visibility and incident response capabilities. The joint 
electronic health record (EHR) system is stored within the DOD-
authorized enclave (MHS GENESIS) hosted at Cerner Corporation. MHS 
GENESIS risk management and continuous monitoring activities are 
supported through Defense Health Agency (DHA), DOD Health Management 
System Modernization (DHMSM) Program Management Office (PMO), and 
Office of Electronic Healthcare Record Modernization (OEHRM) unified 
interagency cybersecurity programs.

    d. Will you commit to keeping the Committee informed about the 
implementation of the contract?
    VA Responses: Yes, VA understands the importance of transparency 
and will continue to keep Congress informed about the Department's new 
EHR rollout. VA meets quarterly with with staff from the House and 
Senate Appropriations and Veterans' Affairs Committees to brief on the 
progress of the EHRM development and implementation.
                      office of inspector general
    Question 32. Several Members of the Committee have voiced concerns 
regarding the independence of the Office of the Inspector General; in 
fact, we approved an amendment to affirm the role of the Inspector 
General and to preclude VA from impeding in any IOG investigation. 
Since your confirmation, have you met with IG Missal? Have you 
reaffirmed VA's commitment to providing OIG with any and all 
documentation the office requests for investigations?
    Response. As I stated during the hearing, I view the Inspector 
General as a partner and not subordinate to the Secretary. The 
Inspector General works closely with the Office of Accountability and 
Whistleblower Protection and the Veterans Health Administration's 
Office of Medical Inspector to investigate allegations of misconduct or 
other improprieties. In my previous position, I worked with the 
Department of Defense Inspector General and plan to foster that same 
working relationship with Mr. Missal. I was asked during the hearing if 
I would commit to not interfere or hinder the independence of the 
Inspector General and be transparent with requested information. I 
would like to state again that I am commitred to that. I have met with 
Mr. Missal as recently as October 5, 2018, and it is my goal to 
regularly meet with him for updates and discussion. I strongly support 
the Inspector General's investigations and mission.
                               personnel
    Question 33. Currently there the Deputy Secretary and Under 
Secretary of Health Affairs positions are filled with someone in an 
acting capacity. How are you working with the Administration to find 
individuals to fill these senior leadership positions?
    Response. To fill the Under Secretary for Health (USH) position 
there is a process that includes forming a commission which is convened 
under the provisions of 38 U.S.C. Section 305. The commission consists 
of the Deputy Secretary of VA along with specific members who have 
experience in various areas of the Health Administration fields. VA's 
Corporate Senior Executive Management Office (CSEMO) begins the process 
by gathering all the applicants' resumes and conducting a minimum 
qualifications review. After that, the remaining candidates are 
referred to a Subject Matter Expert (SME) panel, who then provides a 
rating and ranking of the candidates' applications. The scores are then 
compiled, and a ``best qualified'' list is then presented in the form 
of a binder (with all supporting documents) to the Commission, which 
conducts the interviews. We are currently at the stage where we are 
compiling the scores to identify those best qualified. We expect to 
present the list to the Commission and have the interviews conducted 
during the last week of November. After those interviews are conducted, 
the Commission will make a recommendation of at least three individuals 
to the Secretary. The Secretary will then forward the recommendations 
to the President with appropriate comments for the President's 
consideration.
    Currently, there is a permanent Principal Deputy Under Secretary 
for Health (PDUSH) in place (Dr. Richard Stone) and he is currently 
serving as the Executive in Charge of VHA. Because of his role, there 
is an ``Acting'' in place for the PDUSH position, but that is only 
until a new USH is identified and onboarded. After that, Dr. Stone will 
resume his duties as PDUSH.
                             patient safety
    Question 34. Does VA leadership review OIG reports related to 
patient safety with adverse outcomes? And if leadership does review 
these reports, are the recommendations and findings applied throughout 
the entire VA healthcare system?
    Response. VA and VHA leadership reviews OIG reports and involves 
the National Center for Patient Safety to ensure any findings that risk 
harm to Veterans are assessed and used to inform system wide 
improvements.
    In general, VA leadership learns of adverse outcomes to patients 
through communications with facility or VISN leadership and takes 
actions as soon as possible upon learning of a potential risk to 
patient safety. Understandably, if a serious safety issue has been 
reported to the OIG, VA cannot (and does not) wait for the OIG to 
complete its review and publish its investigative report before 
assessing the situation on the ground and determining what corrective 
action, if any, is needed to eliminate any actual or potential patient 
safety risks. In other words, VA does not delay any needed corrective 
action but acts promptly in the interim. Typically, the OIG will 
assess, as part of its investigation or review, any interim corrective 
action taken by VA and its sufficiency. Patient safety is paramount.
    In response to reported adverse events for which there may be 
systemic root causes, VHA's National Center for Patient Safety assesses 
patient safety findings, usingindustry standards. If a safety risk is 
of nationwide concern, the National Center for Patient Safety issues a 
nationwide alert that informs the field both of the problem, affected 
facilities or service-lines, and the follow-up actions to be taken in 
response. See VHA Handbook 1050.01 for a fuller discussion of the 
Patient Safety Program.
                             va mission act
    Question 35. As VA begins to implement the VA MISSION Act, can you 
discuss what metrics you will use to ensure care that veterans receive 
in the community is the same standard and timely? What metrics will you 
use to track whether community providers are trained in veteran 
specific conditions?
    Response. Section 133 of the MISSION Act requires VA to develop 
competency standards for community providers in which VA has clinical 
expertise. At this time, the Section 133 group is still working out the 
metrics that will meet the spirit of Section 133. Currently, this 
includes all community providers completing an overview course covering 
military culture, caring for Veterans, suicide prevention, and other 
resources. Moreover, required training for sub-specialty providers in 
the areas of Traumatic Brain Injury (TBI), post-traumatic stress 
syndrome (PTSD), and Military Sexual Trauma (MST) is also being 
reviewed by the Section 133 team.
    As for tracking the completion of the courses previously discussed 
and opioid training through Section 131 of the MISSION Act, the courses 
will be accessed through VHA TRAIN, which is the external system that 
houses community provider training. At this time, VA currently tracks 
community provider completion of opioid training and additional courses 
will be added (as noted above). Once a training course is uploaded into 
VHA TRAIN, course completion will be cross-referenced with a master 
list of community providers the VHA Office of Community Care maintains 
for tracking and reporting.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to 
 Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
                 va under secretary for health vacancy
    Question 36. President Trump has yet to nominate someone for the 
important role of Under Secretary for Health. The Veterans Health 
Administration has a lot on its plate in the coming years including 
implementation of the new Veterans Community Care Program and 
Electronic Health Record modernization so a permanent, stable leader is 
vital. However, instead of moving toward a permanent lead, Dr. Carolyn 
Clancy, Acting Under Secretary for Health, was replaced in mid-July by 
Dr. Richard Stone. Could you please provide an explanation for that 
staffing change and an update on any progress toward a permanent Under 
Secretary?
    Response. To fill the Under Secretary for Health (USH) position 
there is a process that includes forming a commission which is convened 
under the provisions of 38 U.S.C. Section 305. The commission consists 
of the Deputy Secretary of VA along with specific members who have 
experience in various areas of the Health Administration fields. VA's 
Corporate Senior Executive Management Office (CSEMO) begins the process 
by gathering all the applicants' resumes and conducting a minimum 
qualifications review. After that, the remaining candidates are 
referred to a Subject Matter Expert (SME) panel, who then provides a 
rating and ranking of the candidates' applications. The scores are then 
compiled, and a ``best qualified'' list is then presented in the form 
of a binder (with all supporting documents) to the Commission, which 
conducts the interviews. We are currently at the stage where we are 
compiling the scores to identify those best qualified. We expect to 
present the list to the Commission and have the interviews conducted 
during the last week of November. After those interviews are conducted, 
the Commission will make a recommendation of at least three individuals 
to the Secretary. The Secretary will then forward the recommendations 
to the President with appropriate comments for the President's 
consideration.
    Currently, there is a permanent Principal Deputy Under Secretary 
for Health (PDUSH) in place (Dr. Richard Stone) and he is currently 
serving as the Executive in Charge of VHA. Because of his role, there 
is an ``Acting'' in place for the PDUSH position, but that is only 
until a new USH is identified and onboarded. After that, Dr. Stone will 
resume his duties as PDUSH.
                               mar-a-lago
    Question 37. On April 20, 2018, as Acting Secretary, you traveled 
to West Palm Beach and attended a meeting with the ``Mar-a-Lago Crowd'' 
at Mar-a-Lago, a property owned by President Trump. Chief of Staff 
Peter O'Rourke also traveled with you on that trip. In documents 
obtained by ProPublica through the Freedom of Information Act, Mr. 
O'Rourke's expense report for the trip details that he stayed at Mar-a-
Lago the night of April 19, 2018 at a cost of $195. Mr. O'Rourke also 
incurred lodging fees of $202.27 for that same night at a Holiday Inn, 
the original hotel that was canceled late on the same day as check in, 
resulting in a charge of one night's stay. In an email, it is explained 
that Mr. O'Rourke was ``redirected by a White House task after the 24-
hour cancellation period.'' Could the Department please provide 
additional information regarding what official task Mr. O'Rourke was 
directed to carry out that required him to redirect to one of the 
president's properties, at additional cost to taxpayers?
    Response. The COS was redirected to stay at this lodging in order 
to facilitate his attendance at a required meeting with the then-Acting 
Secretary of Veterans Affairs.
                   provider recruitment and retention
    Question 38. The most recent data from the VA Office of the 
Inspector General shows that nationwide the VA is still dealing with 
staffing shortages. In Honolulu, psychiatry is the number one shortage 
and there are 42 clinical shortage areas. Can you provide an update on 
what VA is doing to improve provider recruitment and retention in 
Hawaii and nationally?
    Response. In response to a Government Accountability Office Report 
in March 2018, VA Pacific Islands HCS (VAPIHCS) organized a 
multidisciplinary systems redesign group to review and evaluate 
strategies to promote physician recruitment and retention. The group 
identified a list of best practices (some of which were already being 
utilized by VAPIHCS) that have proven beneficial at other VA 
facilities, including the use of a task force to explore options for 
improving recruitment and retention. In May 2018, VAPIHCS appointed a 
physician recruitment and retention taskforce aimed at identifying 
additional actions that could be taken to improve physician recruitment 
and retention. To date, the task force has identified several 
recommendations, which are currently being implemented:

    1. Initiate the hiring process immediately after being notified of 
an upcoming vacancy
    2. Utilize open continuous recruitment
    3. Expedite the credentialing and privileging process
    4. Maximize use of Recruitment/Retention/Relocation incentives (``3 
Rs'')
    5. Maximize use of the Education Debt Reduction Program (EDRP)
    6. Present salary offer early in the hiring process
    7. Utilize other recruitment events in addition to USA Jobs

In addition, VAPIHCS authorized more than $200,000 in relocation and 
retention funds for physicians. Of the nine physicians who received 
funds on 2018, eight are still on staff at VAPIHC.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Joe Manchin III to 
 Hon. Robert L. Wilkie, Secretary, U.S. Department of Veterans Affairs
    Question 39. Each generation of veterans have had their own form of 
toxic exposure, whether Mustard Gas, Agent Orange, or any number of 
chemicals and hazardous environments our service personnel work in 
today.
    a. What efforts are currently being undertaken to identify and 
track toxic exposures?
    Response. There are several Department of Veterans Affairs (VA)/
Department of Defense (DOD) collaborative activities aimed at improving 
the identification and tracking of toxic exposures. The primary 
initiative, which has been 25 years in the making, is the development 
of the web-based solution, Individual Longitudinal Exposure Record 
(ILER). The ILER pilot was launched on October 1, 2018. ILER addresses 
a critical gap in current readiness and healthcare capabilities to 
assess and better document individuals' service related exposure.
    ILER will bridge this gap by providing an easily accessible and 
searchable electronic record of a servicemember's occupational and 
environmental exposures (garrison- and deployment-related) from initial 
entry to end of service.
    ILER will enable improvement of exposure knowledge, healthcare, 
epidemiological assessments of exposures, exposure-related medical 
research, and disability evaluation and claims processes for 
servicemembers and veterans.
    ILER will leverage and collate the exposure and deployment data 
available to present the most relevant information to DOD and VA. The 
ILER Pilot version 1.0.0.0 will leverage information provided from the 
following sources:

     Defense Occupational and Environmental Health Readiness 
System--Industrial Hygiene (DOEHRS-IH)
     Military Exposure Surveillance Library (MESL)
     Military Health System (MHS) Data Repository (MDR)
     Armed Forces Health Surveillance Branch (AFHSB)
     Defense Manpower Data Center (DMDC)
     Defense Enrollment Eligibility Reporting System (DEERS)
     Contingency Tracking System (CTS)

    These systems will provide the initial data source of the pilot and 
will provide a person-centric record that can be utilized by 
Clinicians, Claims/Benefits Processors, Program and Policy Analysts, 
Researchers and Informatics/Analytics Professionals to enhance medical 
care and perform a more comprehensive health surveillance.

    b. What steps can be taken to prepare the Department of Veterans 
Affairs and the next generation of veterans with toxic exposures for 
the next 20 years?
    Response. Please see efforts described in response to (a) above.

    c. Is the tracking of toxic exposures being considered in the 
design of the new Electronic Health Record?
    Response. Yes, VA will track self-reported toxic exposures to 
Veterans with its new EHR. The EHR will utilize a commercial population 
health platform, HealtheIntent, which provides registries as part of 
its suite of capabilities. Migration of current VA self-reporting 
registries, such as Traumatic Brain Injury (TBI), military sexual 
trauma (MST), airborne hazards and open burn pit registry (AHOBPR), 
will be transitioned into the HealtheIntent platform as part of VA's 
data migration efforts.

    Question 40. The Departments of Defense and Veterans Affairs 
previously attempted to replace their separate EHR systems with a 
single shared system through the Integrated EHR (iEHR) initiative, 
unfortunately this effort was abandoned in 2013. Communication and 
collaboration between the two departments will be essential for the 
success of the current, interoperable EHR rollout.
    Please detail the current structures in place to facilitate 
communication and collaboration between the two departments. What 
systems and structures are planned to be put in place as the rollout 
continues?
    Response. VA and DOD are continuing to work closely together to 
advance transparency and hone governance through an interagency 
decisionmaking perspective through the DOD/VA Interagency Program 
Office (IPO) established by Congress. The Departments' Secretaries 
recently announced a joint statement reconfirming their commitment to a 
joint and interoperable EHR rollout. VA is currently working with DOD 
and IPO to analyze and assess prospective additional efficiencies that 
may optimize the utilization of other resources across VA, DOD, and 
IPO's organizational EHR implementation and modernization portfolios.

    Question 41. It was reported that the DOD's rollout of the Cerner 
system in the Pacific Northwest was plagued with problems that 
significantly impacted patient care. Any rollout of a new EHR system is 
going to experience significant challenges, but it is important to 
learn from those and adjust future strategies.
    a. Does the VA have detailed reports on the problems encountered 
during the DOD's initial Cerner EHR rollout?
    Response. Yes, DOD lessons learned were shared with VA during the 
alpha contract negotiations phase with Cerner Corporation. These 
lessons learned were immediately leveraged to improve the quality of 
the Indefinite Delivery, Indefinite Quantity contract that was 
ultimately signed on May 17, 2018 between VA and Cerner Corporation. VA 
maintains a running log of lessons learned, and incorporates regular 
feedback from DOD, DHA, and DHMS PEO into its lessons learned 
documentation. By learning from DOD, VA will be able to proactively 
address challenges and further reduce potential risks at VA's IOC 
sites.

    b. What were the underlying causes of those problems? Which of 
these underlying causes are likely to impact deployment of a Cerner EHR 
system in VA hospitals?
    Response. To mitigate possible impacts to the deployment of VA's 
new EHR in VA hospitals, VA is leveraging DOD's lessons learned from 
their IOC sites. Several examples of efficiencies VA is leveraging 
include: revised contract language to improve trouble ticket resolution 
based on DOD challenges; optimal VA EHRM governance structure; fully 
resourced PMO with highly qualified clinical and technical oversight 
expertise; effective change management strategy; and utilizing Cerner 
Corporation as a developer and integrator consistent with commercial 
best practices. For additional specificities on DOD's lessons learned, 
VA recommends reaching out to DOD.

    c. What office will be responsible for cataloguing the ``lessons 
learned'' from the DOD rollout and who will be leading that office?
    Response. VA, specifically the Office of Electronic Health Record 
Modernization (OEHRM), is responsible for cataloguing and utilizing 
DOD's lessons learned to mitigate potential challenges throughout its 
deployment.

    Question 42. One in ten Veterans Affairs jobs are currently 
unfilled. As of September 26th, there are 128 positions posted in 
USAJOBS for West Virginia Hospitals and Benefits offices, including for 
many important clinical and social work positions. Vacancies have the 
potential to increase the burn out rate of employees as well increase 
the number of veterans that need to be sent out into the community for 
care.
    a. In the 60 days that you have been in office, has there been 
discussion of developing and/or implementing a vacancy action plan?
    b. If no such plan is in place will you commit to working on one 
and reporting back to us?
    Response. I understand your concern about vacancies in VA. It is 
important to note that staffing plans consider workforce turnover and 
growth, and built into those staffing plans, is the expectation that 
there will always be vacant positions in some stage of recruitment. We 
know that Veterans receive the same or better care at VA medical 
centers as patients at non-VA hospitals. Vacancies reflect a hiring 
demand signal, but do not indicate significant shortages in most 
instances. In areas where vacancies are higher due to factors such as 
rurality, high cost geographic areas, and market competition, VA 
utilizes the authorities granted under the VA MISSION ACT to partner 
with community care providers. The best indicators of adequate staffing 
levels are Veteran access to care and health care outcomes, and we are 
continuing to make substantial progress on these measures.

    Question 43. We are pleased to see that the VA is implementing an 
appeals improvement and modernization plan. However, our office alone 
is currently working with the department on 200 cases. Some 
constituents are dealing with claims that have been lost or put off for 
over 5 years.
    a. What have you observed that could improve the appeals process?
    Response. The current appeal process for VA benefit claims does not 
serve Veterans well, with resolution times for veterans averaging 3 to 
7 years depending upon whether the Veteran appeals to the Board of 
Veterans' Appeals (Board). To improve this process, VA worked closely 
with its stakeholders (including Veterans Service Organizations, 
private attorneys, and Congressional staff) to develop a new, more 
efficient, decision-review process for claims. The President signed 
this process into law as the Veterans Appeals Improvement and 
Modernization Act in August 2017. VA is on track to implement it in 
February 2019 for claimants who receive decisions on their claims after 
the February implementation date.
    The new law provided VA several options to improve the appeals 
process by increasing efficiencies in established practices and by 
providing Veterans with opportunities to opt into a new system that 
provides claimants with the opportunity to file supplemental claims 
based on new evidence, have higher-level adjudicators review prior 
decisions, or appeal directly to the Board.

    b. What steps are you taking to better address the initial veteran 
claim process to ensure there is not a backlog of appeals?
    Response. Historically, Veterans consistently initiate appeals of 
claim decisions at a rate of 10 to 12 percent. The solution to 
effectively managing disagreements is through more review options and 
timely decisions under the new statute, which has replaced the long, 
complex, and confusing legacy appeals process.
    VA remains committed to resolving its legacy appeals as quickly as 
possible by adding additional appeal processing resources both in VBA 
and at the Board, and implementing RAMP. As noted above, RAMP provides 
Veterans with legacy appeals an opportunity to opt into the process 
authorized by the Modernization Act. If they elect to participate in 
RAMP, Veterans have access to the key features of the new process, to 
include more review options, quicker decisions, protection of the 
effective date for payment of benefits regardless of the review option 
chosen, protection of favorable findings made in VA decisions, and 
processes that are easier to understand.
    Beyond the legal changes that will go into effect in February, VBA 
is looking to increase operational efficiencies. Accordingly, effective 
October 1, 2018, VBA established three new Decision Review Operations 
Centers (DROCs) at the St. Petersburg and Seattle Regional Offices, as 
well as the former Appeals Resource Center in Washington, DC. The DROCs 
will consolidate the processing of all Board remands, Board full grants 
under the new system, and higher-level reviews under the new system.

    Question 44. The VA Office of the Inspector General reported that 
the claims backlog only covers about 79 percent of relevant cases, with 
a host of others misclassified, mistakenly excluded and, in some cases, 
only acknowledged as overdue after the files had finally been 
processed. What steps are being taken to more accurately count and 
report the number of claims awaiting decision for more than 125 days?
    Response. The VA Office of Inspector General (OIG) reported, and 
the Veterans Benefits Administration (VBA) acknowledged, that VBA's 
claims backlog has historically and consistently included only a set of 
rating-related end products that grant entitlement to disability 
compensation and pension benefits. OIG notes that additional claims are 
not counted in the backlog that, in their opinion, should be, because 
they require a rating decision. The relevant claims identified by OIG 
that are not counted in VBA's rating claim inventory or backlog but do 
require a rating decision, are those that do not consider entitlement 
to the core disability compensation and pension benefits. Examples of 
these end products are provided by OIG and include technical 
corrections to rating decisions (where a rating-related end product had 
already been completed by the agency) and entitlement to special 
housing benefits.
    Additionally, OIG identifies a very small number of claims missing 
from backlog reporting due to human error. OIG identified situations 
where some claims are erroneously excluded from the backlog and other 
situations where claims are erroneously counted as backlog, when they 
are in fact not. However, OIG also acknowledged that VBA staff who 
discovered these errors made the necessary adjustments to properly 
reflect the backlog status. VBA has concurred in principle with the 
OIG's recommendation to consider revising which claims are included in 
VBA's reported disability claims backlog and will engage with 
stakeholders to ensure that any proposed changes are well understood. 
VBA is currently reviewing how best to supplement or adjust reporting 
on the rating-related backlog, which has followed consistent rules 
since the backlog was defined and reporting began in 2009.

    Question 45. The most recent data from HUD found that the number of 
homeless veterans increased by almost 2 percent from 2016 to 2017, the 
first time the number has risen since 2010. Meanwhile, over the past 
year, VA has issued and subsequently reconsidered proposals to 
terminate or reallocate funding within programs like Grant Per Diem and 
HUD-VASH. This has left providers in West Virginia concerned about 
whether their grants will be renewed and forced difficult decisions on 
staffing and capacity.
    How do you plan to keep local providers informed of changes 
relevant to their grant programs in a timely manner?
    Response. The GPD National Program Office provided regular 
communication regarding the grant selection timeline, notifications of 
conditional selection and non-selection of applicants, as well as the 
transition process for non-selected applicants who had grants that 
would be ending September 30, 2018.

     May 14, 2018--GPD National Program Office held a 
conference call reviewing the anticipated timeline regarding the grant 
selection process. This included the plans for notification via 
correspondence which was to occur at the end of the month of May. 
Presentation slides for this call were subsequently posted on the GPD 
provider website https://www.va.gov/HOMELESS/GPD_ProviderWebsite.asp
     May 29, 2018--Correspondence was mailed to all applicants 
noting whether their application was conditionally selected or non-
selected. Additional correspondence was sent to non-selected applicants 
that had a GPD grant award that would be ending on September 30, 2018, 
which provided instructions for winding down their grant projects. This 
included working with the local VA medical center to ensure the 
placement of any homeless Veterans in the program to permanent housing 
or alternative services by September 30, 2018. In addition the GPD 
National Program Office was in communication with the Directors of 
VHA's other homeless programs to alert them of coming changes and 
coordinate support with these program services to assist homeless 
Veterans as needed.
     June 11, 2018--GPD National Program Office held a 
conference call to review the notification correspondence that had been 
sent to grant applicants, as well as to review the status of grantees 
who were eligible for an option year renewal in Fiscal Year 2019. The 
presentation slides were posted on the GPD provider website.
     The GPD National Program Office also responded to 
inquiries from applicants via phone call and a special email group 
available to communicate with the grant office.
     In addition to the notifications of grantees, the GPD 
National Program Office was in communication with the Network Homeless 
Coordinator for VISN 5 and the GPD liaison in Martinsburg, WV (where 
Potomac Highlands Supported Services, a non-selected applicant with 
grant ending September 30, 2018 is located) to monitor the status of 
all the Veterans residing there and to ensure these Veterans were 
successfully placed. All the Veterans in the program were successfully 
placed by September 5, 2018.

    Question 46. Staffing shortages are a persistent challenge at the 
VA as well as many other Federal agencies. In order to fulfill its 
vital missions it is important that the VA is adequately staffed with 
well trained and highly motivated employees, in both clinical and non-
clinical positions. A recently released Office of the Inspector General 
report stated the most commonly cited challenges to staffing at VHA 
facilities fit into three categories: (1) lack of qualified applicants, 
(2) non-competitive salary, and (3) high staff turnover. In a letter to 
congressional leaders announcing there would be no pay increases for 
Federal Employees in 2019 President Trump stated ``These alternative 
pay plan decisions will not materially affect our ability to attract 
and retain a well qualified Federal workforce.''
    Do you agree with the President's assessment that canceling 
scheduled pay increases will have no material effect on recruitment and 
retention of well-qualified VA employees?
    Response. I understand your concern about vacancies in VA. It is 
important to note that staffing plans consider workforce turnover and 
growth and the expectation that there will always be vacant positions 
in some stage of recruitment. We know that Veterans receive the same or 
better care at VA medical centers as patients at non-VA hospitals. 
Vacancies reflect a hiring demand signal, but do not indicate 
significant shortages in most instances. The best indicators of 
adequate staffing levels are Veteran access to care and health care 
outcomes, and we are continuing to make substantial progress on these 
measures. Cancelling the scheduled annual pay adjustment for 2019 will 
make it even more challenging for VA to recruit and retain staff in 
clinical and non-clinical positions. In most, it not all of the rural 
locations, and even in some major cities, VA salaries lag significantly 
behind the local labor market for some occupations. In addition, 
several clinical occupations with special rates continue to have 
recruitment and retention problems due to VA's inability to offer 
competitive salaries.

                            A P P E N D I X

                              ----------                              


          Prepared Statement of Max Stier, President and CEO, 
                     Partnership for Public Service
    Chairman Isakson, Ranking Member Tester and members of the Senate 
Committee on Veterans' Affairs, Thank you for the opportunity to offer 
the views of the Partnership for Public Service on the progress the 
department is making during the first 60 days of Secretary Wilkie's 
leadership. As a nonpartisan, nonprofit organization that strives for a 
more effective government for the American people, we help agencies 
attract mission-critical talent, advocate for systemic changes to 
modernize government's outdated personnel system and develop high-
performing Federal leaders. The topic of leadership is core to the 
Partnership's mission and one that we know to be crucial to agency 
mission success.
    Secretary Wilkie and his leadership team have a big job ahead of 
them and limited time in which to do it. The secretary is responsible 
for leading an organization of over 300,000 employees, 145 medical 
facilities, one-hundred-plus burial sites, dozens of benefits offices 
and 9 million veteran patients with just a handful of years to lay out 
a vision and set a course.\1\ There will be strong incentives to focus 
on policy implementation at the expense of strengthening the management 
systems that are the groundwork for the department's long-term success. 
To position the VA to meet the needs of current veterans while setting 
itself up for the future, Secretary Wilkie and his team must 
effectively collaborate with Congress, the veterans community and other 
key stakeholders, promote greater accountability at all levels of the 
department and assume responsibility for the overall health of this 
organization that is so important to the millions of veterans they 
serve.
---------------------------------------------------------------------------
    \1\ Statement of Hon. Michael J. Missal Inspector General of the 
Department of Veterans Affairs before the Committee on Veterans' 
Affairs U.S. House of Representatives Hearing on ``The Curious Case of 
the VISN Takeover: Assessing VA's Governance Structure,'' 115th Cong., 
13 (2018).
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    Congress is an essential stakeholder and steward of the 
government's solemn commitment to veterans and their families. The 
Partnership believes that the VA performs best when it is supported by 
and accountable to the legislative branch. The Committee deserves 
recognition for the way it has conducted rigorous bipartisan oversight, 
promoted constructive dialog with the department's leaders and 
committed itself to the difficult work of transforming the department. 
The commitment of this Committee to proactive and thorough oversight of 
the VA's management and programs sets a positive example for other 
committees to follow.
    An ongoing area of emphasis for the Committee has been personnel, 
and for good reason--dedicated, mission-driven employees are critical 
to VA's success. While this Committee has focused on the need for the 
department to hold its employees accountable for their performance, and 
understandably so, we believe it is equally important to learn from the 
hundreds of thousands of Americans, many of whom are veterans 
themselves, who accomplish great things for veterans and on behalf of 
veterans every day as department employees. The secretary and the 
Committee can learn from their success, and find ways to replicate it 
throughout the department.
    The Partnership's Service to America Medals (Sammies) program is an 
annual event that recognizes incredible civil servants who have led 
significant accomplishments on behalf of the American people, and VA 
employees are well-represented among our honorees. These individuals 
each demonstrate just some of the incredible work of the department's 
employees and their dedication to serving veterans.
    One such employee is Marcy Jacobs, the executive director for VA's 
Digital Service Team, who worked with her team to enhance the Vets.gov 
website to help veterans apply for, track and manage their benefits. By 
giving veterans a single point of contact, her team has made it easier 
for veterans to access the department's services, with more than 1.6 
million veterans having logged into an account. Another honoree, Dr. 
Rory Cooper, led the VA's Human Engineering Research Laboratories to 
help improve mobility and quality of life for hundreds of thousands of 
disabled veterans. Dr. Cooper and his team spearheaded innovations that 
include wheelchairs with robotic arms, improved motorized wheelchairs, 
and other features that have earned his team 25 separate patents.
    VA employees are also on the front lines of addressing homelessness 
among the veteran population. Dr. Thomas O'Toole of the Providence VA 
Medical Center helped found the National Center on Homelessness Among 
Veterans, which helps veterans access the comprehensive medical care, 
housing assistance and social services they need to reclaim their 
lives. Another VA employee, Anne Barker Dunn, created two programs that 
provided support to incarcerated veterans that offered access to 
critical services and assisted with substance abuse and housing needs.
    We recommend that the Committee do more to engage the secretary and 
the department's staff in understanding why these civil servants are 
able to innovate and solve problems, and how those lessons learned can 
be applied across the department. While the passage of the Veterans 
Affairs Accountability and Whistleblower Protection Act of 2017 
represents a significant shift in the department's approach to 
addressing accountability and leadership challenges, the cultural 
changes this Committee would like to see at the VA will not occur 
simply by firing underperforming employees. As the stories above 
demonstrate, the VA's employees are the department's greatest asset-not 
a cost to be borne. The focus of VA's leaders should be on supporting, 
encouraging and engaging high-performing employees and building a 
culture of excellence. This is hard work and requires a critical view 
of every aspect of the organization-accountability is simply one part. 
Perhaps most critical is the need to examine the effectiveness of the 
department's most senior political and career leaders who are charged 
with motivating, inspiring and managing each of the VA's three hundred 
thousand-plus employees.
    Capable leadership is essential to a healthy organizational 
culture. Research by the Partnership for Public Service as part of our 
Best Places to Work in the Federal Government Rankingsr has found that 
leadership is the single biggest driver of employee satisfaction and 
commitment across government and within the Department of Veterans 
Affairs specifically. The rankings show that in 2017 VA ranked second 
to last among large agencies in employee satisfaction with senior 
leaders and last in satisfaction with supervisors.\2\ I strongly 
encourage the Committee to take a hard look at VA's All-Employee Survey 
and the non-VA Federal Employee Viewpoint Survey to assess the impact 
of last year's accountability legislation and the administration's 
progress in turning around the department's culture. As the 
administration's nominee for the Office of Accountability and 
Whistleblower Protection, Tamara Bonzanto, told the Committee earlier 
this month, ''[I]f you improve the culture and employees are satisfied 
with their environment that they're working in and they feel safe 
working in that environment in reporting concerns, hopefully, we can 
get improvement in customer services'' and, ultimately, better care for 
veterans.
---------------------------------------------------------------------------
    \2\ ``Department of Veterans Affairs.'' Best Places to Work in the 
Federal Government. 2017. Accessed September 25, 2018. http://
bestplacestowork.org/BPTW/rankings/detail/VA00#tab_ category_tbl.
---------------------------------------------------------------------------
    Undergirding the transformation pursued by the Committee and 
Secretary Wilkie must be a commitment to the stewardship of the 
Department of Veterans Affairs as an organization--in other words, the 
management systems, infrastructure, and employees who make the 
department's success possible. The VA's leaders, particularly its 
political appointees, must assume a sense of ownership for the long-
term health of the institution. Secretary Wilkie should, even now, be 
thinking beyond his tenure at the department to the department he will 
be leaving to the individual who follows him as secretary. As a 
practical matter, such leader ownership requires prioritizing the VA's 
organizational health by building a pipeline of future leaders, 
connecting management to performance outcomes using data, 
institutionalizing key reforms, and holding leaders at every level 
accountable, including through the use of performance plans as required 
by the VA Choice and Quality Employment Act.\3\
---------------------------------------------------------------------------
    \3\ Section 203 of S. 1094, 115th Cong. (2017) (enacted).
---------------------------------------------------------------------------
    I believe the priorities Secretary Wilkie laid out during his 
nomination hearing-to improve the department's culture, to focus on 
customer service and access to care, to strengthening mission support 
functions like information technology and human resources-are the right 
ones. Secretary Wilkie can promote a sense of ownership while 
effectively addressing those priorities by taking advantage of 
promising practices and innovations already occurring within the VA. 
For example, the Veterans Health Administration's Innovators Network 
promotes and spreads promising practices initiated by frontline 
employees across the VHA healthcare system. Innovative ideas developed 
by employees include using 3D printing to help surgeons prepare for 
procedures and interviewing veterans about their lives so that their 
stories can help medical providers offer improved care.\4\ While these 
improvements are occurring in pockets of the agency, the department can 
do more to promote innovation widely: data from the 2017 FEVS found 
that just 32.4 percent of employees believed that the VA rewarded 
creativity and innovation.
---------------------------------------------------------------------------
    \4\ Ogrysko, Nicole. ``How the VHA Innovators Network Is 'changing 
Narrative' of Complacency.'' FederalNewsRadio.com. September 12, 2018. 
Accessed September 25, 2018. https://Federalnewsradio.com/veterans-
affairs/2018/09/how-the-vha-innovators-network-is-turning- changing-
narrative-of-complacency/.
---------------------------------------------------------------------------
    The department has the talent, resources, and commitment to mission 
that it needs to allow innovation in the service of veterans to thrive. 
The secretary set the right tone in his initial address to VA employees 
in July, stating that ''[I]t is from you that the ideas we carry to the 
Congress, the VSOs and to America's Veterans will come.'' \5\ It will 
be up to Secretary Wilkie and other leaders across the department to 
follow through and create an environment in which that is truly the 
case.
---------------------------------------------------------------------------
    \5\ Wilkie, Robert. ``A Message to VA's Workforce from Secretary 
Wilkie.'' VAntage Point. August 03, 2018. Accessed September 25, 2018. 
https://www.blogs.va.gov/VAntage/50910/a-message- to-vas-workforce-
from-secretary-robert-wilkie/.
---------------------------------------------------------------------------
    Congress and this Committee can and should play an important role 
in supporting innovation and promoting a sense of ownership and 
accountability in spirit and practice. Through its oversight, the 
Committee can look for bright spots within the VA and ways to replicate 
them across the department. The Committee can ensure that the VA is 
maximizing the use of new personnel and programmatic authorities 
granted to it over the last several years to improve service and care. 
Finally, it can continue to work with Secretary Wilkie, his leadership 
team, and others in the department in a collaborative spirit. I believe 
Ranking Member Tester's words during Secretary Wilkie's confirmation 
hearing, that ``if there is good communication between you and the 
Members of this Committee, particularly the chairman and myself, I 
think we can smooth a lot of those rough waters.'' \6\ I urge the 
Committee to continue in that spirit.
---------------------------------------------------------------------------
    \6\ Hearing on the Nomination of Robert Wilkie to be Veterans 
Affairs Secretary before the Committee on Veterans' Affairs, U.S. 
Senate, 115th Congress. 2 (2018), https://www. veterans.senate.gov/
hearings/pending-nomination_-secretary-06272018
---------------------------------------------------------------------------
    Chairman Isakson, Ranking Member Tester and Members of the 
Committee, thank you for the opportunity to share the Partnership's 
views on the opportunities and challenges confronting the Department of 
Veterans Affairs as Secretary Wilkie begins his tenure and the next 
chapter in the story of the VA's transformation. Success now and in the 
future will require close collaboration between the VA and Congress, a 
focus on engagement as well as accountability, leaders taking ownership 
of the department as an institution, and a continuing commitment to 
innovation. It is an important way to honor our shared commitment to 
America's veterans.
      

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