[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


 US DEPARTMENT OF VETERANS AFFAIRS BUDGET REQUEST FOR FISCAL YEAR 2020

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

                                HEARING

                               BEFORE THE

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

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        WEDNESDAY, APRIL 3, 2019

                               __________

                            Serial No. 116-4

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
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                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tenessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
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unintentional errors or omissions. Such occurrences are inherent in the 
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further refined.
                            
                            C O N T E N T S

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                        Wednesday, April 3, 2019

                                                                   Page

US Department Of Veterans Affairs Budget Request For Fiscal Year 
  2020...........................................................     1

                           OPENING STATEMENTS

Honorable Mark Takano, Chairman..................................     1
Honorable David P. Roe, Ranking Member, prepared statement only..    47

                               WITNESSES

The Honorable Robert L. Wilkie, Secretary, U.S. Department of 
  Veterans Affairs...............................................     3
    Prepared Statement...........................................    47

        Accompanied by:

    Dr. Paul Lawrence, Under Secretary for Benefits, U.S. 
        Department of Veterans Affairs

    Dr. Richard Stone, Executive in Charge, VHA, U.S. Department 
        of Veterans Affairs

    Mr. Jon Rychalski, Assistant Secretary of Management/CFO, 
        U.S. Department of Veterans Affairs
Ms. Joy Ilem, National Legislative Director, Disabled American 
  Veterans.......................................................    37
    Prepared Statement...........................................    58

        Accompanied by:

    Ms. Heather Ansley, Associate Executive Director of 
        Government Relations, Paralyzed Veterans of America

    Mr. Patrick Murray, Associate Director, National Legislative 
        Service, Veterans of Foreign Wars
Larry L. Lohmann, Esq., Senior Legislative Associate, Legislative 
  Division, The American Legion..................................    38
    Prepared Statement...........................................    64

                        QUESTIONS FOR THE RECORD

House Committee Members To: Department of Veterans Affairs (VA)..    78

                   MATERIALS SUBMITTED FOR THE RECORD

Letter From Elaine Luria To: Department Of Veterans Affairs......    80
Letter From Chairman Mark Takano and David P. Roe, Ranking Member 
  To: Department Of Veterans Affairs.............................    80
Letter From Robert L. Wilkie To: Mark Takano, Chairman...........    81

 
 US DEPARTMENT OF VETERANS AFFAIRS BUDGET REQUEST FOR FISCAL YEAR 2020

                              ----------                              


                        Wednesday, April 3, 2019

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 2:20 p.m., in 
Room 1334, Longworth House Office Building, Hon. Mark Takano, 
[Chairman of the Committee] presiding.
    Present: Representatives Brownley, Rice, Lamb, Levin, 
Brindisi, Rose, Pappas, Luria, Lee, Cunningham, Cisneros, 
Peterson, Sablan, Allred, Underwood, Roe, Bilirakis, Radewagen, 
Bost, Dunn, Bergman, Banks, Barr, Meuser, Watkins, Roy, Steube, 
and Mast.

           OPENING STATEMENT OF MARK TAKANO, CHAIRMAN

    The Chairman. Good afternoon. I call this hearing to order.
    First, I'd like to welcome Secretary Wilkie and our 
Veterans service organizations, the American Legion, Disabled 
American Veterans, Paralyzed Veterans of America, and the 
Veterans of Foreign Wars to this hearing on the President's 
Fiscal Year 2020 Budget Request.
    This budget reflects the Administration's priorities, many 
of which we can all agree upon. The fact that we can agree on 
so much is a bright spot in the function of this chamber and 
our government.
    However, in some cases we continue to see the same 
proposals from this Administration that we will never support. 
Proposals like taking disability benefits from veterans by 
rounding down the cost of living adjustment to pay for other 
veterans' programs.
    The VA budget does not contain the proposed cuts to its 
programs and benefits that we see in other parts of the 
President's fiscal year 2020 budget request.
    Yet we cannot forget that cuts to important safety net 
programs like SNAP benefits, Medicare, and Medicaid, and the 
agencies responsible for providing them will have serious 
impacts on the lives of veterans and their families who depend 
on those benefits, and will likely place a greater strain on VA 
resources as veterans look to fill the void these programs have 
left.
    Although VA's budget reflects an overall increase of 9.5 
percent over Fiscal Year 2019 appropriate levels, I remain 
concerned about whether this budget provides appropriate levels 
of funding to implement the VA MISSION Act, address VA's 
information technology needs and provide Blue Water Navy 
veterans exposed to Agent Orange disability and health care 
benefits, and address veteran suicide, including an alarming 
trend of veterans committing suicide on VA campuses.
    Now, we are all aware of the significant challenges at VA 
and our task today is to ascertain whether this budget request 
goes far enough to address these challenges, and whether 
funding has been prioritized to best support the needs of 
veterans.
    For example, with the passage of the MISSION Act, 
implementation of the law and providing coordinated community 
care has been a focus of the Department. However, funding for 
this program and the prioritization of this program must not be 
done at the expense of addressing VA's significant workforce 
and infrastructure needs.
    Based on the Congressional Budget Office's cost 
projections, we do not know if this budget request goes far 
enough to cover the projected cost of this program, an 
estimated $47 billion over five years without pulling resources 
from other VA programs.
    The hasty rollout of IT systems and programs like Medical 
Surgical Prime Vendor without involving the clinicians and 
users of these systems, or having the leadership and governance 
in place has led to disruptions in services, and we are afraid 
problems with the delivery of care and benefits to veterans may 
continue without the appropriate leadership commitment, 
expertise, and resources.
    Most recently we witnessed this with a disruption to 
student veterans GI Bill Housing Stipend benefits.
    The VA includes a hefty increase of $426 million to prevent 
veteran suicide. Yet, last year VA spent only $57,000 on 
suicide prevention outreach to veterans. It took oversight from 
the Inspector General and this Committee to get the VA back on 
track. The budget request includes an additional $15 million 
for suicide prevention outreach and if VA receives this 
funding, I intend to closely monitor spending of these funds to 
ensure that every last cent is spent to get the word out to 
veterans in crisis.
    If we are to be successful in preventing 20 veterans from 
taking their lives each day, veterans must have easy access to 
VA mental health care, and they must know that VA is ready and 
immediately available to help when veterans need it most.
    The VA must be prepared to provide disability benefits and 
health care to the Blue Water Navy veterans who have been 
waiting over 40 years for their benefits. It must invest in its 
workforce, including recruitment of providers to fill the 
48,985 vacancies in the department, and address severe morale 
issues at some facilities.
    VA contracting has now been added to the Government 
Accountability Offices' high-risk list, and the Veteran's 
Health Administration has remained on that list since 2015. 
These challenges play out each day at the D.C. VA Medical 
Center, practically footsteps from the White House.
    The D.C. VA was in the news again last night because of low 
morale, severe understaffing, and a dysfunctional medical 
supply chain. Meanwhile, the clinicians and front-line staff at 
that hospital make do with limited resources and support to 
provide high quality and timely care to veterans. We wanted to 
know which funds in the budget are requested to address these 
challenges.
    Then we talk about student veterans, who have been robbed 
of their time and GI Bill benefits by predatory for-profit 
schools and must be made whole. The recent closings at Argosy 
campuses have left thousands of veterans in limbo. Congress was 
forced to step in two years ago to restore benefits to veterans 
affected by for-profit schools closing, such as ITT Tech and 
Corinthian, and we may have to do it again.
    But the Department has a role in preventing these schools 
from taking advantage of veterans in the first place. We need 
to know how VA's budget addresses this problem. And finally we 
need to understand the Administration's rationale for the 
proposed $17 million cut to VA research, and 45 percent cut to 
VA's construction budget, which is contrary to what our veteran 
service organizations recommend.
    I have invited them here today so that they can weigh in on 
what they believe to be the appropriate funding levels and 
priorities for VA.
    Now these challenges are not insurmountable and as I said 
in our last hearing we are to work with VA as a partner to 
ensure VA can meet these challenges now and in the future. To 
do that, we need transparency from VA so that we can have an 
open and honest dialogue about the resource needs of the 
Department, and today we are here to conduct oversight so that 
Congress, veterans, and the American people all understand our 
investment in the VA and ensure the funds that we provide are 
used to support the needs of veterans.
    I see that I started the hearing without Dr. Roe here, and 
I'm sorry I did that. I'm sorry. So what I will do is I want to 
recognize the Secretary for his opening comments and then I'll 
recognize Dr. Roe when he arrives.

                   STATEMENT OF ROBERT WILKIE

    Secretary Wilkie. Mr. Chairman, I'll stop when Dr. Roe 
comes. Thank you again for your courtesy to me. This is my 
second appearance in the last, I think, month in front of the 
Committee and I am pleased to present to you the largest budget 
recommendation in the history of our department. I am very 
happy to be here with veterans. Jon Rychalski, who is our Chief 
Management Officer; Dr. Richard Stone, who is our Executive in 
Charge of health and the recent award winner for outstanding 
senior executive in the Federal government; Dr. Paul Lawrence 
who works for our VBA.
    I have said before, Mr. Chairman, that we are in the middle 
of the greatest transformative period in the history of our VA. 
We are no longer on the cusp; we are in the middle. And that 
is, in part, because of the leadership of this Committee and 
your companion in the United States Senate.
    We are also very happy to report in response to some of the 
things that you pointed out that morale at VA is at an all-time 
high. For the first time in my professional career the 
Department of Veterans Affairs is no longer 16 out of 17, or 17 
out of 17 when it comes to the best places in government to 
work. We are at sixth place and we are rising.
    In addition, our veterans are voting with their feet. The 
satisfaction rate for America's veterans for the services that 
they get at the Department of Veterans Affairs has now reached 
90 percent.
    That is also my response to those who say that we are in 
the middle of privatizing this wonderful institution. Our 
veterans are telling the world that they are getting the best 
service in the country from their VA, and I am very proud to be 
part of that team.
    I will be short then and allow Dr. Roe to take his usual 
place, but I did want to finish. I'm not giving you an 
extensive statement since I did that a few weeks ago, but to 
respond to something that you raised during your hearing 
yesterday with Dr. Stone, and that was questions about 
community care and our ability to carry forth with the payment 
of our doctors and community medical facilities if contracts 
are under challenge.
    I am happy to say that because of the military training 
that all of us at this table have that we believe in 
redundancy, and TriWest is responsible for handling those 
accounts until a new contract is in place and people are 
working those new contracts. So there is not going to be an 
interruption in service.
    Our new community care contracts are coming into place and 
there will be no gap between what TriWest has been doing and 
what our new partners will be doing when it comes to fulfilling 
our community care obligation.
    So I will stop and not give a lengthy opening statement and 
yield to Dr. Roe.

    [The prepared statement of Robert L. Wilkie appears in the 
Appendix]

    Mr. Chairman. Thank you, Mr. Secretary. Before I recognize 
Dr. Roe, without objection Mr. Mast will be permitted to sit at 
the dais and ask questions when recognized. I now recognize Dr. 
Roe for his opening statement.
    Mr. Roe. Mr. Chairman, I think what we can do, and we have 
a long hearing this afternoon. I'll just submit it for the 
record, and we can move on.

    [The prepared statement of David P. Roe appears in the 
Appendix]

    The Chairman. Thank you, Dr. Roe. We've already heard from 
the Secretary. I would like now to recognize myself for five 
minutes, and I want to begin with a question to Secretary 
Wilkie.
    Mr. Secretary, I understand from an interview you did with 
the Colorado Public Radio station that you said, and I quote, 
``I refute everything in that report,'' and I'm referring to 
the report by the U.S. Digital Service. You go on to say, 
``that's an interesting report that was done without discussing 
any of the issues with any senior leader at the Department of 
Veterans Affairs, including the people who actually handle our 
information technology systems.''
    In a hearing this Committee held yesterday, Dr. Glynn, the 
Assistant Secretary for the Office of Enterprise Integration 
confirmed that she herself requested the report from the United 
States Digital Service and said it was standard practice for VA 
to request such a report from subject matter experts, and 
requested a briefing that was attended by VA senior staff to 
discuss the report's findings.
    So do you still stand by your assertion that no senior 
leaders or individuals handling the information technology 
systems were briefed or took part in discussions with USDS?
    Secretary Wilkie. I do, and I'm talking about process, Mr. 
Chairman. That report was in pro publica before any of us saw 
it. It was a draft report. It was not a complete report. What 
was interesting to me is that for an organization that 
specializes in high tech, 80 percent of the draft report was 
about policy.
    Having grown up in this institution I know what would have 
happened in the Majority Leader's office in the Senate where I 
worked, if we had a report that was incomplete and was in the 
press before the Majority Leader saw it.
    That was the thrust of my remarks that it is bad process 
for me and for the leaders at this table to read about a report 
in pro publica before any of us have ever seen it.
    So I was talking about process and I was saying that I 
refute the process that was involved in releasing that before 
any of us at the table saw it.
    The Chairman. So you were not refuting the content in that 
report?
    Secretary Wilkie. I don't refute all of it, no. I was 
talking about the process in which I found out about it.
    The Chairman. I see. Well, you know, Dr. Roe the Ranking 
Member and I both sent you a letter on March 21, and I'm 
holding the letter in my hand, requesting that the VA provide 
all U.S. Digital Service reports on VA systems for the last 
five years, and without objection I'm going to enter this 
letter and the response that we received from you on March 29, 
and I'm holding your response right here--the March 29 response 
from you into the record. So without objection I enter both 
documents in the record.
    After the deadline of March 28, we received your response, 
and this is that response I'm speaking of, that VA could not 
provide these reports to us because they belong to OMB. 
However, we discussed these reports with OMB, and this is not 
true.
    These reports are VA documents. Will you provide Ranking 
Member Roe and me with these reports by the close of business 
this Friday, April 5?
    Secretary Wilkie. First of all, Mr. Chairman, I understand 
that the White House counsel itself wrote that letter and 
anything that's in VA's purview to hand to this Committee, I 
will hand to this Committee.
    The Chairman. So we can expect these reports by Friday?
    Secretary Wilkie. Anything that is in our purview to hand 
to you, I will do that.
    The Chairman. I appreciate that, but specifically the U.S. 
Digital Service Reports that we've asked for the past five 
years. That's what I'm asking. I understand those to be in VA's 
possession.
    Secretary Wilkie. And I don't know all of the details, but 
you've got my promise that if we have the authority to release 
things that are in our custody, I will release them.
    The Chairman. Well, my understanding is that they are in 
your custody and that it is the purview of the oversight of 
this Committee to request and be able to receive those reports 
and I will expect those reports by Friday.
    I see that I'm running out of time. I had wanted to ask you 
about the Loma Linda Medical Center, but I hope we can dialogue 
more about that, but I will now recognize Ranking Member Roe 
for his five minutes.
    Mr. Roe. Thank you, Mr. Chairman. I'm going to yield at 
this time to Mr. Banks.
    Mr. Banks. Thank you, Mr. Chairman and Ranking Member Roe. 
First of all, Mr. Secretary and Dr. Stone, I would just like to 
add that I, too, think that the U.S. Digital Service makes a 
valuable contribution.
    Technology is one of our government's biggest struggles and 
the members of USDS are some of the best and brightest from the 
private sector coming to work with Federal agencies each and 
every day. Just because USDS may have gotten outside of their 
lane in this particular report, and some of their 
recommendations were taken out of context, I don't believe that 
they should be discredited.
    So, Mr. Secretary, do you intend to continue working with 
USDS in the future?
    Secretary Wilkie. Yes, sir, and I wasn't discrediting their 
work. I was simply saying that I was asked to respond to 
something that I had never seen, and I think you know from your 
political life that is a very interesting place for a leader to 
be in.
    Mr. Banks. Fair enough. Let me move on to something else, 
Mr. Secretary. The VA is now adopting DoD's logistics software 
demos at the James Lovell Medical Center to harmonize the two 
supply chains.
    I agree with this concept, though I'm worried about adding 
demos onto the EHR modernization too early. How exactly is this 
software different from what you have now and what else will it 
enable you to do?
    Secretary Wilkie. Well, it is also a process question. What 
is different now is that we have systems that are spread out 
throughout the Department of Veterans Affairs. We don't have a 
single comprehensive supply chain management system.
    We have different parts of the country--different medical 
centers asking for things in an inchoate way. I testified in 
front the Senate a few weeks ago that we actually--I came 
across warehouses of material that had been ordered willy-nilly 
without any centralized accounting system to make provision for 
them.
    What this will do is create a nationwide system that will 
allow our people to punch into it and put in requests that they 
need, and we will be able to distribute supplies and material 
across the country to meet the greatest need.
    I would be lying to you if I told you I was an expert in 
IT. But having been on the other side as the Undersecretary of 
Defense, I know how well that system works.
    I want it to work for us because we're not going to be able 
to do--if everything in the MISSION Act worked perfectly, if we 
don't have a modern supply chain system, a modern HR system and 
the electronic health record, it's going to be difficult to 
continue the progress VA has been making.
    Mr. Banks. Let me follow up on that. The OIT budget 
proposal allocates $36.8 million for this supply chain 
initiative. Is that just the cost for the pilot site or to 
purchase demos in VA across--
    Secretary Wilkie. That's the cost of the pilot site.
    Dr. Stone. Yes, sir, that is the cost of the pilot site. 
There are nine different subsystems within supply in 
maintenance that are held within the supply chain. So how we 
maintain the services on our major end items like CT scanners 
and MRIs, right down to how we buy Band-Aids. So there's nine 
different subsystems.
    Right now what we discovered when we arrived is that about 
36 of our medical centers that are on a system called Sword 
Maximo, that was not propagated across the rest of the system.
    What see in demos is an opportunity to combine closely with 
Department of Defense and really leverage the power of both 
departments against potential savings for the American 
taxpayer.
    Mr. Banks. Okay. So $36.8 million is the cost of the pilot. 
How much will demos and the rest of the supply chain initiative 
cost when it's rolled out nationally? And when will that 
national rollout occur?
    Dr. Stone. So we will break the code on how we've done it 
north Chicago about mid-May and begin to look at the financial 
implications of it. Should it make sense we'll then go forward 
in the initial operating sites in Spokane and Seattle and at 
that point we'll step back and see if we can--
    Mr. Banks. If we're making an investment of $36.8 million 
for a pilot site, what can we expect the cost totally when it's 
rolled out nationally?
    Dr. Stone. It would be our hope that this can be self-
funded. That is the plan, is to try and self-fund this 
initiative from savings in the supply chain.
    Mr. Banks. My time is almost expired. I'll yield back.
    Mr. Rychalski. One comment about that is we are doing the 
cost analysis now. One point here is demos is a fully mature 
system, so we have pretty good cost information. We also don't 
have to develop anything so it's a matter of installing the 
system. We can provide you cost estimates frankly for the 
continuation once we have them later this year.
    Secretary Wilkie. And I would add, sir, if the Chair would 
indulge me because Chairman Takano mentioned this in his 
opening remarks. My impetus for moving was precisely the 
situation that the Chairman laid out.
    I was familiar with what was going on at the D.C. VA. The 
stories in the Washington Post about how operating room 
technicians running across the parking lot to MedStar to get 
equipment that they should have had. You cannot run a modern 
organization without a modern supply chain, especially for an 
organization that has 170 hospitals.
    The Chairman. I now recognize Ms. Brownley for five 
minutes.
    Ms. Brownley. Thank you, Mr. Chairman, and thank you, Mr. 
Secretary for being here today and thank you for your visit to 
my office last week. I enjoyed it very, very much.
    I have two questions that I want to ask and both questions 
are under the umbrella of IT, one for the MISSION Act and the 
other for the electronic health care records.
    So, the first on the MISSION Act and its implementation. I, 
too, as some members have already expressed was very concerned 
at yesterday's hearing, having read the USDS report and I 
understand what you're saying. It's never fun to have the press 
out in front of you. I get that.
    And as you said it's a draft and somewhat incomplete, but 
there were still some very alarming issues that were raised 
within that report and I think it actually put our oversight 
responsibilities on sort of high alert.
    I also recognize that you have written a letter to the 
Appropriations Committee about an increase in funding for 
MISSION Act implementation.
    And so given the concerns from yesterday's meeting I 
actually have a letter that I wrote to you that I'd like to 
deliver to you today just asking some follow-up questions with 
regard to the IT systems and the implementation of the MISSION 
Act, and if you would be so kind to respond to me, I'd 
appreciate it.
    Secretary Wilkie. I will, and I also thank you for the 
visit. Let me answer quickly about what will happen on June 6.
    I mentioned a few minutes ago the issue of redundancy in 
military systems. That's how I was trained. I expect a decision 
support tool which was mentioned in that report to be online on 
June 6. It is a tool for our doctors and health care 
professionals at VA. It is not a tool for our veterans' 
community to use. It is for the doctors to determine in 
consultation with the veteran what the best health care outcome 
is, where to go. So, that is that.
    The other side is we're going to be implementing MISSION 
Act even if the decision support tool is at 70 percent or 50 
percent. Our people have been trained on how to work with our 
veterans in getting the accessibility and availability 
standards to them and to get them out into the community if we 
do not have that particular service.
    Ms. Brownley. And Dr. Stone said the same thing yesterday, 
as well. But still some concerns obviously and we don't have--I 
think it's fair to say that we don't have the greatest 
reputation when it comes to IT implementation.
    But second question around the MISSION Act is I know that 
your people are meeting with our Committee staff I think on a 
monthly basis and now that we're in essence three months away 
from the MISSION Act rollout, I was hoping that we, and I think 
staff is, and I think the Chairman supports me in this request 
in terms of having more frequent briefings with the Committee 
staff just so that we can have some greater oversight.
    And would you agree to in these next few months to provide 
the Committee staff with biweekly updates rather than monthly 
updates?
    Secretary Wilkie. Yes.
    Ms. Brownley. Thank you, sir.
    Secretary Wilkie. And anything you need on that.
    Ms. Brownley. Thank you very, very much. And then my last 
question is with regard to the electronic health record.
    Yesterday we had a hearing with the IG and GAO and I 
believe it was the GAO who said--I'm paraphrasing, but the gist 
of what she said was that if DoD and the VA don't square off on 
the issues and issues that have to be adjudicated, if that 
can't be done, implementing the electronic health record is 
going to fail. Period.
    And so that also raised my hackles and I think it did for 
everyone on the Committee and, you know, obviously again our 
oversight on that is on red alert, as well. Your comments?
    Secretary Wilkie. Actually I would agree with the statement 
that says if we can't agree with DoD then the process is in 
trouble. I would not have embarked on this if I thought that 
was a potential.
    I mentioned that the precursor to this was me sitting with 
Secretary Mattis and we were finally able to say to both the 
DoD and the VA community that we will deliver a continuum of 
care from the time that a young American walk into the entrance 
processing station, and the time that that American is handed 
over to VA.
    I am looking at making the Integrated Program Office much 
more robust. It's worked in more complex defense programs than 
the electronic health record. I think it will be the coming 
together for the first time of two major departments of the 
Federal government for a common system. I'm absolutely 
confident that we're going to get this onboard and I will again 
use the personal impetus for me proving this. Days of people 
like my father with an 800-page paper record walking around 
have to be over.
    Ms. Brownley. You will be the first to break through these 
silos, so we are all counting on you. Thank you very much and I 
yield back.
    The Chairman. I'm going to recognize Dr. Roe for five 
minutes.
    Mr. Roe. Thank you all. Thanks for being here. Dr. Warren, 
she's very quickly--we're about six weeks into appeals 
modernization. How is that going?
    Dr. Lawrence. Very well. The experience you had when you 
were down in Nashville has been validated. One month in I think 
we received about 1,100 of new appeals and those-- some of them 
have been processed within 30 days. So far so good. Some 
tweaks, we're doing some after action but we're going forward 
as planned.
    Mr. Roe. I think that is a real ongoing success story for 
VA and one that folks should know about.
    I had an opportunity, Mr. Secretary, to go through the 
budget and as we go into the MISSION Act, what's the total 
budget for non-VA care?
    Secretary Wilkie. The total budget, and I'll give you the 
percentage, Dr. Roe, is about 19.1 percent with 81 percent 
being within VA, and that meets the trends that you and I have 
discussed, and I mentioned earlier that we foresee veterans 
continuing to vote with their feet and come to VA. I think that 
81-19 split is perfectly in line with that.
    Mr. Roe. In real dollars how much is that?
    Mr. Rychalski. So for the consolidated community care it's 
about--in purchasing power it will be about $16.8 billion.
    Mr. Roe. Okay. I just wanted to--and that pretty well, if 
you looked at the six other ways that VA had to provide care 
and add that to what we provided with choice, I think that's 
about where that number--am I correct on that?
    Mr. Rychalski. That's correct.
    Mr. Roe. Okay. The second question I have is I was looking 
at the budget and we know VA's record on major construction 
projects has been less than stellar. I noticed there was a $2 
billion in a new--what's that $2 billion for?
    Mr. Rychalski. Two billion dollars in new construction?
    Mr. Roe. Yes, sir.
    Mr. Rychalski. I think some of it was--it was in major and 
minor construction. I think there was 1, maybe 1.2, some of 
that for Louisville. I think New York, Manhattan. I'll have to 
look at the other projects.
    Mr. Roe. Are these new hospitals that we're building?
    Secretary Wilkie. The Louisville hospital is new and 
Manhattan is a complete overhaul.
    Mr. Roe. Okay. Well, I know my good friends in Kentucky 
will probably not like me saying this, but should we be 
thinking about looking at the Air Act and has that been taken 
into consideration? Maybe they're both needed and it's great if 
they do. We got it. We need to go ahead.
    But the question is does that fall into the market 
assessments that we've done and let's don't lay out $2 billion 
worth of new construction and find out five years from now we 
goofed up?
    Secretary Wilkie. Well, yes, sir. I am almost as vocal a 
proponent of the market assessments and the Air Commission as 
you are. This is the wave of the future. We are conducting the 
market assessments as we speak.
    My understanding is that the requests for Louisville and 
Manhattan long predated my tenure here. But it is my intention 
to come to this Committee in the near future as the market 
assessments are completed and actually ask for the Air 
Commission to begin its work in a time sooner than what is in 
the legislation.
    The legislation calls for 2022. I think we'll be finished 
with most of this next year and we owe it to our veterans to 
get this commission rolling because of the issues that you've 
just raised.
    Mr. Roe. Yeah. I mean, they may be absolutely needed. They 
might fit right in the niche exactly. But I don't want us to be 
sitting there having spent this money and then realize that we 
don't have any veterans to take care of.
    So anyway I just wanted to know about that. So your 
suggestion would be to step up, as the market assessments are 
done in 2020 to go ahead and begin to assimilate the 
commission?
    Secretary Wilkie. And, yes, sir. And as I said we have 
started the market assessments. Thirty one of the 96 that the 
legislation calls for are already underway. They're running 
concurrently across the country and I am very happy with their 
progress.
    Mr. Roe. When will we have access to those so we can begin 
to get our arms around it on the Committee?
    Secretary Wilkie. I don't know the answer to that. As soon 
as the information that I have I will share.
    Mr. Roe. Okay. Thank you very much. I yield back.
    The Chairman. Thank you, Dr. Roe. I now recognize Mr. Lamb 
for five minutes.
    Mr. Lamb. Thank you, Mr. Chairman. Mr. Secretary, welcome 
back. Thank you for the budget proposal. I'm encouraged by a 
lot of the things that we saw in there.
    When you were here for the VA 2030 hearing we talked a 
little bit about vacancies in the VA and you mentioned your 
priorities were primary care, women's health, and mental health 
and I saw the increases in the budget for hiring full-time 
employees, student loan incentives, that kind of thing.
    Is there a plan within VA to target those three 
specialities, or Dr. Stone if this is better for you, please go 
ahead? I was just kind of curious on the details of how we're 
going to go out and get those folks once we have the additional 
funding.
    Dr. Stone. Congressman, yes. There is a plan to increase 
all of these. We have very active mini-residencies in women's 
services that we'll train another 600 providers, especially in 
our rural areas trying to get the right expertise into the 
remote areas of our delivery system.
    For mental health we had committed over the last 15 months 
to hire 1,000 additional behavioral health providers. We've 
exceeded that and we'll continue to grow.
    Within this budget there is the plan to grow our employment 
by another 13,000 individuals to ensure access. I'm quite 
pleased at the continued reduction in wait times across much of 
the delivery system. But we will progress on all of these 
fronts.
    Mr. Lamb. Thank you. And I guess what I am asking you is 
how are you going to go and get them and get them to the places 
where we really need them? Is there a recruiting challenge or 
do you feel like with the additional money you can kind of just 
post the jobs, or what's the strategy there?
    Dr. Stone. Hiring medical professionals and getting them 
into remote areas is a difficulty across all of American 
medicine but you've given us within the MISSION Act some great 
tools.
    You've given us location specific pay. You've given us the 
ability to pay in enhanced amounts relocations. You've given us 
the ability to pay back student loans, and those are all proper 
areas and we appreciate those portions of the Act.
    Mr. Lamb. Thank you.
    Secretary Wilkie. And my view on that is in the next budget 
I believe I will be coming back to you and asking to make that 
program more robust. I've talked about a veteran's equivalent 
of the Peace Corps.
    Mr. Lamb. I noticed that in your testimony.
    Secretary Wilkie. And I think that's where Chairman Takano 
has been in the last few years, to get our young people back 
into rural areas in exchange for debt relief which this 
Committee championed in exchange for a specific period of 
service.
    Mr. Lamb. Thank you. And I agree, we want to help 
legislatively. Please let us know besides the budget what we 
can do to help carry the ball on that.
    Dr. Lawrence, sorry. Mr. Cisneros, could you lean back or 
something? Thank you.
    Mr. Lamb. I have to say I know Dr. Roe characterized the 
appeals modernization process as a success so far and I think 
in a lot of ways on paper it might be. But I had a very 
troubling meeting with a lot of folks who are kind of on the 
front lines of this for us in Pittsburgh under VBA.
    And they were called in. These are ordinary raters. They 
were called in on the Friday before this thing went live and 
told they needed all kind of new training and they needed to do 
things differently, and they did not feel anywhere close to 
adequately prepared for the changes that came, again at the 
ground level.
    So I don't know what the strategy was there, but can you 
explain why a significant number of your employees would have 
only been told that really the business day before this thing 
went live that they had to do things differently than they were 
doing before?
    Dr. Lawrence. No, I really can't. I'll have to get behind 
that and maybe talk to you as to how that came about. The major 
processing of the appeals is done in Seattle and Tampa, so 
those are where we hired the 605 people you allocated for us. 
Some of the runoff is done in a couple of other places like 
that. I don't understand why that happened.
    We had schedules that laid out several months in advance 
what was to take place, who was identified in the training they 
were provided. That's the anomaly but I'm happy to go and look 
and we can back to you on that.
    Mr. Lamb. We'll follow up with you on that. I appreciate 
it. It definitely caused a distressed workforce. So I don't 
know if it was just a local decision to start doing things 
differently in advance of this or not. But I would appreciate 
it if you could look into that and maybe we could follow up on 
it.
    Mr. Chairman, I yield back. Thank you.
    The Chairman. I now recognize Dr. Dunn for five minutes.
    Mr. Dunn. Thank you, Chairman Takano.
    Secretary Wilkie, Dr. Stone, it is nice to see you again. 
Thank you for your time here today. I think we all know that 
there is a crushing shortage of GME residency slots in the 
country. The Choice Act authorized an additional 1,500. Can you 
tell me how many of those to date have been filled and what the 
uptake rate is on those?
    Dr. Stone. I can't tell you exactly where we are. I know 
that we are at 123,000 residents that are training in our 
facilities. How many of ours, how many are part of our academic 
affiliates, I can break out for you and I will take that one 
for the record. I know that our goal was to grow over 1,000, 
but we will get that for you.
    Mr. Dunn. I would appreciate the follow-up on that because 
I have to tell you, every single medical group that I speak to 
or comes in the office, that is among their first two or three 
questions, so I appreciate--
    Dr. Stone. If I may, sir, let me add one other thing. We 
had 24 facilities that did not have teaching positions, 
especially in rural areas. In order to enhance rural attraction 
of physicians when they finish, 23 of those 24 are now online--
    Mr. Dunn. Excellent news.
    Dr. Stone [continued].--with residencies. And so, we just 
added that this year.
    Mr. Dunn. Excellent, thank you very much.
    Also, the President's budget acknowledges the 
administrative costs of implementing the MISSION Act's 
transplant authority for increased access. So, does that 
budget, does it include the estimated costs for a veteran 
seeking a transplant outside the VA transplant system? And 
also, does it include the costs for the new authority to pay 
for those who are having a donor, a living-donor transplant, 
and the donor is not a veteran?
    Dr. Stone. It does, sir.
    Mr. Dunn. Excellent, thank you.
    And so, with this revised requested $2.862 billion, 
roughly, for implementing new access standards and the 2021 VA 
advanced appropriations of $4.583 billion, the money, in 
theory, will actually be appropriated well before the final 
roles on transplant authority will be finalized, which we 
expect in July of 2020. So, if we authorize the money for this 
purpose, is there still a delay in implementing the transplant 
policy or would you agree that we don't need to have a delay in 
implementing that policy?
    Dr. Stone. Sir, we are still propagating the regulations. 
We are very hopeful that in the very near future, you will see 
those regulations and they will go out for comment. Following 
the comment, we will work our way through the rest of the 
process, including the comment from this body, that we will 
take. But we are very close with these, and I promised you that 
in a previous hearing. We are very close to having those out.
    Mr. Dunn. You know how near and dear to my heart the 
transplant programs are. I look forward to working on that with 
you in the future.
    Mr. Chairman, I yield back.
    Dr. Stone. Thank you, sir.
    The Chairman. Thank you, Dr. Dunn.
    I now recognize Mr. Pappas for 5 minutes.
    Mr. Pappas. Thank you, Chair Takano.
    Thank you, Mr. Secretary, Dr. Stone, and the panel for 
joining us here today. I understand, Mr. Secretary, we may be 
seeing you later this month up in New Hampshire at the 
Manchester VA?
    Secretary Wilkie. I will be up there in a few weeks, as a 
matter of fact.
    Mr. Pappas. Excellent.
    Secretary Wilkie. I am looking forward to it.
    Mr. Pappas. Well, great. They are in a period of 
transition, but they are on the upswing and I think the 
volunteers, the veterans, the leadership, the staff, is 
certainly really eager to talk with you.
    Secretary Wilkie. And I will add one thing about the 
wonderful reception that people in uniform get in New 
Hampshire. When I was the Under Secretary of Defense and prior 
to that, assistant secretary, the greeting that the people of 
New Hampshire provide to returning soldiers, sailors, airmen, 
Marines, at your airport in Manchester is probably the best in 
the country.
    Mr. Pappas. Thank you. I will relay that message, and I 
don't doubt it.
    I want to talk today about whistleblowers and the 
importance of them. It is a courageous act when someone at the 
VA brings forward information, complaints, or allegations 
regarding serious problems, wasteful and unsafe practices, even 
malfeasance. There is understandable fear that blowing the 
whistle could result in retaliation, including risk to the 
employee's job and livelihood. Whistleblowers represent a 
critical source of information about the VA and we must 
encourage people come forward.
    I recognize that your budget proposal includes a four- and-
a-half-million-dollar increase in the Office of Accountability 
and Whistleblower Protection. It is a good step forward, but I 
have some serious concerns about the office and how well it is 
performing. I have heard of shortcomings in meeting the needs 
of whistleblowers and whether they are protected from 
retaliation.
    And, Mr. Secretary, I was curious if we have your 
commitment to an open and robust dialogue about the VA's 
support of whistleblowers and the strength and effectiveness of 
the Office of Accountability and Whistleblower Protection?
    Secretary Wilkie. Absolutely. I had the pleasure of serving 
as the acting VA secretary for 8 weeks. One of the first visits 
I made was to the now-Chairman's office. Whistleblower 
protection was the first IT that he raised in that meeting.
    I can say for the first time, we are requesting a direct 
appropriation for the Office of Accountability and 
Whistleblower Protection. We have, finally, a confirmed leader 
in place, someone known to the leadership of this Committee; 
she came off of the staff of this Committee.
    In the last year, we have assessed about 2,400 
whistleblower submission. We have 1,000 referred investigations 
in place. It is absolutely vital, particularly in an area as 
sensitive as veterans' care, that that office is as robust as 
possible.
    Mr. Pappas. Well, thank you. And, Mr. Secretary, the budget 
that is appropriated, will that also result in more resources 
for responding to FOIA requests by whistleblowers?
    Secretary Wilkie. Oh, yes.
    Mr. Pappas. Thank you. And I will have my team follow up 
with your office at a later time to continue that discussion. I 
appreciate it.
    Secretary Wilkie, your budget includes $107 million for the 
Department's Office of Inspector General, representing about a 
fifteen-million-dollar increase. The inspector general, the 
agency's independent watchdog, obviously plays a critical role 
in overseeing the operations of the VA, investigating instances 
of waste, fraud, and abuse. I applaud the increase.
    I understand that the VA still has a lot of work to do in 
implementing many of the IG's recommendations; in fact, there 
are 557 recommendations that have yet to be addressed, 
including more than 140 that have remained unimplemented for 
more than a year, some for many years. Concerning the financial 
implications of not implementing recommendations, I am 
wondering if you can respond to this, and in addition to that, 
talk about your willingness to respond to the GAO high- risk 
list, which just recently added contracting to that list. Talk 
about your ability to implement and address these concerns.
    Secretary Wilkie. Well, let me talk about the latter, 
first. And that is part of our response is modernizing the 
institution through business transformation. We are spending 
about $189 million or requesting $189 million on business 
transformation. Some of that is for IT funding. We have a 
1960s- and 70s-business process system. That is why we are 
engaging in that reform, as well as supply chain.
    As for the Office of Inspector General, that is why we 
requested additional monies, because we are doing so many 
things at one time. I would also say that we have an advantage 
that other departments don't have. We have really three law 
enforcement mechanisms. We have the Office of Accountability 
and Whistleblower, we have the IG, and we have the general 
counsel. There is a reason for that: Because no one else has 
the kind of mission that we have, and the results of us not 
doing our job can, at times, be catastrophic. So, that is why I 
put more emphasis on those arms.
    Mr. Pappas. Thank you. We have got work to do.
    I yield back, Mr. Chair.
    The Chairman. I recognize Mr. Bost for 5 minutes.
    Mr. Bost. Thank you, Mr. Chairman.
    Dr. Lawrence, I am going to go down probably the path that 
Mr. Lamb did, because I don't think that it is a localized 
issue. You know, we have been working really hard to ensure the 
new disability appeals system is implemented correctly. And I 
have recently been in contact with some of my constituents who 
are working to implement it and the concern that they have is 
they don't feel that the proper training is being done at the 
level and at the speed in which they need it to be able to 
implement the program.
    Can you kind of explain to us what collaboration is taking 
place between the Appeals Management Office and Comp Services 
for training all of our employees.
    Mr. Lawrence. Sure. So, first, I will follow up and try to 
understand that. This is important. Training on appeals 
modernization began more than 3 years ago with the 
understanding of what was new about the law and the different 
lanes it set in motion. About a year out, after working through 
the IT issues, began to identify the need for staffing and how 
we would actually process.
    As I indicated, specialized centers were set up in St. Pete 
and Seattle for this reason; for this dedicated sorted of 
stuff. One lane would--it is a little complex--requires some 
work be distributed to around the regional offices. Some of 
those folks were to handle that other, what I call ``runoff 
work'' earlier. They were to get the training you are talking 
about. I don't understand how both, you and Mr. Lamb, described 
that, because the training schedules and the feedback that I 
received throughout was very, very positive about how it was 
done.
    There is an element of learning going on. We appreciate 
that. There is an element of understanding by our team that we 
measure performance and they are naturally uncomfortable when 
that happens, but it wasn't designed--it was designed to 
provide training for this very purpose. So, I would be happy to 
follow up and better understand.
    Mr. Bost. I hope you do. Believe me, I am one that 
understands old dog, new trick, okay, but these are pretty 
young people and they actually know their systems pretty well 
and it concerns me. And we want to make sure it works. Dr. Roe 
is right, I think it is a great process.
    But that is going to lead me to my next question, and I 
don't know whether to ask the secretary or possibly you, 
Doctor. In 2020, the VA is projecting to complete 1.3 million 
disability-rating claims and the number of claims pending 
longer than 125 days will remain between 90 to 100,000 claims. 
My concern has been the legacy appeals, really.
    So, can you please kind of explain how you intend to handle 
the legacy appeals and bring them online and get them to faster 
resolutions.
    Mr. Lawrence. Sure. In terms of legacy appeals--I have had 
this conversation with Dr. Roe and his office about 6 or 8 
months ago--we understand that it is important. So, as we shift 
to the new appeals modernization, we want to work off the 
legacy appeals we have; those before appeals modernization by 
the end of 2020. In our math, we have the dedicated staff to do 
that and it is our desire to get that down to, essentially, 
zero--a little bit north of zero because of some puts and takes 
on that next year.
    The claims you talked about are traditional disability 
claims are the 1.3 to 4 million we process every year for what 
they are: disability claims. A couple of things are going in on 
that and that backlog is slowly creeping up and we have plans 
to deal with that. But it is sort of some simple math if I can 
share with you, right. The number of claims continues to go up 
every other year 3 to 4 percent. The number of folks we have 
working claims is essentially flat. We try to find some people 
and free them up and go do that. And the claims are getting 
more complex, more issues per claim. So, you see the math begin 
to work that way.
    We are very concerned about rework and quality and we think 
that those are areas we could improve, which would enable the 
claims to process faster and bring those numbers down.
    Mr. Bost. Like I said, I think it is a good program. I 
think we have to work the bugs out of it and speed up the 
process.
    So, Mr. Secretary, I want to--also in my short period of 
time that I have left here-- I recently introduced legislation 
that would require VA medical centers to do cost- benefit 
analysis of treating medical waste on-site. Now, I am asking 
for your support of it to bring the VA in line with the 
practices of CDC and world health organizations, because I 
think it would save us a lot of money. I think we are kind of 
behind the overall curve on implementing the waste disposal.
    Are you familiar with what we are trying to get done?
    Secretary Wilkie. I know the subject in general, and I will 
take a close look. I don't know if Dr. Stone has a medical 
response.
    Dr. Stone. I agree with you, sir. I think it is time that 
we take a good, strong look at that, and we would support that.
    Mr. Bost. Thank you. Mr. Chairman, I yield back.
    The Chairman. I now recognize Mr. Brindisi for 5 minutes.
    Mr. Brindisi. Thank you, Mr. Chair.
    Thank you, Secretary, for being here. Just an issue that is 
important in the district that I represent in New York state. 
The Albany VA Medical Center has proposed to move the 
Bainbridge CBOC, which is in the congressional district I 
represent, to a neighboring county.
    Bainbridge and the surrounding Chenango County are 
extremely rural. Transportation and health care options are 
very limited, and the population is aging. Over 3,600 veterans 
reside in Chenango County and any potential move of the CBOC 
out of the Bainbridge area would have a tremendous impact on 
the veterans and their families in having access to VA care.
    The Bainbridge clinic does not have a shortage of veterans 
utilizing its services; in fact, they are operating above 
capacity. So, if the VA does go through with moving the CBOC 
out of Bainbridge, as it is proposing, how will you make sure 
that veterans relying on the Bainbridge CBOC are able to access 
reasonable care and health after moving the clinic?
    Secretary Wilkie. Congressman, I am familiar with this 
issue, and this clinic really draws from 3 counties. One of the 
difficulties we have in the current location is a lack of 
public transportation, and many of our veterans need help 
getting there. So, we considered moving about 20 miles away to 
an area that does have public transportation.
    The lease on this facility that they are in, they have 
outgrown the footprint. We got some issues for women veterans 
in privacy in the current structure there. We have also got 
some issues in the surrounding buildings on this, as far as the 
safety of the area.
    So, our lease is up in 2021. We are just in the early 
process of looking. This came to my attention been the last 
month. We are taking another look at it and would be happy to 
engage your office in that discussion. Especially because of 
the rural nature of this, we do have the need to be able to 
accommodate another PAC team at that site and we don't feel 
that specific facility will accommodate it. But whether we 
could accommodate a closer location than going all the way to 
the hub of the area where public transportation is, I think, is 
an open discussion and I will more than willing to have it with 
you.
    Mr. Brindisi. I would like to have that discussion, because 
I think the county that you would be moving from, that is where 
the public transportation options are very limited. So, getting 
the veterans from that rural area into a more populated area is 
going to be very difficult for them to get there.
    The other issue that I was pleased to hear the secretary 
say that he is a vocal proponent of market-area assessments, 
which I think is a great thing and certainly a requirement 
under the VA MISSION Act. As I understand it, there is not a 
market-area assessment that is going to take place until at 
least 2020 in this region. So, why move forward with moving the 
CBOC until you do that market-area assessment to determine the 
needs of that community?
    Dr. Stone. I understand, and I am in full agreement with 
the secretary on the market-area assessments. Please remember, 
though, that the lease on this facility is not up until 2021, 
so we would be through a market-area assessment before we 
decided on that move.
    Mr. Brindisi. Okay. So, I can get a commitment from you 
today that you are not moving the CBOC until at least 2021?
    Dr. Stone. Unless I am substantially misunderstanding this 
issue, and I would be more than happy to engage after the 
hearing in this one to make sure that I have got the dates 
right.
    Mr. Brindisi. Okay. I would love to follow up with you 
after.
    And just second, I was pleased to read in the secretary's 
testimony that the VA remains committed to investing in the 
National Cemetery Administration's infrastructure, including 
constructing new cemeteries. As you know, one of the NCA goals 
is to provide access to a national or VA-funded state cemetery 
within 75 miles of a veteran's residence. And I read in your 
testimony that following completion of planned expansion 
projects, nearly 95 percent of veterans will have access to 
these burial options. I think this is great progress, but 
unfortunately, the veterans from the district that I represent 
would still be part of that 5 percent that is still lacking 
access to a national cemetery. The closest cemetery to our 
district is over 90 miles away in Albany, New York.
    So, I just would encourage you to look at that and ensure 
that we can close the gap certainly in those areas that are a 
little more rural and a little further away from some of the 
national cemeteries.
    Secretary Wilkie. Yes, sir, absolutely. And I understand 
that the Under Secretary for memorial affairs, Randy Reeves is 
either visiting with you or your staff to discuss the way 
forward. I also encourage Secretary Reeves across the country, 
to make sure that we also interact with states in terms of us 
getting grants to the state so that state-veteran cemeteries 
are made whole. But he will have a way forward for you when he 
meets with you.
    Mr. Brindisi. Thank you so much, Secretary.
    I yield back, Mr. Chairman.
    The Chairman. I now recognize Ms. Radewagen for 5 minutes.
    Ms. Radewagen. Thank you, Chairman Takano, and Ranking 
Member Dr. Roe for today's hearing.
    Thank you to Secretary Wilkie and the rest of VA for 
coming. It is always a pleasure to see you, and I also want to 
welcome the VSOs and thank them for their input today.
    Mr. Secretary, one of the provisions of the MISSION Act 
included an assessment of health care furnished by the 
Department to veterans who live in the territories of the 
United States. The report determined that VA furnished health 
care in the territories overall and it is considered both, 
sufficient and efficient, but also projected an increase in 
demand for services and noted that veterans in the U.S. 
territories have to travel to Hawaii or the mainland for much 
of their care.
    The report seemed optimistic about the VA's ability to 
handle health care needs of the territories through the use of 
Community Care to provide services closer to home. The report 
cites projections of our territory veterans' demands for care 
across 10 to 20 years. Does this same sort of foresight apply 
to this budget proposal? And could you please go over, briefly, 
the VA's short-term and long-term plans to meet the needs of 
the territories and remote areas.
    Secretary Wilkie. I have been very, very open about my 
desire to serve those communities in the country, in our rural 
areas, and in our territories, particularly in the Native 
American communities and the native communities of the Pacific.
    One of the reasons I have stated is that no group of 
Americans serves in higher number than those Americans, and no 
group of Americans has more medals of honor per capita than the 
Americans that you represent. I will be headed to the 
territories at the end of May.
    In the short term, our budget for telehealth is the 
quickest way that we can respond to the needs of diverse 
populations, not only in your area of the Pacific, but also in 
places like Alaska. By getting our VA doctors to service those 
veterans in your area, across jurisdictional lines, state 
lines, in addition to doing as much as we can to make more 
robust the clinics that we have in the territories.
    We are not going to be able to give you a 100 percent 
answer that 100 percent of the health delivery--health services 
that we provide will be available to all the territories, but 
it is something that we are working diligently on. And I do 
think that telehealth is the most important investment that we 
can make right now to make a difference.
    Ms. Radewagen. Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you. And now I will recognize Ms. Rice 
for 5 minutes.
    Ms. Rice. Thank you, Mr. Chairman. Secretary Wilkie, in 
response to the IG report that found millions of dollars in GI 
bill benefits going to for profit colleges that violated VA 
standards, what steps have you at the VA taken to address this 
issue and where are you in the process of implementing the IG's 
recommendations?
    Secretary Wilkie. I would say before Dr. Lawrence answers, 
I do want to respond to something that the Chairman said. It is 
our policy when these institutions that you described fail to 
make our veterans whole, they will not be penalized when an 
organization goes out of business.
    Dr. Lawrence can talk about some of the hurdles that we 
have under the law, dealing with state accrediting agencies. I 
think that is a topic for another hearing. But I did, before he 
answers, want to make sure that veterans who find themselves in 
those situations, we will make whole again.
    Mr. Lawrence. Sure. We agreed with the report. And we began 
expeditiously to implement the recommendations almost 
immediately. Perhaps the most thing that had the direct effect 
was in the fall when we renegotiated our contracts with the 
state approving agencies, we put in more of the teeth they 
suggested we do to get them to make some of the things we 
requested of them not so optional, that they would go and do 
it. But we are implementing those recommendations. Most of them 
were to take place over a year and we are on track to have them 
all done.
    Ms. Rice. Secretary Wilkie, do you support closing the 9010 
loophole?
    Secretary Wilkie. I support institutions--let me, I will 
confess I am not an expert on that matter. I support 
institutions that serve students. And yes, I will say something 
that is probably against interest, I agree with the Chairman's 
view that institutions that are primarily dependent on Federal 
students and students who bring to those institutions' Federal 
money, they need to be looked at carefully.
    Ms. Rice. So have you spoken personally with Betsy DeVos 
about ways to address this issue?
    Secretary Wilkie. I actually have spoken with her. We have 
had one meeting on it.
    Ms. Rice. And can you expound on that?
    Secretary Wilkie. And I shared my concerns.
    Ms. Rice. So I want to talk about women veterans, in order 
to ensure that they are included in VA health care and 
benefits. We often concentrate solely on health care, but there 
are other non-health care related issues that affect women 
veterans, which includes access to benefits. Now, you have 
testified to this Committee now on more than one occasion that 
the VA is working to increase the trust of women veterans in 
the VA, so they choose the VA for benefits and services. 
However, there still remain cultural barriers women veterans 
face at many, not all, but many, VA facilities. And it 
continues to be a significant deterrent for women in terms of 
accessing VA benefits.
    You have got the issue of sexual harassment, which remains 
a major problem at VA facilities, and for the roughly 30 
percent of women veterans who have reported being harassed or 
assaulted while serving in the military, and for those 
specifically seeking treatment from the VA for military sexual 
trauma, this type of environment isn't only an impediment to 
accessing VA benefits, it can be traumatic. Beyond that, women 
veterans continue to say they are made to feel like they don't 
belong at the VA, often citing situations where VA employees 
assume, they are a veteran's spouse, rather than a veteran or 
combat veteran themselves.
    Now, you and I disagree on the VA motto. And I am going to 
ask you to please reconsider your position. Because it is not 
just what you do internally once a woman begins to wear the 
uniform of this great country of ours, which over 2 million 
women have, but it is what you say and what you hold out as the 
motto of this great agency that speaks to women about how they 
are going to be respected within the VA. So do you--
    Secretary Wilkie. Well, let--
    Ms. Rice. So do you consider changing the culture at VA to 
be one of the department's goals under your leadership, and how 
are you working to address the cultural barriers that have 
inhibited women veterans from accessing services at the VA?
    Secretary Wilkie. Let me take a step back and talk about my 
record and then the change in culture. But I will first say 
that those same VA satisfaction reports that I mentioned at the 
beginning of my testimony, 84 percent of all women veterans who 
use VA trust the VA and they are very satisfied with the VA.
    As the Under Secretary of Defense and some of the members 
have been on the Armed Services Committee, my first directive 
was to give the Department of Defense its first comprehensive 
sexual harassment and equal opportunity policy. I am the son of 
a combat soldier. My father spent most of his career in the 
82nd Airborne Division. It was unthinkable as a child that I 
would see an American woman wearing the red beret of the All-
American division. It is not unthinkable anymore because of the 
changes in the military culture.
    VA has moved to change with that culture. The young 
Americans who serve today are not the veterans who served with 
my father in Vietnam. We have a diverse and integrated 
military, and those changes are bleeding over into VA. It is my 
goal to make sure that our VA is as welcoming as possible, and 
I talked a little bit about that in the last hearing. But I am 
very happy that for the first time, I can tell you that the 
satisfaction rates for American women using the VA are at an 
all-time high and they are getting better. 500,000 women had VA 
appointments last year.
    In terms of the budget, about 10 percent of the budget that 
we spend on medical care go to American women. That represents 
10 percent of the veterans' population. So we are moving. Our 
people are being trained. Certainly if we find any problems, we 
address them right away.
    Ms. Rice. I just ask you, when we talk about all these 
issues and modernization, you cannot leave women out of that 
modernization.
    Secretary Wilkie. Absolutely not.
    Ms. Rice. Thank you, Mr. Chairman.
    Secretary Wilkie. Absolutely not.
    The Chairman. I now recognize Mr. Bilirakis for five 
minutes. Mr. Bergman, General Bergman.
    Mr. Bergman. Thank you, Mr. Chairman. Every budget cycle, 
we have been giving the VA more money because we are not only 
hopeful, but we are optimistic that you are going to provide 
better outcomes, you know, with that money. One of the 
challenges that we have all--we have had hearings on is the 
appeals process. And I have got an appeal here dated March 
22nd, 2019, in which basically the word remanded is used in six 
different instances. Okay, so one more time back through the 
loop.
    And this--my constituent caseworkers have been working on 
this for a while, working with an 85-year-old veteran, 9-year-
old Legacy, one more time just recently remanded by the Board 
of Veterans Appeals. Unfortunately, and it has been remanded 
multiple times. Unfortunately, the VA regional office erred by 
not complying with the Board's previous remand order, which 
further prolonged--you know, you see the scenario I am building 
here.
    As the VA updates and modernizes the appeals process, what 
improvements--I mean, really, what improvements are we going to 
make so that we can--I mean, maybe--hopefully this is just an 
outlier, but we talk about the numbers of, I was going to say 
back orders, but backlog, if you will, on the timeliness issue. 
How are we going to improve the accountability, the timeliness, 
especially when errors occur of our own doing? If we kick the 
ball in the stands, do we have a way to bump it up in priority 
saying because this 85-year-old is not getting any younger. And 
we owe it to them.
    Secretary Wilkie. So I will let Dr. Lawrence get into the 
particulars, but let me tell you where we are. We have the 
largest budget request in the history of the appeals process. 
That is to sustain about 1,500 full time people handling 
appeals. We will achieve the largest number of appeals ever 
processed by VA this year, over 90,000. But this is not immune 
to the modernization efforts that we have under way. There are 
too many appeals that start with the hand processing of those 
appeals.
    So my directive is to modernize and have an IT system in 
place so that the triaging is rapid, that we don't have 
somebody who sits at a desk and processes 10 appeals a day, a 
request manually. That that process is modernized, and it is 
made efficient and relevant to the 21st century.
    Mr. Lawrence. Let me comment without going too much into 
the weeds, sir. But part of what you are seeing is an outlier, 
but it is not unusual. Part of what happens, which led to 
appeal modernization, is a case made its way to appeal. And 
while it was waiting, the reasons why the veteran was asking 
for help changed. And so when it came time to deal with the 
claim, the reasons that changed, and they would send it back 
and say, ``We now need more information.'' The condition has 
gotten worse and this doesn't reflect that. That led to appeals 
modernization in part because it was designed to sort of have 
these lanes, which could deal with things.
    Thing one would be a higher level of review. A math mistake 
was made, can you correct it? A more senior person could look 
at that and deal with that right away. Additional evidence is 
needed, but it can be done quickly. Each of those two lanes 
will hopefully enable the appeal to be resolved quickly so it 
doesn't linger and require the looping back and forth that you 
described. I am happy to learn more about that and look in on 
and see if we can't figure out why it is going back.
    Mr. Bergman. Thank you. And we are dealing with exceptions 
here and not the rule, but the question is how do you--we have 
to have a way. And just one quick last question because I see 
my time is getting short. And this is a yes or no answer. The 
current budget funds an increase of over 13,000 positions, you 
know, within the Veterans Health Administration. Is there a TO, 
table of organization, that we could look at that shows those 
13,000 openings so you know exactly when we hire them, we have 
got a place to put them?
    Dr. Stone. The answer is we are getting closer and it is 
not as simple as yes or no.
    Mr. Bergman. As you got one, I would certainly like to see 
it.
    Dr. Stone. It is not like you were used to in the 
Department of Defense.
    Mr. Bergman. Okay. Well, we like those tables of 
organization to give an idea.
    Secretary Wilkie. Mr. Chairman, may I give a more complete 
answer to that?
    The Chairman. Proceed.
    Secretary Wilkie. Thank you for your indulgence. You just 
hit it. We are used to more complete table of organization in 
the Department of Defense. I have used this description before 
in testimony. I don't know that I have used it in the House. My 
first week as secretary, I asked two different senior leaders 
for the number of employees that we had. I got two different 
answers.
    And then I asked for a manning document, which you know is 
the table of requirements and the people needed to meet them. 
We never had one. We now have a modern sophisticated HR team in 
place, some of whom coming on were senior leaders in the A-1 of 
the Air Force. One is already on board. Another is coming. They 
are going to get that manning document and we are going to--we 
will put in place the type of HR system that you are used to in 
your military career, I am used to, the people at this table 
are used to.
    Again, that is part of the overhaul of a department that I 
think if General Bradley walked into it a year ago, he would 
probably recognize a lot of the processes.
    The Chairman. Now, I will recognize Mr. Cisneros for 5 
minutes.
    Mr. Cisneros. Thank you, Mr. Chairman. Thank you, 
gentlemen, for being here this afternoon. Mr. Secretary, I just 
want to follow up really quickly on Ms. Rice's question about 
the GI bill and your statement about making the veterans whole.
    My hope would be that when they would--that these veterans 
that were at these schools that have been closed, they would be 
able to transfer their credits to an accreditable university. 
But in cases where the existing credits cannot transfer or the 
school closed mid-semester, that the veteran would hopefully 
receive their tuition back, receive their VA stipend back. That 
is my definition of whole. What would be your definition of 
whole?
    Mr. Lawrence. We are very similar. So when schools are 
closed, we then reach out to the students and figure out 
exactly how we restore eligibility. As part of the Forever GI 
bill, that is the new benefit exactly as you said. You don't 
lose the months. You continue on a new process. So we restore 
months of eligibility when this happens.
    Mr. Cisneros. That would be a student who is maybe going to 
school, been there three years already, used maybe about 24--
we'll say 24 months of his eligibility, school closes. Would he 
be able to get all 24 months back?
    Mr. Lawrence. Perhaps. But also, he would hopefully 
transfer credits and only needs a limited number of those. So 
everything is case specific. But that is the intention to not 
penalize them the way you are describing for the school's 
behavior.
    Mr. Cisneros. Secondly, I want to talk about vocational 
rehabilitation employment program. I had a veteran's roundtable 
recently in my district and a lot of the veterans that we sat 
down and spoke with were saying that they were constantly 
shifted counselors. They would tell them their story. They 
would get a counselor and explain their situation. And then 
next time, it was a whole different counselor and they would 
have to start the process all over again.
    To that end, I understand that in 2016, Congress passed 
into law a requirement that the VA must ensure a ratio of 125 
veterans to every 1 voc. rehab counselor. And I also understand 
that the VA is moving 127 of those counselors out of those 
positions and into full time positions for support and 
management. How are we going to hire more people and how are we 
going to fill those positions to ensure that the veterans, that 
we are keeping the proper ratio?
    Mr. Lawrence. I was confirmed about a year ago. And in 
preparation for that confirmation, I learned about the law, the 
1 to 125 and realized we were out of balance. One of the first 
things that happened when I came onto the job, when I was 
confirmed, is to begin executing a plan of hiring counselors to 
deal with exactly that. We are in the process of hiring to meet 
that number and hope to have it done shortly. We had to hire a 
couple hundred through the process.
    In addition, we had to reallocate. I don't know about the 
moving amount of management positions because that would work 
against the intent to meet the ratio. I will tell you that we 
had some misallocation of those that I inherited in the wrong 
place. Also we had some of the wrong people in the jobs, and we 
had some of the churn you are describing. So we are in the 
process of not only hiring, but reallocating to make sure that 
doesn't happen the way you are describing. But it is our intent 
to fund and support the voc. rehab program directly and 
consistent with the law.
    Mr. Cisneros. So when do we think we will have a timeline 
of when that will be fully?
    Mr. Lawrence. I am tempted to tell you a date off the top 
of my head, but it will be wrong. There are little puts and 
takes as some people were recruited away from us. So shortly 
and I will be happy to get back to you with the exact date.
    Mr. Cisneros. So currently, you are going to spend about 
$60 million in overtime for these counselors. You are only 
asking for about $35 million from the 2020 budget. So can we 
expect maybe that is because you are going to have the number 
hired by 2020? You think you will be fully manned by 2020 or is 
it going to go beyond that?
    Mr. Lawrence. Let's separate two issues. I think the 
overtime request we are making is for more broadly all of VBA, 
not just the counselors, sir. But the answer is yes. We are 
going to have them hired in fiscal year 2019. I don't want to 
give you a date to be off by a couple of weeks, but I am going 
to give you a date that precisely shows you when we are going 
to meet the ratio.
    Mr. Cisneros. So you are saying--I will take 2019. By the 
end of fiscal year 2019, you are saying we will be fully 
manned? We will have enough counselors to me the 1--
    Mr. Lawrence. Not only that, I will come to your office on 
the day it is, and we will count the days between the end of 
the fiscal year to see how many there are.
    Mr. Cisneros. All right. I will hold you to that.
    Mr. Lawrence. I will be happy to come and talk to you about 
voc. rehab then, sir.
    Mr. Cisneros. I yield back my time.
    The Chairman. I recognize Mr. Barr for 5 minutes.
    Mr. Barr. Thank you, Mr. Chairman. And gentlemen, then you 
for your service in uniform, and thank you for your service 
today to our veterans.
    Mr. Secretary, this budget request provides $15.3 billion 
for medical community care. You are asking for a $2.9 billion 
appropriation to roll out the access standards for the program. 
Obviously, you see that there is a need for veterans to be able 
to access care in our own community, yet this funding is not 
going to be effective if there is a lack of quality providers 
in the community who choose not to participate in the community 
care program.
    Are we funding the MISSION community care program in a way 
that supports provider reimbursement and in a way that attracts 
quality providers and makes the program work? And Dr. Stone, 
you can answer that question as well.
    Dr. Stone. Congressman, I think the only way you retain 
providers to any delivery network is to pay him in a timely 
manner and treat him respectfully. So therefore, the community 
care contracts, the first of which in Region 1 where we are 
beginning to implement is in full partnership with the provider 
networks. We continue to stress timely payment. I am quite 
pleased that in the month of March, we paid over 1.7 million 
claims in less than 30 days. That in comparison to a year ago 
was at 140,000 in a month.
    We anticipate going over 2.3 million claims paid in the 
month of April as we continue to progress through this. But 
retaining good community providers at high quality institutions 
will only be effective if we can treat them respectfully and 
pay them in a timely manner.
    Mr. Barr. I fully agree with that. And the community care 
program is certainly something that the veterans that I 
represent are clamoring for, but they obviously--it won't be 
effective if we don't not only timely reimburse, but adequately 
reimburse to attract quality specialists to the program. And on 
that point, Mr. Secretary, if the requested budget were to be 
enacted as requested, it looks like 19.2 percent of the VA's 
medical care dollars would be allocated to community care while 
80.8 percent would be allocated to care provided in VA medical 
facilities.
    Given the plan's streamlining of community care options for 
veterans alongside the funding to strengthen VA medical care, 
do you feel that this 80/20 split is accurate or about right in 
terms of meeting the needs of how veterans will seek care?
    Secretary Wilkie. I think it is about right, based on what 
I have seen in terms of patterns of our veterans in terms of 
the care that they seek. The other thing that I would add to 
that is it is adequate because the MISSION Act is not full 
choice. The MISSION Act applies only when we cannot provide the 
veteran a particular medical service within a specific amount 
of time. Based on the numbers that I have seen, that is not 
going to be a regular occurrence for most of our veterans.
    Mr. Barr. No, I understand that. And so your assessment is 
that that 80/20 split is in line with the share of veterans 
actually seeking care within the VA versus within the 
community?
    Dr. Stone. Congressman, let me give a little more detail. 
In 2017, we purchased 32.5 million visits in the community. In 
2018, that dropped by about 2 million to 30,500,000. In 
addition, this year, in the first six months of this fiscal 
year, the direct care system, the VA itself, has grown by over 
a million visits and over 100,000 additional veterans have come 
to us and enrolled in care.
    So we think the split is about right.
    Mr. Barr. Okay. Thank you. Final question, Mr. Secretary. I 
want to ask you about how the VA disburses compensation 
payments for disabilities, specifically sleep apnea. A 2018 VA 
annual benefits report listed sleep apnea as one of the most 
prevalent service-connected disabilities triggering VA 
compensation benefits. It is my understanding, however, that 
the VA does not track to make sure veterans are actually 
complying with treatments as a condition of receiving benefits. 
Meaning that the VA could be expending resources that may not 
actually be helping veterans.
    How much does the VA spend on treating sleep apnea, and how 
does the VA monitor benefit awards to make sure that those 
receiving compensation benefits are actually getting helped 
with treatment?
    Dr. Stone. So CPAP machines are our greatest prosthetic, 
our largest prosthetic that we purchase, and I can get you the 
exact number on that. We are actually progressing very nicely 
with a national contract for that in order to control cost. But 
the second thing is how do we monitor compliance with therapy. 
And it is my understanding, and I am going to correct this. We 
were talking about this in the last 24 hours. It is my 
understanding that the current devices actually have a 
monitoring device that then can be monitored during a physician 
visit to monitor compliance with the use of the device. But let 
me confirm that and bring it back to you, sir, and make sure 
that we have got it. But that is my understanding.
    Mr. Barr. That would be great. My time has expired, but 
obviously we want the veterans to get the help that they need 
as we help them with that. I yield back.
    The Chairman. Ms. Lee is recognized for 5 minutes.
    Ms. Lee. Thank you, Mr. Chairman. Thank all of you for 
being here and for your service to our country's veterans. I 
want to reiterate and touch on what Congresswoman Brownley 
briefly discussed regarding our Subcommittee meeting yesterday, 
where the GAO continues to see governance issues as a problem 
for the implementation of the EHRM.
    We are coming up on almost a year from when the GAO first 
testified and proposed a governance structure that would be 
expected to leverage the existing joint governance and 
suggested the IPO, the inter-agency program office. And then in 
September, the VA, you all then concurred with that 
recommendation and stated that the Joint Executive Committee, a 
joint governance body between the DoD and VA had approved the 
role for the IPO.
    But we do not yet have this inter-agency program office 
plan, this Committee, and the Subcommittee doesn't have this 
either. So Mr. Secretary, when you were before the Senate a 
couple weeks ago, you were not able to provide a timeline then 
for this office. Are you able today to tell us what plan you 
have?
    Dr. Stone. Congresswoman, the inter-agency program office, 
we continue to discuss with DoD. As you know, because of 
substantial oversight, we are working our way through, trying 
to make sure we are complying with what everybody wants and we 
are sharing with you openly how we are proceeding, and that we 
are giving you appropriate chance to give oversight.
    So that said, we have a couple of big problems as we 
approach this implementation. Number one, the common technology 
platform, and secondly, the cybersecurity of this as we move 
into the DoD enclave. We need more rapid decisions. And if we 
are going to deliver potential advantage to the American 
taxpayer based on efficiencies, we need to make these decisions 
quickly together.
    We are in active consultation. I had a discussion Friday 
with the acting Secretary of Defense for health about this as 
we try to decide leadership and move our way through. But there 
are lots of emerging interests as we work our way through this 
very difficult process. But we owe you a common platform of 
leadership that delivers the efficiencies that you expect.
    Ms. Lee. Thank you and thank you, Secretary. I know you 
understand the importance of having this leadership role well 
defined. We have heard that the DoD might leave this office and 
I just wanted to--which causes concern, given that this is 
supposed to be a joint effort and it is true that the VA has a 
bigger investment in terms of dollars and in people. What is 
your view on leadership of the IPO and how will you ensure that 
the VA's equities are just as represented as DoD's?
    Dr. Stone. What we would really like is the best person in 
the place, regardless of their background. We want somebody 
that fully understands both departments, fully understands the 
complexity of these departments. So I would say that first, we 
want the best person. And we want that person to understand 
both departments.
    I think in addition to that, finding the interim leadership 
that can lead us through some decisions in the next 6 months is 
essential. We do believe that this should move beyond the 
acquisition community, which leads both areas today and move to 
the end technical user. And so you should look for a leader 
that understands the end technical and clinical components of 
what we are trying to implement.
    Secretary Wilkie. And I would say that has been my 
emphasis. I have the advantage of having led both 
organizations. Led defense health, now leading VA. I would be 
lying if I said that the Department of Defense was a less than 
complex organization with a less than complex bureaucracy 
because they deal in the most massive expenditures of 
government money in our experience. They tend to look at things 
as acquisition.
    I am not going to be satisfied unless we have what we now 
call a purple person, a joint person, who understands Dr. 
Stone's world and understands the world of the patient. That 
really is my bottom line.
    Ms. Lee. Great. Thank you. Appreciate that. I yield.
    The Chairman. I recognize Mr. Meuser for 5 minutes.
    Mr. Meuser. Thank you, Mr. Chairman. Thank you, Dr. Roe. 
And thank you, all of you, and Secretary Wilkie, very nice 
seeing you again. Appreciate you making the time to join us 
this afternoon.
    I would like to begin by thanking the president and the 
Department of Veterans Affairs for their budget proposal. I 
truly can't think of many tasks more important than ensuring 
our veterans and the VAs have the resources they need to serve 
those who have served our Nation. I recently toured the Wilkes-
Barre VA, met with the director, Russell Lloyd, had the great 
opportunity to meet with many of the veterans that utilize the 
Wilkes-Barre VA. And I also had the chance last week to meet 
again with Director Bob Callahan with the Lebanon VA, who do a 
terrific job for the veterans in the 9th District.
    I have heard from many, I attended a Vietnam veterans 
celebration last week, and I heard many challenges from them, 
of course, and successes, and problems that they may be having, 
but I am very encouraged by the proposal set forth by the 
department to do the best job for the veterans as possible.
    This budget proposal does invest in our Nation's VAs, 
especially with regard to the implementation of the MISSION 
Act, to help ensure that the men and women who fought for our 
country, again, and defended our freedoms received the timely, 
high quality care they deserve.
    So my first question is to Mr. Secretary, the 2020 budget 
request is $220 billion; does it, in fact, fulfill the promises 
made in the MISSION Act? Will it allow you to carry out the 
goals of the MISSION Act?
    Secretary Wilkie. Yes. And it does so by recognizing the 
fundamental change that is made evident actually in the title 
of the legislation, integrated service, where veterans now will 
be part of a nationwide, integrated health care system, with VA 
at the apex, and we will be able to access for them, when 
needed, care in the community when it is called for.
    I think this budget is the first important step, but it is 
a step that goes beyond MISSION, that includes the fundamental 
reform of the entire way we do business; everything from as 
Congresswoman Lee said, the electronic health record, to 
business transformation, to HR transformation, and to supply 
chain transformation, which is all included in the budget.
    Mr. Meuser. Sure. All right, excellent. Very happy to hear 
that. I do represent a part of Pennsylvania that is relatively 
rural. Can you speak about the investments made to help 
veterans in such rural communities?
    Secretary Wilkie. Absolutely. And I have said, I think the 
most important part of this is to create that balance that 
takes cognizant of the fact that almost half of our veterans 
live in rural areas of this Nation and in the territories. One 
of the things this budget calls for is the expansion of 
telehealth. Tele-health allows us to reach into communities 
that in many instances we have not been able to reach. It is on 
the cutting edge of mental health services.
    The other part of this is, as Dr. Stone said earlier, 
making it easier for us to get medical professionals into rural 
areas by using the tools in the MISSION Act: loan forgiveness, 
relocation pay. We are able, thanks to the legislation, to 
provide compensation that is outside of the usual OPM buckets.
    Mr. Meuser. Well, thank you. There are certainly many 
veterans counting on your work. Thank you very much for your 
service, and please continue to notify us as to how we can 
help.
    Secretary Wilkie. Thank you, sir.
    Mr. Meuser. Chairman, thank you. I yield back.
    The Chairman. I am going to recognize Ms. Rice for one 
minute to ask a question, since she was kind enough to yield 
her time to the secretary to answer a question.
    Ms. Rice. Thank you, Mr. Chairman. First, Mr. Secretary, I 
want to thank you for supporting closing the 9010 loophole, 
number one. And number two, I have a question about a concern 
that is based on the VA's challenges with the development of a 
medical surgical supply formula that looking to DoD to solve 
these supply chain challenges may be a mistake, given the fact 
that the DoD has a well-documented history of medical supply 
chain challenges, which is why we have asked GAO to review this 
pilot program. If you could just answer the question, why did 
the VA choose DoD's model?
    Dr. Stone. This is a deeply fractured supply chain within 
the VA, one in which it is very difficult to assess where we 
are at and where we are not. And the secretary has spoken 
extensively in previous testimony about the use of credit cards 
in our system.
    There are two pieces of this decision. One is the use of 
DMLSS as a software system. The second is the potential use of 
DLA as a potential supplier of medical supplies. We have not 
made a final decision on the use of the defense logistics 
agency, and won't until we break the code in mid- May in North 
Chicago. That final decision will not be made until we go 
through the IOC sites in Spokane and Seattle and can 
demonstrate and share with you the actual financial 
implications of this. And this comes back to the previous 
questions on how will you fund this.
    I think there is a lot more data that has to be tackled, 
but I think it is worth a good try. Secondly, you have to 
recognize that all of us grew up with the defense supply chain 
in combat, experienced the defense supply chain's ability to 
get material--medical materials to us anywhere in the world. 
And so we are deeply respectful of it and look forward to its 
ability to potentially meet all of the additional requirements 
that we live with under, including--in our preferred small 
businesses.
    Secretary Wilkie. And I would add, what we have is not 
working. And Dr. Stone mentioned something that I said when I 
appeared in front of the Committee in December. Last year, 
there were almost 4 million individual credit card 
transactions, buying everything from boxes of tongue depressors 
to radiological equipment. That is a system not only ripe with 
inefficiencies, but I believe is ripe for potential corruption. 
And getting to the heart of this is the only way I believe that 
we can provide veterans with the stability that they deserve 
when it comes to their VA facilities having equipment ready and 
able to meet their needs.
    Ms. Rice. Thank you.
    The Chairman. I know recognize Mr. Levin for 5 minutes.
    Mr. Levin. Thank you Chair Takano for holding this hearing. 
I would also like to thank Secretary Wilkie and his team, as 
well as the representatives from our key VSOs, who are joining 
us today. I have the great opportunity to be the Chairman of 
the Economic Opportunities Subcommittee, so I would like to 
focus today on the issues of veteran homelessness, education, 
and employment.
    Mr. Secretary, I appreciate your comprehensive overview you 
provided to us. I did notice that your budget request only 
provides level funding for homelessness programs. And while I 
understand that the number of homeless veterans nationwide has 
dropped over the last decade, as we discussed last time you 
were here, it is obviously a very big issue in Southern 
California where I represent. During the VA 2030 hearing, you 
said, and I quote, ``If we got a handle on homelessness in 
Southern California, the number of homeless veterans in this 
country would reduce exponentially. That is the epicenter.'' 
And unfortunately, that is, as you know, that is an accurate 
statement.
    We had the 2018 point in time count recently and it found 
that nearly 29 percent of our Nation's homeless veterans are 
located in California. So it stands to reason that the 
resources should be directed accordingly, but that is not 
always the case. For example, in fiscal year 2019, our state 
only received 18 percent of funding under Supportive Services 
for Veteran Families.
    So my question for you, Mr. Secretary, can you tell me how 
the department plans to ensure that the requested $1.8 billion 
targets the geographic areas that need it the most?
    Secretary Wilkie. Well, it is my intention and my directive 
that we go to the heart of the matter. There is a good news 
story. A few years ago, there were 700,000--let's say almost 
700,000 veterans experiencing homelessness at any time of the 
year. That is down to about 40,000 now. As you mentioned, 
primarily on the west coast and in Hawaii.
    What we have been able to do is use HUD and some of our 
partners to address the immediate needs of those who are 
homeless. It is a good news story in that we have over 60 
communities in this country who have effectively ended 
veterans' homelessness. I will speak to Southern California.
    Before he left office, I had conversations with Governor 
Brown. I have had conversations with Mayor Garcetti. The only 
way we are going to get a handle on this is to increase the 
amount of money flowing to the states and localities to help us 
find those homeless veterans.
    I will say emotionally, one of the saddest sights that I 
have seen in my professional life and in my time being around 
the military is West Los Angeles at night when veterans come in 
in their cars, and they have jobs, but they have no place to 
live.
    I talked to the Mayor about establishing more transitional 
homeless housing for them. I have asked HUD to increase the 
number of vouchers. But I am also looking at ways, big cities 
like New Orleans, and smaller cities like Abilene, Texas, have 
been able to eliminate homelessness by engaging what properly 
called NGOs. As I said, 64 communities, 3 states have 
eliminated homelessness.
    So it is not a VA specific issue. It is one that requires 
more close cooperation with the states and localities, as well 
as HUD, and some of the other agencies.
    Mr. Levin. Sir, obviously our Subcommittee would love to 
follow up and work with you on that.
    Another question for you, during the 2030 hearing again, we 
discussed your commitment to implement Sections 107 and 501 of 
the Forever GI Bill by Spring 2020, while simultaneously 
correcting claims retroactive to August of 2018. And you said 
then that you didn't envision any new staff needing to be hired 
due to improvements under the new IT system.
    I noticed this budget actually cuts education by $30 
million and 45 full time employees. So how do you plan to 
transition to this new system and implement the Forever GI bill 
with fewer resources? And have you planned for the possibility 
that technological glitches may occur, which would actually 
increase staff workloads?
    Mr. Lawrence. Sure. A couple things. Our plan is to 
implement in Spring 2020 as we have indicated. We have been 
working this very closely. We are on track to do that. Our 
intention is to do so. One of the things the new plan will have 
is increased automation, making those few people unnecessary 
and the savings accordingly. We are on track to do that. Worst 
case scenario is we will continue to process it as we have 
been, and we executed the spring of this year on schedule. So 
positive news there for that. Everything is positive going 
forward. We think we are going to meet that, and we talk 
regularly to your staff once a month about the status of where 
we are, what we are doing, and how it is going.
    Mr. Levin. I am over time, Mr. Chair, but I appreciate your 
answers. Thank you.
    The Chairman. I now recognize Ms. Luria for 5 minutes.
    Ms. Luria. Thank you, again, Secretary, for appearing 
before our Committee, and I wanted to thank you for your 
recommendations against an appeal of Procopio. As you know, 
Blue Water Navy veterans have waited decades to receive 
benefits for diseases related to herbicide exposure during 
their service in the Republic of Vietnam.
    Dr. Stone. Particularly on Hampton Roads.
    Ms. Luria. Yes.
    Secretary Wilkie. And in light of that, I wanted to follow 
up on my question from our hearing in February regarding VA 
health care benefits for Blue Water veterans. At that time, I 
asked you if you plan to treat Blue Water veterans as eligible 
for Priority Group 6 health care benefits based on service in 
Vietnam.
    I was wondering if you have an update on that now.
    Dr. Stone. I believe that is our intention, but let me 
confirm that for sure.
    Ms. Luria. Okay. And I will submit for the record, as well, 
a follow-up letter that I sent on April 1st also requesting the 
information from the previous hearing.
    Ms. Luria. On the note of that with the Blue Water 
veterans, have you estimated the additional full-time 
equivalents or additional costs or additional personnel that 
you will need in order to process these claims for Blue Water 
veterans?
    Secretary Wilkie. Before Dr. Lawrence talks, I will say 
what I have said to departments of our Federal Government and 
to some VSOs: We are just beginning to get our hands around the 
issue in the sense that part of our process will involve being 
historical detectives. The Navy in the Vietnam era had no 
standard policy when it came to report service in the waters 
off of Southeast Asia.
    I will give you an example. You might have a destroyer 
captain who gives all of the members of his crew a service 
ribbon for time in those waters.
    Ms. Luria. Are the deck logs of all of our ships not 
available through the Navy?
    Secretary Wilkie. Many have deteriorated.
    Ms. Luria. Okay.
    Secretary Wilkie. And then the carrier that it is serving 
with 6,000 sailors doesn't have that ribbon. I have looked at 
some of these records and they fall apart.
    Ms. Luria. So, I understand the complexity. And do you 
acknowledge that it will take additional resources to do this 
analysis?
    Secretary Wilkie. Yes, and we will look to that.
    Ms. Luria. Okay. Thank you.
    Secretary Wilkie. I think Dr. Lawrence had a comment.
    Ms. Luria. No, I would like to just move on in the limited 
time I have left. So, looking at the budget, and I will just 
reference the page, VBA 57, it gave a table of veteran 
compensation by degree of disability. And so, I went through 
this table between 2012 and 2018 and I noticed that during that 
six-year timeframe, there was an increase in 1.2 million 
veterans, about 200,000 a year, or a 35 percent increase during 
that timeframe.
    And then I broke it down a different way to look at both, 
the number of veterans over 50 percent as well as the number of 
veterans at 100 percent disability. So, in the over-50 percent 
category, that went up by 11.8 percent in the six-year period, 
or a 27 percent increase, and in the 100 percent, it went up by 
4.26 percent, or a 42 percent increase over that timeframe, 
between 2012 and 2018.
    And this seems like both, a large number, an increase of 
200,000 additional veterans being qualified as having a 
disability requiring compensation over that period of time, and 
then also a shift, as well, in those receiving higher levels of 
compensation.
    So, do you have a reason or a cause to attribute this rise 
to?
    Mr. Lawrence. I would be happy to talk to you in more 
detail about this. The numbers reflect what we are seeing as 
veterans apply for benefits broadly--and I know your analysis 
is not broad--broadly, as our population of veterans ages, and 
we understand more about the medicine and the problems that 
they are dealing with. They are applying for claims and we are 
adjudicating them. That is what you are seeing taking place in 
those numbers; they are accessing the benefits that they have 
earned.
    Secretary Wilkie. I didn't finish answering your first 
question about 39,000, 40,000 veterans who have--Blue Water 
veterans who have at least one Agent Orange condition have been 
treated by VA for that condition. So, this is not a zero-sum 
game. We are actually in the process of--
    Ms. Luria. But when you refer to that approximately 39 or 
40,000 people, because this ruling is recent, they would 
already be treated for other reasons that qualify them for a 
disability; is that correct?
    Secretary Wilkie. For Agent Orange, right. For Agent Orange 
conditions; the conditions that are listed as conditions that 
we have to treat as a result of the Agent Orange Act.
    It is not as if under Blue Water, we are going to be 
starting afresh. We have thousands of veterans who are being 
treated who fall into that category.
    Ms. Luria. They fall into that category because they served 
in that time and place, but they are currently being treated 
and they are rated for a disability because of other causes, 
because this was not previously recognized as a standalone 
cause; is that correct?
    Mr. Lawrence. So, again, let me take you into the weeds. If 
you were on a ship in the Blue Water and you came onto the 
land, you then now had access to the presumptive, because you 
are on land, and that is where the presumptive covers you. Some 
of what the secretary is referring to is that sort of taking 
place.
    Ms. Luria. Thank you.
    Dr. Stone. Congresswoman, I think you are substantially 
correct in your assumption that part of that tens of thousands 
that we are currently treated are not related to their Blue 
Water service; it has to do with other forms of disability.
    Ms. Luria. Thank you.
    The Chairman. I now recognize Ms. Underwood for 5 minutes.
    Ms. Underwood. Thank you, Mr. Chairman.
    And thank you, Mr. Secretary, for appearing before the 
panel today.
    Based on the most recent data available, the suicide rate 
was one and a half times greater for veterans than non- veteran 
adults and based on that same data, the suicide rate for women 
veterans was 1.8 times higher than the suicide rate for non-
veteran women. While the population of women veterans continues 
to grow, the actual number of female veterans makes research 
into the population difficult and more expensive.
    And so, Secretary Wilkie, how is the VA incentivizing 
research into risk factors for suicides specific to women 
veterans, and does your suicide-prevention requests or research 
requests include funds for this more expensive, yet important 
research?
    Secretary Wilkie. Well, our budget for suicide prevention 
is about $222 million.
    Ms. Underwood. Uh-huh.
    Secretary Wilkie. That is about $16 million over last year.
    Ms. Underwood. Uh-huh.
    Secretary Wilkie. What has changed is that I am now in 
charge of a national suicide-prevention effort and as a result 
of the President's executive order, on the task force. The goal 
of this task force is to treat suicide prevention in a way that 
we have not, and that is a whole-health, Whole-of- Government 
Approach.
    My view is that we bring together NIH, HHS, DoD, and we 
strike at the heart of those causes of suicide with our 
veterans, but more importantly--and this applies to both men 
and women--14 out of the 20 veterans who take their lives every 
day are not in the VA system.
    Ms. Underwood. Right.
    Secretary Wilkie. My goal is to open the aperture of 
funding to the states and localities to allow them outreach 
into the community to help us find them. I will give you an 
example. I was in Alaska in October. Half of the veterans in 
Alaska are outside of VA and I asked the Alaska Federation of 
Natives to double the number of veterans' tribal 
representatives that they have in order to reach those 
veterans.
    That is absolutely essential. Not only in rural--
    Ms. Underwood. Sir, I am going to ask you to focus on the 
research part.
    Secretary Wilkie [contined].--but also in the urban areas.
    You want to hit research?
    Ms. Underwood. Please.
    Dr. Stone. I think there is a number of very troubling 
things about the population of female veterans. High rates of 
pain, as much as 70 percent complaining of chronic pain--
    Ms. Underwood. Sure.
    Dr. Stone [continued].--high rates of military sexual 
trauma; as mentioned previously by one of your colleagues, 30 
percent--29.1 percent with history of military sexual trauma; 
about 40 percent with mental health-related issues. But that is 
in the 25 percent of women veterans that we have attracted to 
the system. For the other 70--
    Ms. Underwood. Sir, I would like to ask you to specifically 
focus your comments on the research dollars and any incentives 
to study the female veteran.
    Dr. Stone. Yeah. So, my specific answer to that is, what we 
have to do is find the reasons that the other 75 percent of 
American women veterans are not choosing us.
    Ms. Underwood. I understand the research question. I am 
talking about the funding.
    Secretary Wilkie. I will answer that. That is the reason 
for the Suicide Task Force.
    Ms. Underwood. I understand--
    Secretary Wilkie. That is to go outside of VA to pull in 
the research capabilities of NIH, DoD, and HHS--
    Ms. Underwood. Okay.
    Secretary Wilkie [continued].--because they have more 
expansive research capabilities than we have. In my discussions 
with the White House about that, that is what I insisted upon.
    Ms. Underwood. So, are you saying that there is no 
incentive in your current structure or in this current budget 
request for the VA suicide-prevention research funding to focus 
on women veterans who have a higher risk of suicide: yes or no?
    Dr. Stone. I think there is incentive.
    Ms. Underwood. What is that incentive?
    Dr. Stone. I think that incentive is the programs that we 
have set up specifically for women veterans and to attract, 
train, and retain those medical specialists that will support 
the reduction in harm to women.
    Secretary Wilkie. It is to take care of all veterans who 
are on this terrible spectrum. And I would go beyond your 
question, because the research that we actually have that 
started before the President announced his task force includes 
what your colleague just said, homelessness and opioid abuse, 
which is on that spectrum that creates many of these problems.
    So, a one-off VA program, in my opinion, was not sufficient 
to tackle the problems that you have addressed. That is why the 
President has created the national task force that will bring 
together all of the things that you just said you wanted, to 
focus on this one terrible issue.
    Ms. Underwood. Okay. Well, any veteran suicide is tragedy 
and it is our goal with the dollars that the Federal 
Government, that the Congress appropriates for the Federal 
Government to spend in this area to be properly used. We know 
that there is a problem specifically of the subset of female 
veterans and we need to make sure that as we do the research in 
the Whole-of-Government Approach, that there is a specific 
targeting of this female veteran's population, okay.
    And so, I think that we do need to outline some kinds of 
incentives to get there and we are happy, as a Committee, to 
help work with you to do that.
    Mr. Chairman, thank you.
    The Chairman. I now recognize Mr. Mast for 5 minutes.
    Mr. Mast. Thank you, Mr. Secretary for waiving me onto the 
Committee or thank you, Mr. Chairman, for waiving me onto the 
Committee.
    Thank you, Mr. Secretary, for being here.
    Secretary Wilkie. Thank you, sir.
    Mr. Mast. I was glad to see you take this post. We have 
known each other for a number of years. I need to ask you about 
some things going on back in my own--
    Secretary Wilkie. Yes.
    Mr. Mast. Are you aware of what happened at the West Palm 
Beach VA on March 14th, 2019?
    Secretary Wilkie. I am aware of several instances of 
tragedy that happened at West Palm Beach--suicide, an attempt 
at police-induced suicide, at West Palm Beach, yes.
    Mr. Mast. Yes. March 11th, Bruce Dash came in under a Baker 
Act for suicidal thoughts. March 14th, he was found at 6:00 
p.m. dead on the mental health ward, unfortunately tragic, as 
you said.
    February 27, Larry Bond, admitted, again, under a Baker 
Act, drew a gun from his motorized scooter and shot Dr. Bruce 
Goldfeder, another bystander; again, very, very tragic.
    Not that you would be expected to know this, but going back 
to January 10th of 2018, I visited the Department of Veterans 
Affairs, here in Washington, specifically to discuss Veterans 
Affairs security issues nationwide, but very specifically, back 
home.
    May 30th of 2018, my legislative director met with the 
administration at our local VA hospital, came down and met with 
the administration there about security issues local to the 
hospital.
    On June 29th, 2018, I met with the West Palm Beach VA 
director about security concerns that we had in the facility. 
Weekly, my staff and I, we hold office hours at the West Palm 
Beach VA, where we have spoken to the security personnel about 
the issues and concerns that we have here.
    I would like to know, Mr. Secretary, have you or Dr. Stone 
before to the West Palm Beach VA since the recent suicide and 
recent shooting?
    Dr. Stone. I have not. My director of mental health 
services will be down there later this week.
    Mr. Mast. Mr. Secretary, have you been?
    Secretary Wilkie. No, I have not; although, as you know, 
that was the very first place that I visited when I became the 
secretary. We are, as a result of what happened at Palm Beach, 
we have a new security protocol in place that will apply to the 
entire country.
    But you have hit on an issue that is wider than your 
district. Last year, I believe 19 veterans across the country 
took their lives in various VA facilities and as a result of 
that, we have undergone a complete review of our security 
protocols. We found that on the medical front that these are 
not connected; that there is not one pattern.
    But what happened at Palm Beach with the wounding of the 3 
medical professionals, has led us to revamp the entire way we 
do security. Because I will tell you that the method that was 
used there was entirely unexpected.
    Mr. Mast. I am glad to hear that. I believe that these 
tragic events, they warrant your direct attention, as well as 
you, Dr. Stone. So, I am asking for the most valuable thing 
that you both have to offer; that is your time.
    Will you give us your time in West Palm Beach, come down, 
let us show you our concerns in the facility. Meet behind 
closed doors with our veterans that would love to have the 
chance to speak to you both about what they are experiencing, 
what they are seeing, what they are concerned about. Will you 
give us your time, come down to the West Palm Beach VA? I am 
asking this to both of you.
    Secretary Wilkie. Well, I am in Florida quite a bit, and, 
of course, I will come.
    But let me refer back to an answer that I gave earlier.
    Mr. Mast. So, I have your commitment?
    Secretary Wilkie. I will be happy to come with you.
    Mr. Mast. Will you meet--
    Secretary Wilkie. I will meet with everybody. I would meet 
with everybody; in fact, in the first 3 months that I was 
secretary before this current condition got me and I couldn't 
travel, I was in almost 20 states--I think 20 states.
    Mr. Mast. Before my time runs out, can you give me a 
timeframe when yourself, when Dr. Stone will find time to meet, 
most importantly, with my local veterans. I know that we have 
access to one another--
    Secretary Wilkie. I will say as soon as possible, but let 
me also finish by saying--
    Mr. Mast. I was a bomb technician. We used to always use 
vague terms like that so people would never know exactly when 
we would get on the ground. I would like a more specific 
answer.
    Secretary Wilkie. Well, the problem is that as a secretary, 
I don't control my own time, so I have to respond to the entire 
country. And that is what I was going to answer in this sense 
of what I just said about suicide. Palm Beach had tragedies. 
The thrust that we have undertaken--and Palm Beach, if you go 
back and listen to my remarks in the Roosevelt Room in the 
White House, I said that Palm Beach was the final impetus that 
got us across the finish line in creating a national suicide 
task force. It was Palm Beach that allowed the President to put 
his signature on the Suicide Task Force. I said that at the 
signing ceremony.
    Because Palm Beach is indicative of what we are seeing 
across the country, and my thrust is national. Obviously, I 
will go as many places as I can, but as the leader of this 
institution, I am taking, as a result of what happened in your 
district, a national approach that is now buttressed by the 
President of the United States and his emphasis on suicide.
    Mr. Mast. Thank you, Mr. Secretary. I will look forward to 
seeing you back home.
    Thank you, Mr. Chairman.
    The Chairman. Mr. Secretary, I thank you for your 
testimony, and the first panel, you are now excused.
    Mr. Roe. Let me ask him one question, and not to get 
answered on the way out the door, but give me an answer to 
this.
    The Chairman. Mr. Roe?
    Mr. Roe. Yeah, just a very simple thing for you all. I saw 
your opioid initiative and I just wonder how many inpatient 
treatment facilities that the VA has for opioid addiction 
across the country. And you can answer--the secretary--the 
Chairman has been very kind to let me ask the question.
    Secretary Wilkie. Can I take that one for the record, 
Doctor?
    Mr. Roe. Yes.
    Secretary Wilkie. I don't know off the top of my head.
    Mr. Roe. I think I would like to know that because I think 
it would probably be inadequate.
    The Chairman. All right. The panel is excused.
    Thank you, Mr. Secretary, again, for your testimony.
    I am going to, out of mercy for, I would presume myself, 
but also maybe Dr. Roe, a 5-minute recess before we call the 
next panel.
    [Recess.]
    The Chairman. I now invite our second panel to the witness 
table: Ms. Joy Ilem, the National Legislative Director for 
Disabled American Veterans; Mr. Patrick Murray, representing 
the Veterans of Foreign Wars; Ms. Heather Ansley, representing 
Paralyzed Veterans of America; and Mr. Larry Lohmann, Senior 
Legislative Associate of the Legislative Division from The 
American Legion.
    Ms. Ilem, I now recognize you for 5 minutes.

                     STATEMENT OF JOY ILEM

    Ms. Ilem. Thank you, Chairman Takano, Ranking Member Roe, 
and Members of the Committee.
    On behalf of the co-authors of the Independent Budget, DAV, 
PVA, and VFW, representing our more than 2 million members, I 
am pleased to present our views regarding the President's 
funding request for the Department of Veterans Affairs for 
fiscal year 2020.
    For more than 30 years, our organizations have worked 
together to develop Independent Budget and policy 
recommendations that reflect the true needs of America's 
veterans. We believe the implementation of the VA MISSION Act 
reforms, along with the projected increased demand for veterans 
of benefits and medical care both, inside VA and in the 
community, validates our funding increases we are recommending 
for 2020.
    The IB recommends total discretionary funding of $103 
billion to ensure the VA is able to fully and faithfully 
implement the MISSION Act and deliver timely benefits to 
veterans, their families, and survivors, and provide medical 
care service to all enrolled veterans using VA care.
    We appreciate that Congress remains committed to improving 
services for our Nation's veterans; however, the serious access 
problems in the health care system identified in 2014 and the 
ultimate passage of the MISSION Act have created high 
expectations which, absent sufficient resources to fully enact 
the law, could erode promised reforms and modernization.
    To ensure these promises are kept, the IB recommends 
approximately $88 billion in total medical care funding for 
fiscal year 2020; $4 billion more than the Administration's 
request. Of the $88 billion, we recommend $70 billion to fund 
VA-provided medical care and the remaining $18 billion for 
Community Care funding; nearly double current funding levels.
    The amount includes $8.5 billion to meet all related VA 
MISSION Act requirements, including replacing the Veterans 
Choice Program and the new Veterans Community Care Program by 
the start of fiscal year 2020, and expanding transplant-care 
services and implementing the new urgent care benefit.
    The Administration's request for VA medical services is 
approximately $4.7 billion below the IB recommendation of $56 
billion. Although the Administration's request reflects an 
apparent increase of 3 percent, the IB believes that when taken 
into account the increased costs to maintain current services, 
anticipated increases in workload, as well as increased costs 
for projects inside VA mandated by the MISSION Act, that the 
apparent increase falls short of what may be needed.
    The $56 billion includes an additional $1.2 billion for 
several other important health care programs to include 
increased funding for VA's long-term care services, its 
comprehensive caregiver program, the women veteran's health 
program, reproductive services, and prosthetics and sensory 
aids program. The IB recommends $6.1 billion for information 
technology to sustain VA's electronic health record 
modernization efforts and to reverse the trend of underfunding 
development and innovation of IT. We strongly believe IT 
improvements are critical to the overall success of reform 
efforts underway. The IB recommends $840 million for medical 
and prosthetic research. VA's research program ensures ill and 
injured veterans have access to the most advanced evidence-
based and cost-effective treatments available; one of VA's core 
missions.
    The Administration's request of $762 million for this 
critical program represents a 2 percent cut below current 
funding, compounded by medical research inflation estimated to 
be 2.8 percent.
    The IB recommends $3.5 billion for VA's major- and minor-
construction programs to repair, renovate, expand, and replace 
VA's aging infrastructure. The Administration's request of $1.8 
billion represents a 44 percent reduction from VA 2019 levels 
and a significant retreat in funding when VA estimates at least 
$60 billion necessary over the next 10 years to address VA's 
infrastructure issues.
    Finally, while the Administration's recommended funding 
level of $3 billion for the Veterans Benefit Administration is 
sufficient, we oppose several proposals that would negatively 
impact veterans; specifically, we oppose the rounding down of 
cost-of-living adjustments and making it harder for veterans to 
receive examinations necessary to establish their disability 
claims.
    In closing, we thank you for the opportunity to testify 
today and present our budget views and recommendations for 
fiscal year 2020 and we would be happy to answer and respond to 
any questions that you or Members of the Committee may have. 
Thank you.

    [The prepared statement of Joy Ilem appears in the 
Appendix]

    The Chairman. Mr. Lohmann, you are recognized for 5 
minutes.

                   STATEMENT OF LARRY LOHMANN

    Mr. Lohmann. Chairman Takano, Ranking Member Roe, 
distinguished Members of the Committee, on behalf of Brett P. 
Reistad, national commander of The American Legion, and our 
nearly 2 million members, we thank you for the opportunity to 
present our position on President Trump's proposed fiscal year 
2020 budget for the Department of Veterans Affairs.
    Last month, The American Legion celebrated our 100th 
anniversary. When National Commander Reistad testified earlier 
this year before a Joint Committee on Veterans Affairs, he 
spoke about The American Legion's mission: a mission to care 
for veterans, a mission to provide patriotic youth programs, a 
mission to advocate for strong national defense, and a mission 
to instill pride about what it means to be American. As he 
said, our mission continues.
    Inherently, an adequately funded VA budget provides care to 
veterans and that makes it a paramount objective in the The 
American Legion's mission. The American Legion generally 
supports the President's proposed budget for fiscal year 2020 
as it applies to VA programs, though we believe additional 
funding is needed in several areas.
    We appreciate the continued commitment of the President, 
Congress, and the Committee following through with promises 
made to care for those who have served our great country in 
uniform. The fact that the Department of Veterans Affairs is 
only one of two civilian agencies that will experience an 
increase in funding in 2020 is not lost on The American Legion. 
At a time when most federal agencies are experiencing a 
decrease in their respective budgets, the VA, will hopefully, 
with assistance from this critical committee, receive a much-
needed increase in line with, or greater than the President's 
proposal.
    As VA continues to serve the veterans of this Nation, it is 
vital the secretary has the necessary tools and resources to 
ensure that those who have served receive timely, professional, 
and courteous service. They have earned it.
    Today, I will focus on a few key issues highlighted in the 
budget: implementation of the VA MISSION Act, appeals 
modernization, and COLA round downs. The 115th Congress was 
very productive in enacting veteran legislation.
    One critical piece of legislation championed by The 
American Legion was the VA MISSION Act. If faithfully 
implemented, the VA MISSION Act will expand the availability of 
high-quality medical care to veterans in a timely manner. Two 
of the most notable functions of the VA MISSION Act include 
reforms for the Department of Veterans Affairs health care 
system and expanding the VA's caregiver service support 
program.
    MISSION consolidated 7 existing Community Care programs, 
including the Veterans Choice Program, and further expanded VA 
Caregiver Support Program to eligible veterans severely injured 
prior to September 11th, 2001. The underlying principles behind 
the creation of these programs is fundamentally sound; however, 
success of these programs depend upon the existence of 
sufficient resources.
    Under the President's proposed budget, we are concerned 
with the ability of VA to expand its comprehensive Caregiver 
Support Program to severely injured World War II, Korean, and 
Vietnam War veterans and their family caregivers under the 
statutorily mandated timetable.
    VA MISSION Act will require more resources that have been 
provided through regular appropriations in fiscal year 2019 and 
will cause care-appropriation needs for the VA for future 
fiscal years. These appropriation needs must be addressed by 
Congress.
    Also passed by the 115th Congress, the Appeals 
Modernization Act. The Appeals Modernization Act, or MA, became 
fully effective earlier this year. The MA sets forth specific 
elements that VA must address in its implementation.
    The American Legion currently holds power of attorney on 
more than 1.3 million claimants. We spend millions of dollars 
each year defending veterans through the claims and appeals 
process. As such, we feel we have a vested interest in the 
success of this new system.
    The American Legion believes working together with VA and 
Congress is vital to ensuring the success of the new appeals 
system. The American Legion supports the funding of the 
President's budget as it applies to VA programs and urges 
Congress to appropriate this money as it uses its oversight 
authority to make sure stakeholder voices continue to be heard.
    In addition to funding newly implemented laws, care for 
veterans means making sure long-existing programs continue to 
operate as they were intended to. The President's proposed 
budget seeks multiple cost-of-living adjustment round downs. 
These round downs would impact both, dependency indemnity 
compensation, as well as education programs.
    The American Legion, through resolution, opposes these 
round downs. The effect of these proposed round downs would 
serve as a tax on disabled veterans and their survivors, 
decreasing the amount of money they receive each year. Veterans 
and their survivors rely on their compensation for cost-of-
living to make sure essential purchases, such as 
transportation, rent, utilities, and food.
    The American Legion is opposed to any COLA round down. The 
Administration and Congress should not seek to balance the 
budget on the backs of veterans who have served their country.
    In closing, Chairman Takano, Ranking Member Roe, and 
distinguished Members of this Committee, The American Legion 
stands ready to work with Congress and the VA. We understand 
with creative solutions that have been made possible with 
innovative legislation enacted by the last Congress, come new 
questions to be answered. Together with cooperation and by 
remaining flexible, we will make these programs work and answer 
those questions for America's veterans.
    The American Legion thanks you for the opportunity to share 
with you this afternoon, and I am happy to answer any questions 
that you may have.

    [The prepared statement of Larry Lohmann appears in the 
Appendix]

    The Chairman. Ms. Ilem and Mr. Lohmann's full written 
testimony will be included in the hearing record.
    I now recognize myself for 5 minutes, and I want to begin 
by asking our VSO representatives this question. The 
Administration has stated this budget proposal would provide 
the highest funding levels in the Department's history. In many 
of your testimonies, you expressed concern that the 
Administration's request was not wholly sufficient to provide 
for both, VA's internal capacity and the full and faithful 
implementation of the MISSION Act.
    What do you believe will be the consequences for veterans 
if this budget is adopted as is, beginning with Ms. Ilem?
    Ms. Ilem. If it was adopted, as is, without the additional 
funding, we believe, you know, there could be severe 
consequences, again, for veterans. We might be back in the same 
situation with access issues that occurred.
    With this big--with the implementation of the MISSION Act, 
it is such a critical period right now, we are not sure how the 
access standards are going to work, how this is all going to 
roll out, obviously; there are a lot of unknowns. So, we want 
to make sure that veterans--this, you know, goes as seamless as 
possible for them.
    And we want to make sure that a sufficient budget is there 
to support VA. So, whether they need to continue to make the 
reforms inside that they have promised, in terms of the IT 
reforms and all the other hiring of clinical staff and the 
other necessary improvements in VA, as well as be able to build 
their network and be able to make sure that veterans have 
access to that Community Care if VA is not able to provide it.
    The Chairman. Mr. Lohmann?
    Mr. Lohmann. Thank you, Mr. Chairman, for the question. We 
share your concerns with the funding of the VA. We have a 
system we are saving that goes out and visits VAs through the 
year and we have 2 million members that are regularly 
participating in the VA system.
    We believe that once those problems become recognizable, we 
would be able to react to it. And I think that it is something 
that we will keep monitoring and we want to address 
proactively, but we want to see how the funding is currently 
working that has been appropriated.
    The Chairman. Mr. Murray?
    Mr. Murray. Sir, I believe that it is--I agree with our 
partners in the IB. It is absolutely critical that this funding 
is done properly and make sure that the attention for the right 
programs is being put on different parts within the budget 
appropriately. I think that just saying that it is a higher 
dollar amount isn't enough if the right attention isn't being 
given to the right areas.
    The Chairman. Ms. Ansley.
    Ms. Ansley. Thank you, Chairman, for the question. PVA, as 
part of the Independent Budget, believes that if the budget 
were implemented as requested, that it would leave shortfalls 
in key areas, including the implementation of the VA MISSION 
Act to Community Care, medical research, and through VA's 
provision of care through its direct-care system. And we 
believe, ultimately, as was stated by our partners, it would 
lead to problems that we have seen in the past and also to 
veterans not receiving the care that they have deserved and 
earned.
    The Chairman. Thank you. The VA's shift toward a public 
health approach to suicide prevention has led the agency to 
begin developing veteran-focused community-based support 
systems. Do any of you believe that the VA does enough to 
prepare a veteran's personal support system, his or her family 
or friends, to understand and respond to the red flags that 
often indicate suicidality? Anyone who would care to start--Ms. 
Ilem, go ahead.
    Ms. Ilem. Certainly VA's public health approach is a big 
challenge for them. I mean, they are reaching way beyond their 
capacity internally and trying to reach those veterans who 
haven't engaged with VA.
    VA has tried to provide a number of--they have a number of 
programs on suicide prevention and that are on their website 
available--the Be There campaign--and a number of ones that are 
specifically about outreaching to family members, looking at 
red flags, trying to coach veterans into care that--are a 
family member might be reaching out to the VA saying, I think 
my loved one, my veteran needs help, but they are very 
resistant in doing it, what can I do?
    So, I know that they are trying, but it is very insular 
within VA. So, hopefully, this program, the public approach, 
they will share some of that information wider, to this wider 
network in the community, because I think they do have some 
excellent programs that they have tried to set up to make that 
information available to family members about the red flags. 
And they are also doing a lot of outreach to veteran service 
organizations on their suicide hotline, you know, the crisis 
line, and how to spot when people are in trouble, and 
especially when they call in and you just might be talking to a 
veteran on the phone, how to pick up on signals that there 
might be something serious and that how you can help get that 
veteran the help that they need.
    The Chairman. Thank you. My time is expired.
    I now recognize Dr. Roe for 5 minutes.
    Mr. Roe. Thank you, Chairman.
    And thank you all for being here, and thank you for your 
partnership over the last several Congresses in trying to 
advance the status of our veteran population in the country.
    One of the things that I was asking Jon here during the 
first panel was, how much money does the VA carryover? How much 
money that they had, that they did from fiscal year 2014, 2015, 
2016, whatever, how much they have carried over, and it is my 
understanding--and we sort of looked it up. It is about $3 
billion in health care.
    Does that give you all some peace of mind to know that 
there will be plenty of enough resources to take care of the 
needs that you just discussed? And anyone can take that.
    Mr. Murray. Sir, yes. We have found that same number, but 
one of the questions we actually have for VA is: What is that 
money targeted for? If they are just simply putting it in, you 
know, a general fund is one thing, but making sure that it is--
in the past, those monies have gone to Community Care to fund 
extension for that. There have been some excess monies that 
have gone to the Filipino Veterans Fund that they have had 
extra, almost slush money to put there.
    What we would like to see is that this money is being kind 
of allocated for specific programs, and then we would like to 
be a little bit more reassured about where that is going, sir.
    Mr. Roe. Yeah, we can help. Believe me, they will have to 
answer to this Committee, so I think we have a lot of leverage 
there on that issue.
    We were talking a lot about--and the Chairman and I have 
agreed that one of our focuses will be on suicide prevention--
and we spend a tremendous amount of money on suicide 
prevention, to the tune of billions of dollars and we haven't 
moved the needle at all. So, we are looking at alternative ways 
or whatever, and if you all would assist us in that, if you 
find out there when you are traveling, you are all out there in 
the country and your members are, NGOs or others that are doing 
this that are having some success, please share those with us, 
because we would like to see if those are scalable.
    And we are looking at things that are, already, and 
changing some of the things that we are currently doing. I know 
that the effort is there. I know the will of the Congress and 
the President; the Administration is there. We just have not 
seen the results and I am not sure why. I wish I had the answer 
to it.
    One little something we looked up, which is really 
astonishing to me, in fiscal year 2020, the budget request for 
homeless veterans, as treatment costs and initiative spending, 
is $9.3 billion, and the fiscal year 2020 budget request for 
Post-9/11 veteran medical needs are 8.3. We are actually 
spending more money on medical needs and initiatives and 
homeless veterans than we are our Post-9/11-injured veterans. I 
found that an amazing number.
    And with today's economy being what it is, as good as it 
is, I think we also need to do--and the Chairman and I have 
also talked about this--to do a deep dive on homeless veterans 
and find out--and I think it was mentioned by one of our 
colleagues here--in California, a huge number of homeless 
veterans are in Southern California, mainly.
    So, if you could help us with that, we would be--I would 
much appreciate that. And any of you can make a comment if you 
would like.
    Ms. Ansley. Thank you, Ranking Member Roe.
    Certainly, the Independent Budget spoke to the needs of 
homeless veterans, as it has. We continue to work together to 
ensure that every veteran is able to be housed and receive the 
care and services they need to be able to live full lives.
    And we commit to working with you and the Committee, 
continuing on that issue. We know it has been an initiative for 
a number of years and Congresses, but as you said, there is 
still more to be done and we want to make sure that we are a 
part of that solution.
    Mr. Roe. And it is one of the VA's successes. I mean, I 
have met veterans out there who have been homeless. I met one 
in Nashville not long ago that was out of the street and had a 
HUD voucher, had a job, and is doing great. And I have run 
across that many, many times. So, I don't think that we hear 
those stories enough.
    We talk about the things that's not happening, but we 
should talk about the things that have happened, positively, 
and that is one of the things.
    And very quickly, because my time is about gone, please 
elaborate on the Independent Budget's contention that the 
current budget request will not allow VA to fully and 
faithfully implement the MISSION Act.
    Ms. Ansley. Thank you, Ranking Member.
    The Independent Budget's recommendation for the Community 
Care effort was $18.1 billion versus the Administration's 
request of $15.3 billion. We have concerns that that funding is 
not going to be sufficient to meet the requirements. Also, our 
estimates did not include the access standards as it relates to 
the drive time and wait lists that recently came out from the 
Administration in looking at access standards.
    So, we have concerns moving forward that will be sufficient 
funding to address all of those needs. There is a lot of 
unknowns still. Even, you know, 60 days out or so as the 
program is beginning into effect is how many veterans are going 
to be using that. The marketing assessments are not complete to 
know what resources are available in the community. And all of 
those come together to just give us pause that there may not be 
sufficient funding available.
    Mr. Roe. Thank you. I yield back.
    The Chairman. I now recognize General Bergman for 5 
minutes.
    Mr. Bergman. Thank you, Mr. Chairman.
    I guess the only thing between us ending is me; is that 
right? Okay. Well, then, let's get right to the meat of the 
point, and this is your chance.
    What is the one heartburn that each of you have with the 
budget?
    Mr. Lohmann. I think, principally, the one thing that 
really hits--resolutions is the COLA round downs. I think every 
time that these come up, every single budget is something that 
we continually have to keep sticking to is that these round 
downs affect veterans and it turns into a tax every single time 
to nickel-and-dime our veterans that have served and continue 
to rely on this money for rent and tight budgets, and to 
incrementally chip away at it.
    Mr. Bergman. So, round downs, okay.
    This is like one of these one-minute speed rounds.
    Mr. Murray. So, sir, for my portion, I would say aging 
infrastructure. The VA is not properly funding its capital 
infrastructure program. There are billions of dollars of 
seismic correction that need to be done that are not being 
funded at anywhere an appropriate rate to get rid of those.
    Mr. Bergman. Okay. So, infrastructure?
    Mr. Murray. Infrastructure.
    Ms. Ilem. I would say women veterans. As part of the 
Independent Budget, we requested an additional $76 million. VA 
has made a lot of progress, but we really want to see more 
being done. A number of the members today talked about there 
was concern over women veterans' issues within VA and how they 
are going to resolve them.
    Mr. Bergman. Okay. So, process? Bureaucratic? I am trying 
to get a word down--get it down to a word.
    Ms. Ilem. Culture issues, and just having enough focus on 
making sure that VA has the providers it needs that have 
expertise in women's health to serve the small--it is a small 
population: 500,000--but it is growing. It grew 175 percent 
over a short period. So, VA has been playing catchup.
    Mr. Bergman. Okay.
    Ms. Ilem. So, between just making sure culture, that all 
women veterans feel welcome, and feel that they are being, you 
know, treated with dignity and respect, just like any veteran--
    Mr. Bergman. Okay.
    Ms. Ilem [continued].--and we want to make sure that all 
veterans can go to VA and take advantage of their great 
services.
    Mr. Bergman. Culture?
    Ms. Ilem. Yes.
    Mr. Bergman. Okay.
    Ms. Ansley. I would say the decrease that we have seen in 
medical research. IB recommended $840 million. The 
Administration came in at $762 million. This will not even keep 
up with the rate of medical inflation that occurs.
    And, certainly, research is important to all types of 
issues, and, particularly, to PVA members.
    Mr. Bergman. Okay. I appreciate your candor and I 
appreciate your directness. One of the challenges that we have 
as a Committee, whether it be round downs, infrastructure, 
culture, medical research, is that how do we get the most bang 
for our buck? And what we count on for everybody, whether it is 
the VA or the VSOs, is that we look, honestly, at how much 
value we are getting for our dollar and being able to say--I am 
just going to pick on infrastructure for a second here, because 
it is--we don't need more buildings, necessarily, but we need 
places for veterans to get health care.
    So, anyway, my point is we got that review. I am not asking 
for a response, okay, but the idea is how do we get our 
veterans the health care in a timely manner? And it is quality 
health care, whether it is through telehealth, whether it is 
through CBOCs, whether it is through the VA hospital, whether 
it is through whatever it happens to be. So, the goal is the 
same. The question is: How do we get there?
    Mr. Chairman, I yield back.
    The Chairman. Thank you. I have a few words that I would 
like to say before I close the hearing.
    While I appreciated the secretary and the members of the 
senior staff of the VA appearing before us today, I had hoped 
that they would remain to hear the concerns of our VSOs and I 
am disappointed that they did not do so.
    But I want you to know that we have heard your concerns. I 
have heard your concerns, and we will be working closely with 
all of you.
    I did want the VA to hear--and this will go into the 
record--that when this Committee invites a VA witness to 
participate in the hearing, the VA is required to make that 
witness available to provide testimony until that witness has 
been excused, and I am willing to work with the Department if 
it believes another witness would be more appropriate, and work 
to schedule hearings when the witnesses are available.
    The VA's refusal to provide a witness at the Technology 
Modernization Subcommittee hearing yesterday was unacceptable. 
If the VA refuses to make witnesses available, I will take 
steps to compel the appearance of witnesses, if necessary.
    With that, I will say that all Members will have 5 
legislative days to revise and extend their remarks and include 
extraneous material.
    Again, thank you for appearing before us today, and this 
hearing is now adjourned.

    [Whereupon, at 4:59 p.m., the Committee was adjourned.]


                            A P P E N D I X

                              ----------                              

           Prepared Statement of David P. Roe, Ranking Member
    When I came to Congress in 2009, the Department of Veterans 
Affairs' (VA's) budget totaled $97.7 billion.
    Today - a decade later, despite years of fiscal austerity that has 
impacted virtually every other Federal agency - that budget has more 
than doubled.
    Coming in at just over $220 billion - an increase of 9.6 percent 
above 2019 - the Trump Administration's fiscal year (FY) 2020 budget 
submission once again requests a record amount of funding for VA.
    I commend the President for his unflagging commitment to investing 
in our Nation's veterans and ensuring that they receive the support 
they need from the government they fought for.
    This budget reflects our mutual goal of strengthening VA by 
increasing easy access and timely receipt of care, benefits, and 
services to veterans across the country.
    It continues to advance the important modernization efforts that 
this Committee has prioritized and Secretary Wilkie has since 
championed, including electronic health record modernization.
    It also funds the implementation of the MISSION Act, which will 
transform the VA health care system and benefit veteran patients for 
years to come.
    I am grateful to Secretary Wilkie and his team as well as to the 
representatives from the veteran service organizations for being here 
this afternoon and I look forward to hearing from them shortly.
    But - before I yield, Mr. Chairman - I want to address Secretary 
Wilkie's comments before the Senate Veterans' Affairs Committee last 
week regarding VA's physical infrastructure requirements.
    Mr. Secretary, you testified that the Department has a $60 billion 
capital investment need over the next decade.
    You and I both know that that need is far from new and that it 
exists in large part because of how costly and complicated it is to 
operate a health care system whose medical facilities are five times 
older than they are in the private sector.
    I wholeheartedly agree with you that the Asset and Infrastructure 
Review (AIR) Commission that was included in the MISSION Act is key to 
addressing that need and should be ready to go as soon as the 
Department has completed the market assessment process that will inform 
the Commission's work.
    I understand that the market assessments are on track to be 
complete by next summer and I want to work hand-in-hand with VA to 
remove any barrier that stands in the way to getting the Commission 
underway not long after that.
    I thank all of our witnesses once again for being here.

                                 
                 Prepared Statement of Robert L. Wilkie
    Good afternoon, Mr. Chairman, Congressman Roe, and distinguished 
Members of the Committee. Thank you for the opportunity to testify 
today in support of the President's Fiscal Year (FY) 2020 Budget for 
the Department of Veterans Affairs (VA), including the FY 2021 Advance 
Appropriation (AA) request. I am accompanied today by Dr. Richard 
Stone, Executive in Charge, Veterans Health Administration (VHA), Dr. 
Paul Lawrence, Under Secretary for Benefits, and Jon Rychalski, 
Assistant Secretary for Management and Chief Financial Officer.
    I begin by thanking Congress and this Committee for your continued 
strong support and shared commitment to our Nation's Veterans VA. In my 
estimation, two Federal Government departments must rise above partisan 
politics-the Department of Defense (DoD) and VA. The bipartisan support 
this Committee provides sustains that proposition. To continue VA's 
momentum, the FY 2020 budget request fulfills the President's strong 
commitment to Veterans by providing the resources necessary to improve 
the care and support our Veterans have earned through sacrifice and 
service to our country.
                  Fiscal Year (FY) 2020 Budget Request
    The President's FY 2020 Budget requests $220.2 billion for VA - 
$97.0 billion in discretionary funding (including medical care 
collections). The discretionary request is an increase of $6.8 billion, 
or 7.5 percent, over the enacted FY 2019 budget. It will sustain the 
progress we have made and provide additional resources to improve 
patient access and timeliness of medical care services for the 
approximately 9 million enrolled Veterans eligible for VA health care, 
while improving benefits delivery for our Veterans and their 
beneficiaries. The President's FY 2020 budget also requests $123.2 
billion in mandatory funding, $12.3 billion or 11.1 percent above 2019.
    For the FY 2021 AA, the budget requests $91.8 billion in 
discretionary funding including medical care collections for Medical 
Care and $129.5 billion in mandatory advance appropriations for 
Compensation and Pensions, Readjustment Benefits, and Veterans 
Insurance and Indemnities benefits programs in the Veterans Benefits 
Administration (VBA).
    For VA Medical Care, VA is requesting $84.1 billion (including 
collections) in FY 2020, a 9.6 percent increase over the 2019 level, 
and a $4.6 billion increase over the 2020 AA, primarily for community 
care and to transition the Choice Program workload to VA's 
discretionary Medical Community Care account. This Budget will provide 
funding for treating 7.1 million patients in 2020.
    This is a strong budget request that fulfills the President's 
commitment to Veterans by ensuring that they receive high-quality 
health care and timely access to benefits and services while 
concurrently improving productivity and fiscal responsibility. I urge 
Congress to support and fully fund our FY 2020 and FY 2021 AA budget 
requests - these resources are critical to enabling the Department to 
meet the evolving needs of our Veterans and successfully execute my top 
priorities.

Customer Service

    It is the responsibility of all VA employees to provide an 
excellent customer service experience (CX) to Veterans, Servicemembers, 
their families, caregivers, and survivors when we deliver care, 
benefits, and memorial services. I am privileged to champion this 
effort.
    Our National Cemetery Administration has long been recognized as 
the organization with the highest customer satisfaction score in the 
Nation. That's according to the American Customer Satisfaction Index 
ACSI). And that's across all sectors of industry and government. We 
need to work to scope that kind of success across all benefits and 
services.
    That's why I incorporated CX into the FY 2018-2024 VA Strategic 
Plan. Last year, I issued VA's first customer service policy. That 
policy outlines how VA will achieve excellent customer service along 
three key pillars: CX Capabilities, CX Governance, and CX 
Accountability. I am holding all VA executives, managers, supervisors, 
and employees accountable to foster a climate of customer service 
excellence. We will be guided by our core VA Values of Integrity, 
Commitment, Advocacy, Respect, and Excellence (I-CARE). These values 
define our culture of customer service and help shape our standards of 
behavior.
    Because of VA's leadership in customer experience, our Veterans 
Experience Office has been designated Lead Agency Partner for the 
President's Management Agenda (PMA) Cross-Agency Priority (CAP) Goal on 
Improving Customer Experience across government.
    Our goal is to lead the President's work of improving customer 
experience across Federal agencies and deliver customer service to 
Veterans we serve that is on par with top private sector companies.
    This is not business as usual at VA. We are changing our culture 
and putting our Veteran customers at the center of our process. To 
accomplish this goal, we are making investments in Customer Service, 
and we are making bold moves in training and implementing customer 
experience best practices.
    Veterans Experience Office. The Veterans Experience Office (VEO) is 
my lead organization for achieving our customer service priority and 
providing the Department a core customer experience capability. VEO 
offers four core customer experience capabilities, including real-time 
customer experience data, tangible customer experience tools, modern 
technology, and targeted engagement. For FY 2020, VEO is shifting from 
a full reimbursable authority (RA) funding model to a hybrid of a RA 
and budget authority (BA) model. The FY 2020 request of $69.4 million 
for the VEO ($8.6 million in BA and $60.6 million in RA) is $8.1 
million above the FY 2019 enacted budget. The budget increase and the 
transition to a BA highlights VA's commitment to customer service and 
the institutionalization of CX capabilities within the Department to 
improve care, benefits and service to Veterans, their families, 
caregivers and survivors.

MISSION Act Implementation

    The VA MISSION Act of 2018 (the MISSION Act) will fundamentally 
transform elements of VA's health care system, fulfilling the 
President's commitment to help Veterans live a healthy and fulfilling 
life. It is critical that we deliver a transformed 21st century VA 
health care system that puts Veterans at the center of everything we 
do. The FY 2020 budget requests $8.9 billion in the VA Medical Care 
program for implementation of key provisions of the MISSION Act: $5.5 
billion for continued care of the Choice Program population; $2.9 
billion for expanded access for care based on average drive time and 
wait time standards and expanded transplant care; $272 million for the 
Urgent Care benefit, and $150 million to expand the Program of 
Comprehensive Assistance for Family Caregivers.
    Access to Care. Over the past few years, VA has invested heavily in 
our direct delivery system, leading to reduced wait times for care in 
VA facilities that currently meet or exceed the quality and timeliness 
of care provided by the private sector. And VA is improving access 
across its more than 1,200 facilities even as Veteran participation in 
VA health care continues to increase.
    From FY 2014 through FY 2018, VA saw an increase of 226,000 unique 
patients for outpatient appointments (a four percent increase). Since 
FY 2014, the number of annual appointments for VA care is up by 3.4 
million. There were over 58 million appointments in VA facilities in FY 
2018-620,000 more than the prior fiscal year. We have significantly 
reduced the time to complete an urgent referral to a specialist. In FY 
2014, it took an average of 19.3 days to complete an urgent referral 
and in FY 2018 it took 2.1 days, an 89 percent decrease. As of December 
2018, that time was down to about 1.6 days.
    Still, our patchwork of multiple separate community care programs 
is a bureaucratic maze that is difficult for Veterans, their families, 
and VA employees to navigate.
    The MISSION Act empowers VA to deliver the quality care and timely 
service Veterans deserve so we will remain at the center of Veterans' 
care. Further, the MISSION Act strengthens VA's internal network and 
infrastructure so VA can provide Veterans more health care access more 
efficiently.
    Transition to the New Community Care Program. We are building an 
integrated, holistic system of care that combines the best of VA, our 
Federal partners, academic affiliates, and the private sector.
    The Veterans Community Care Program consolidates VA's separate 
community care programs and will put care in the hands of Veterans and 
get them the right care at the right time from the right provider. On 
January 30, 2019, we announced proposed access standards that would 
determine if Veterans are eligible for community care under the access 
standard eligibility criterion in the MISSION Act to supplement care 
they are provided in the VA health care system. The proposed regulation 
for the program (RIN 2900-AQ46) was published in the Federal Register 
on February 22, 2019, and was open for comments through March 25, 2019.

    New Veterans Community Care Program Eligibility Criteria

    1. VA does not offer the care or services the Veteran requires;
    2. VA does not operate a full-service medical facility in the State 
in which the Veteran resides;
    3. The Veteran was eligible to receive care under the Veterans 
Choice Program and is eligible to receive care under certain 
grandfathering provisions;
    4. VA is not able to furnish care or services to a Veteran in a 
manner that complies with VA's designated access standards;
    5. The Veteran and the Veteran's referring clinician determine it 
is in the best medical interest of the Veteran to receive care or 
services from an eligible entity or provider based on consideration of 
certain criteria that VA would establish; or
    6. The Veteran is seeking care or services from a VA medical 
service line that VA has determined is not providing care that complies 
with VA's standards for quality.

    Proposed Access Standards. VA's proposed access standards-proposed 
for implementation in June 2019-best meet the medical needs of Veterans 
and will complement existing VA facilities with community providers to 
give Veterans access to health care.

    1. For primary care, mental health, and non-institutional extended 
care services VA is proposing a 30-minute average drive time from the 
Veteran's residence.
    2. For specialty care, VA is proposing a 60-minute average drive 
time from the Veteran's residence.
    3. VA is proposing appointment wait-time standards of 20 days for 
primary care, mental health care, and non-institutional extended care 
services and 28 days for specialty care from the date of request, 
unless a later date has been agreed to by the Veteran in consultation 
with the VA health care provider.

 
----------------------------------------------------------------------------------------------------------------
                                           Primary/Mental Health/Non-
                                           institutional Extended Care                 Specialty Care
----------------------------------------------------------------------------------------------------------------
        Appointment Wait Time                        Within 20 Days                        Within 28 Days
----------------------------------------------------------------------------------------------------------------
         Average Drive Time                           Within 30 Min                         Within 60 Min
----------------------------------------------------------------------------------------------------------------

    VA remains committed to providing care through VA facilities as the 
primary means for Veterans to receive health care, and it will remain 
the focus of VA's efforts. As a complement to VA's facilities eligible 
Veterans who cannot receive care within the requirements of these 
proposed access standards would be offered community care. When 
Veterans are eligible for community care, they may choose to receive 
care with an eligible community provider, or they may continue to 
choose to get the care at their VA medical facility.
    The proposed access standards are based on analysis of practices 
and our consultations with Federal agencies-including the DoD, the 
Department of Health and Human Services, and the Centers for Medicare & 
Medicaid Services-private sector organizations, and other non-
governmental commercial entities. Practices in both the private and 
public sector formulated our proposed access standards to include 
appointment wait-time standards and average drive time standards.
    VA also published a Notice in the Federal Register seeking public 
comments, and in July 2018, VA held a public meeting to provide an 
additional opportunity for public comment.
    With VA's proposed access standards, the future of VA's health care 
system will lie in the hands of Veterans-exactly where it should be.
    Urgent Care. This budget will also invest $272 million in 
implementing the new urgent (walk-in care) benefit included in the VA 
MISSION Act. On January 31, 2019, VA published a proposed rule that 
would guide the provision of this benefit using the provider network 
available through national contracts. Under the new urgent care 
authority, we will be able to offer eligible Veterans convenient care 
for certain, limited, non-emergent health care needs.
    Caregivers. The MISSION Act expands eligibility for VA's Program of 
Comprehensive Assistance for Family Caregivers (PCAFC) under the 
Caregiver Support Program, establishes new benefits for designated 
primary family caregivers of eligible Veterans, and makes other changes 
affecting program eligibility and VA's evaluation of PCAFC 
applications. Currently, the Program of Comprehensive Assistance for 
Family Caregivers is only available to eligible family caregivers of 
eligible Veterans who incurred or aggravated a serious injury in the 
line of duty on or after September 11, 2001. Implementation of the 
MISSION Act will expand eligibility to eligible family caregivers of 
eligible Veterans from all eras.
    Under the law, expansion will begin when VA certifies to Congress 
that VA has fully implemented a required information technology system. 
The expansion will occur in two phases beginning with eligible family 
caregivers of eligible Veterans who incurred or aggravated a serious 
injury in the line of duty on or before May 7, 1975, with further 
expansion beginning two years after that.
    Over the course of the next year, VA will be establishing systems 
and regulations necessary to expand this program. Caregivers and 
Veterans can learn about the full range of available support and 
programs through the Caregivers website, www.caregiver.va.gov, or by 
contacting the Caregiver Support Line toll-free at 1-855-260-3274.
    The FY 2020 Budget for the Caregivers Support Program is $720 
million, $150 million of which is specifically requested to implement 
the program's expansion because of the MISSION Act.
    Telehealth. VA is a leader in providing telehealth services. VA 
leverages telehealth technologies to enhance the accessibility, 
capacity, and quality of VA health care for Veterans, their families, 
and their caregivers anywhere in the country. VA achieved more than one 
million video telehealth visits in FY 2018, a 19 percent increase in 
video telehealth visits over the prior year. Telehealth is a critical 
tool to ensure Veterans, especially rural Veterans, can access health 
care when and where they need it. With the support of Congress, VA has 
an opportunity to continue shaping the future of health care with 
cutting-edge technology providing convenient, accessible, high-quality 
care to Veterans. The FY 2020 Budget includes $1.1 billion for 
telehealth services, a $105 million or 10.5 percent increase over the 
2019 current estimate.
    Section 151 of the MISSION Act strengthens VA's ability to provide 
even more telehealth services because it statutorily authorizes VA 
providers to practice telehealth at any location in any State, 
regardless of where the provider is licensed. VA's telehealth program 
enhances customer service by increasing Veterans' access to VA care, 
while lessening travel burdens.
    In FY 2018, more than 782,000 Veterans (or 13 percent of Veterans 
obtaining care at VA) had one or more telehealth episodes of care, 
totaling 2.29 million telehealth episodes of care. Of these 782,000 
Veterans using telehealth, 45 percent live in rural areas. VA's major 
expansion for telehealth and telemental health over the next five 
years, for both urban and rural Veterans, will focus on care in or near 
the Veteran's home. VA's target is to increase Veterans receiving some 
care through telehealth from 13 percent to 20 percent using telehealth 
innovations like the VA Video Connect (VVC) application, which enables 
private encrypted video telehealth services from almost any mobile 
device or computer. VVC will be integrated into VA clinicians' routine 
operations to provide Veterans another option for connecting with their 
care teams.
    Strengthening VA's Workforce. Recruitment and retention are 
critical to ensuring that VA has the right doctors, nurses, clinicians, 
specialists and technicians to provide the care that Veterans need. The 
FY 2020 Budget strengthens VHA's workforce by providing funding for 
342,647 FTE, an increase of 13,066 over 2019. VA is also actively 
implementing MISSION Act authorities that increased VA's ability to 
recruit and retain the best medical providers by expanding existing 
loan repayment and clinical scholarship programs; it also established 
the authority to create several new programs focused on medical school 
students and recent graduates. VA is also implementing additional 
initiatives to enhance VA's workforce, such as the expanded utilization 
of peer specialists and medical scribes.

Business Transformation

    Business transformation is essential if we are to move beyond 
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 and appeals, GI Bill 
benefits, human resources, financial and acquisition management, supply 
chain management, and construction. The Office of Enterprise 
Integration (OEI) is charged with coordination for these efforts.
    Office of Enterprise Integration. The scale and criticality of the 
initiatives underway at VA require management discipline and strong 
governance. As part of OEI's coordination role in VA's business 
transformation efforts, we have implemented a consistent governance 
process to review progress against anticipated milestones, timelines, 
and budget. This process supports continuous alignment with objectives 
and identifies risks and impediments prior to their realization.
    For example, our VA Modernization Board recently initiated a 
leadership integration forum to synchronize deployment schedules across 
three major enterprise initiatives: adoption of Defense Medical 
Logistics Standard Support (DMLSS), financial management business 
transformation, and our new electronic health record. This forum 
allowed us to assess the feasibility of a concurrent deployment and 
identify an alternate course of action. By implementing strong 
governance and oversight, we are increasing accountability and 
transparency of our most critical initiatives.
    Appeals Modernization. The Veterans Appeals Improvement and 
Modernization Act of 2017 (AMA) was signed into law on August 23, 2017 
and took effect on February 19, 2019. The Appeals Modernization Act 
transforms VA's complex and lengthy appeals process into one that is 
simple, timely, and fair to Veterans and ultimately gives Veterans 
choice and control over how to handle their claims and appeals.
    The FY 2020 request of $182 million for the Board of Veterans' 
Appeals (the Board) is $7.3 million above the FY 2019 enacted budget 
and will sustain the 1,125 FTE who will adjudicate and process legacy 
appeals while implementing the Appeals Improvement and Modernization 
Act. The Board continues to demonstrate its commitment to reducing 
legacy appeals and decided a historic number of appeals - 85,288--in FY 
2018, the highest number for any fiscal year. The Board is on pace to 
decide over 90,000 appeals in 2019.
    To ensure smooth implementation, the Board launched an aggressive 
workforce plan to recruit, hire, and train new employees in FY 2018. 
The Board on-boarded approximately 242 new hires, including 217 
attorneys/law clerks and approximately 20 administrative personnel.

    The new appeals process features three decision-review lanes:

    1. 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. 
VBA has a 125-day average processing goal for decisions issued in this 
lane.
    2. Supplemental Claim Lane: Veterans can submit new and relevant 
evidence to support their claim, and a claims processor at a VA 
regional office will assist in developing evidence. VBA has a 125-day 
average processing goal for decisions issued in this lane.
    3. Appeal Lane: Veterans who choose to appeal a decision directly 
to the Board of Veterans' Appeals (Board) may request direct review of 
the evidence the regional office reviewed, submit additional evidence, 
or have a hearing. The Board has a 365-day average processing time goal 
for appeals in which the Veteran does not submit evidence or request a 
hearing.

    In addition to focusing on implementation of the Appeals 
Modernization Act, addressing pending legacy appeals will continue to 
be a priority for VBA and the Board in FY 2019. VBA's efforts have 
resulted in appeals actions that have exceeded projections for fiscal 
year to date 2019. VBA plans to eliminate completely its legacy, non-
remand appeals inventory in FY 2020 and significantly reduce its legacy 
remand inventory in FY 2020.
    Finally, VBA is also undertaking a similar, multi-pronged approach 
to modernize its appeals process through increased resources, 
technology, process improvements, and increased efficiencies. VBA's 
compensation and pension appeals program is supported by 2,100 FTEs. 
VBA added 605 FTEs in FY 2019 to process legacy appeals and decision 
reviews in the modernized process. As of October 1, 2018, to best 
maximize its resources an enable efficiencies, VBA centralized these 
assets to conduct higher-level reviews at two Decision Review Operation 
Centers (DROC). VBA will convert the current Appeals Resource Center in 
Washington, DC, into a third DROC using existing assets.
    Forever GI Bill. Since the passage of the Harry W. Colmery Veterans 
Educational Assistance Act of August 16, 2017, 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 
202 temporary employees in the field to support this additional 
workload.
    Sections 107 and 501 of the law 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. Pending 
the deployment of a technology-based solution, Veterans and schools 
will continue to receive GI Bill benefit payments as normal. By asking 
schools to hold fall enrollments through the summer and not meeting the 
implementation date for the IT solutions of Sections 107 and 501, some 
beneficiaries experienced delayed and incorrect payments.
    In accordance with the Forever GI Bill Housing Payment Fulfillment 
Act of 2018, VA established a Tiger Team tasked to resolve issues with 
implementing sections 107 and 501 of the Forever GI Bill. This month we 
awarded a new contract that we believe will provide the right solution 
for implementing Sections 107 and 501. By December 2019, we will have 
Sections 107 and 501 fully implemented. By spring 2020, all enrollments 
will be processed according to the Colmery Act. We will recalculate 
benefits based on where Veterans take classes, and we will work with 
schools to make Sections 107 and 501 payments retroactive to the first 
day of August 2018, the effective date.
    The Department is committed to making sure every Post-9/11 GI Bill 
beneficiary is made whole based on the rates established under the 
Forever GI Bill, and we are actively working to make that happen. We 
got the word out to Veterans, beneficiaries, schools, VSOs, and other 
stakeholders that any Veteran who is in a financial hardship due to a 
late or delayed GI Bill payment should contact us immediately.
    In December 2018, we updated the housing rates like we normally 
would have in August. Those rates were effective for all payments after 
January 1, 2019. Additionally, we processed over 450,000 rate 
corrections, ensuring that any beneficiary who was underpaid from 
August through December received a check for the difference. We have 
completed the spring peak enrollment season without any significant 
challenges. We worked with schools to get enrollments submitted as 
quickly as possible.
    As VA moves forward with implementation, we will continue to 
regularly update our Veteran students and their institutions of 
learning on our progress and what to expect. Already, VA has modified 
its definition of ``campus'' to better align itself with statutory 
requirements, and in doing so has lessened the administrative burden on 
schools to report to VA housing data.
    Information Technology Modernization. The FY 2020 budget request of 
$4.343 billion continues VA's investment in the Office of Information 
Technology (OIT) modernization effort, enabling VA to streamline 
efforts to operate more effectively and decrease our spending while 
increasing the services we provide. The budget allows OIT to deliver 
available, adaptable, secure, and cost-effective technology services to 
VA-transforming the Department into an innovative, twenty first century 
organization-and to act as a steward for all VA's IT assets and 
resources. OIT delivers the necessary technology and expertise that 
supports Veterans and their families through effective communication 
and management of people, technology, business requirements, and 
financial processes.
    The requested $401 million funds for development will be dedicated 
to mission critical areas, continued divestiture of legacy systems such 
as the Benefits Delivery Network and the Burial Operations Support 
System, and initiatives that are directly Veteran-facing. Funds will 
continue to support Veteran focused initiatives such as Mental Health, 
MISSION Act and Community Care, and the continued transition from the 
legacy Financial Management System (FMS) to the new Integrated 
Financial and Acquisition Management System (iFAMS). The Budget also 
invests $379 million for information security to protect Veterans' 
information.
    Financial Management Business Transformation (FMBT). As mentioned 
above, a critical system that will touch the delivery of all health and 
benefits is our new financial and acquisition management system, iFAMS. 
In support of the Financial Management Business Transformation (FMBT) 
program, the FY 2020 budget requests $66 million in IT funds, $107 
million in Franchise Fund Service Level Agreement (SLA) funding from 
the Administrations and other Staff Offices to be paid to the Financial 
Services Center (FSC), and General Administration funding of $11.9 
million.
    Through the FMBT program, VA is working to implement an enterprise-
wide financial and acquisition management system in partnership with 
our service provider, CGI Federal Inc. VA will utilize a cloud hosted 
solution, configured for VA, leveraging CGI's Software as a Service 
(SaaS) model. VA will gain increased operational efficiency, 
productivity, reporting capability, and flexibility from a modern 
Enterprise Resource Planning (ERP) cloud solution. The new cloud 
solution will also provide additional security, storage, and 
scalability.
    Infrastructure Improvements and Streamlining. I want to thank 
Congress for providing $2 billion in additional funding for VA 
infrastructure in 2019. This additional funding for minor construction, 
seismic corrections, and non-recurring maintenance will enhance our 
ability to address infrastructure needs. In FY 2020, VA will continue 
improving its infrastructure while transforming our health care system 
to an integrated network to serve Veterans. This budget allows for the 
expansion of health care, burial and benefits services where needed 
most. The request includes $1.235 billion in Major Construction 
funding, as well as $399 million in Minor Construction to fund VA's 
highest priority infrastructure projects. These funding levels are 
consistent with our requests in recent years.

Major and Minor Construction

    This funding supports major medical facility projects including 
providing the final funding required to complete these projects: New 
York, NY - Manhattan VAMC Flood Recovery, Bay Pines, FL - Inpatient/
Outpatient Improvements, San Juan, PR - Seismic Corrections, Building 
1; and Louisville, KY - New Medical Facility. The request also includes 
continued funding for ongoing major medical projects at San Diego, CA - 
Spinal Cord Injury and Seismic Corrections, Reno, NV - Correct Seismic 
Deficiencies and Expand Clinical Services Building, West Los Angeles, 
CA - Site utilities for Build New Critical Care Center, and Alameda, CA 
- Outpatient Clinic & National Cemetery.
    The 2020 request includes additional funding for the completion of 
the new cemetery at Western New York Cemetery (Elmira, NY) and the 
replacement of the cemetery at Bayamon, PR (Morovis), and expansion 
project at Riverside, CA. The national cemetery expansion and 
improvement projects at Houston and Dallas, TX and Massachusetts 
(Bourne, MA) are also provided for. The FY 2020 Budget provides funds 
for the continued support of major construction program including the 
seismic initiative that was implemented in 2019 to address VA's highest 
priority facilities in need of seismic repairs and upgrades.
    The request also includes $399 million in minor construction funds 
that will used to expand health care, burial and benefits services for 
Veterans. The minor construction request includes funding for 131 newly 
identified projects as well as existing partially funded projects.

Leasing

    VA is also requesting authorization of seven major medical leases 
in 2020 to ensure access to health care is available in those areas. 
These leases include new leases totaling $33 million in Colombia, MO 
and Salt Lake City, UT as well as replacement leases totaling $104 
million in Baltimore, MD; Atlanta, GA; Harlingen, TX; Jacksonville, NC; 
and Prince George's County, MD. VA is requesting funding of $919 
million to support ongoing leases and delivery of additional leased 
facilities during the year.

    Repurposing or Disposing Vacant Facilities

    To maximize resources for Veterans, VA repurposed or disposed of 
175 of the 430 vacant or mostly vacant buildings since June 2017. Due 
diligence efforts (environmental/historic) for the remaining buildings 
are substantially complete, allowing them to proceed through the final 
disposal or reuse process.

Suicide Prevention

    Suicide is a national public health issue that affects all 
Americans, and the health and well-being of our nation's Veterans is 
VA's top priority. Twenty (20) Veterans, active-duty Servicemembers, 
and non-activated Guard or Reserve members die by suicide on average 
each day, and of those 20, 14 had 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. 
The FY 2020 Budget requests $9.4 billion for mental health services, a 
$426 million increase over 2019. The Budget specifically invests $222 
million for suicide prevention programming, a $15.6 million increase 
over the 2019 enacted level. The request funds over 15.8 million mental 
health outpatient visits, an increase of nearly 78,000 visits over the 
2019 estimate. This builds on VA's current efforts. VA has hired more 
than 3,900 new mental health providers yielding a net increase in VA 
mental health staff of over 1,000 providers since July 2017. 
Nationally, in the first quarter of 2019, 90 percent of new patients 
completed an appointment in a mental health clinic within 30 days of 
scheduling an appointment, and 96.8 percent of established patients 
completed a mental health appointment within 30 days of the day they 
requested.
    Preventing Veteran suicide requires closer collaboration between 
VA, DoD, and the Department of Homeland Security (DHS). On January 9, 
2018, President Trump signed an Executive Order (13822) titled, 
``Supporting Our Veterans During Their Transition from Uniformed 
Service to Civilian Life.'' This Executive Order directs DoD, VA, and 
DHS to develop a Joint Action Plan that describes concrete actions to 
provide access to mental health treatment and suicide prevention 
resources for transitioning uniformed Servicemembers in the year 
following their discharge, separation, or retirement. On March 5, 2019, 
President Trump signed the National Roadmap to Empower Veterans and End 
Suicide Executive Order (13861), which creates a Veteran Wellness, 
Empowerment, and Suicide Prevention Task Force that is tasked with 
developing, within 1 year, a road map to empower Veterans to pursue an 
improved quality of life, prevent suicide, prioritize related research 
activities, and strengthen collaboration across the public and private 
sectors. This is an all-hands-on-deck approach to empower Veteran well-
being with the goal of ending Veteran suicide.
    For Servicemembers and Veterans alike, our collaboration with DoD 
and DHS is already increasing access to mental health and suicide 
prevention resources, due in large part to improved integration within 
VA, especially between the VBA and VHA. VBA and VHA have worked in 
collaboration with DoD and DHS to engage Servicemembers earlier and 
more consistently than we have ever done in the past. This engagement 
includes support to members of the National Guard, Reserves, and Coast 
Guard.
    VA's suicide prevention efforts are guided by our National Strategy 
for Preventing Veteran Suicide, a long-term plan published in the 
summer of 2018 that provides a framework for identifying priorities, 
organizing efforts, and focusing national attention and community 
resources to prevent suicide among Veterans. It also focuses on 
adopting a broad public health approach to prevention, with an emphasis 
on comprehensive, community-based engagement.
    However, VA cannot do this alone, and suicide is not solely a 
mental health issue. As a national problem, Veteran suicide can only be 
reduced and mitigated through a nationwide community-level approach 
that begins to solve the problems Veterans face, such as loss of 
belonging, meaningful employment, and engagement with family, friends, 
and community.
    The National Strategy for Preventing Veteran Suicide provides a 
blueprint for how the nation can help to tackle the critical issue of 
Veteran suicide and outlines strategic directions and goals that 
involve implementation of programming across the public health 
spectrum, including, but not limited to:

      Integrating and coordinating Veteran Suicide Prevention 
across multiple sectors and settings;
      Developing public-private partnerships and enhancing 
collaborations across Federal agencies;
      Implementing research informed communication efforts to 
prevent Veteran suicide by changing attitudes knowledge and behaviors;
      Promoting efforts to reduce access to lethal means;
      Implementation of clinical and professional practices for 
assessing and treating Veterans identified as being at risk for 
suicidal behaviors; and
      Improvement of the timeliness and usefulness of national 
surveillance systems relevant to preventing Veteran suicide.

    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), 20 Vet Center Outstations, over 
960 Community Access Points and the Vet Center Call Center (877-WAR-
VETS). In the last two fiscal years, clients benefiting from RCS 
services increased by 14 percent, and Vet Center visits for Veterans, 
Servicemembers, and families increased by 7 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.

Electronic Health Record Modernization (EHRM)

    We made a historic decision to modernize our electronic health 
record (EHR) system to provide our nation's Veterans with seamless care 
as they transition from military service to Veteran status. On May 17, 
2018, we awarded a ten-year contract to Cerner Government Services, 
Inc., to acquire the same EHR solution being deployed by DoD that 
allows patient data to reside in a single hosting site using a single 
common system to enable sharing of health information, improve care 
delivery and coordination, and provide clinicians with data and tools 
that support patient safety. The FY 2020 Budget includes $1.6 billion 
to continue to support VA's EHRM effort to create and implement a 
single longitudinal clinical health record from active duty to Veteran 
status, and to ensure interoperability with DoD.
    The request provides necessary resources for post Go-Live 
activities completion of Office of Electronic Health Record 
Modernization's (OEHRM) three Initial Operating Capability (IOC) sites 
and full deployment of the remaining sites in Veterans Integrated 
Service Network (VISN) 20, the Pacific Northwest region. Additionally, 
it funds the concurrent deployment of waves comprised of sites in VISN 
21 and VISN 22, the Southwest region. The solution will be deployed at 
VA medical centers, as well as associated clinics, Veteran centers, 
mobile units, and other ancillary facilities.
    We are working closely with DoD to synchronize efforts as we deploy 
and test the new health record. We are engaging front-line staff and 
clinicians to identify efficiencies, hone governance, refine 
configurations, and standardize processes for future locations. We are 
committed to a timeline that balances risks, patient safety, and user 
adoption while also working with DoD in providing a more comprehensive, 
agile, and coordinated management authority to execute requirements and 
mitigate potential challenges and obstacles.
    Throughout this effort, VA will continue to engage front-line staff 
and clinicians, as it is a fundamental aspect in ensuring we meet the 
program's goals. 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.

Supply Chain Transformation

    VA 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. We are 
pursuing a holistic modernization effort which will address people, 
training, processes, data and automated systems. To achieve greater 
efficiencies by partnering with other Government agencies, VA will 
strengthen its long-standing relationships with DoD by leveraging 
expertise to modernize VA's supply chain operations, while allowing the 
VA to remain fully committed to providing quality health care and 
applying resources where they are most needed. The FY 2020 budget 
includes $36.8 million in IT funding to support this effort.
    As we deploy an integrated health record, we are also collaborating 
with DoD on an enterprise-wide adoption of the Defense Medical 
Logistics Standard Support (DMLSS) to replace VA's existing logistics 
and supply chain solution. VA's current system faces numerous 
challenges and is not equipped to address the complexity of decision-
making and integration required across functions, such as acquisition, 
logistics and construction. The DMLSS solution will ensure that the 
right products are delivered to the right places at the right time, 
while providing the best value to the government and taxpayers.
    We are piloting our Supply Chain Modernization program initially at 
the Captain James A. Lovell Federal Health Care Center (FHCC) and VA 
initial EHR sites in Spokane and Seattle to analyze VA enterprise-wide 
application. On March 7th, 2019, we initiated the pilot kickoff at the 
FHCC for VA's business transformation and supply chain efforts. This 
decision leverages a proven system that DoD has developed, tested, and 
implemented. In the future, DMLSS and its technical upgrade LogiCole 
will better enable whole-of-government sourcing and better facilitate 
VA's use of DoD Medical Surgical Prime Vendor and other DoD sources, as 
appropriate, as the source for VA medical materiel.

Veterans Homelessness

    The FY 2020 Presidents Budget (PB) continues the Administration's 
support of VA's Homelessness Programs, with $1.8 billion in funding, 
which maintains the 2019 level of funding, including $380 million for 
Supportive Services for Veterans Families (SSVF).
    Over the past five years, VA and its federal partners have made a 
concerted effort to collaborate at the federal level to ensure 
strategic use of resources to end Veteran homelessness. Coordinated 
entry systems are the actualization of this coordinated effort at the 
local level. Coordinated entry is seen, and will continue to be seen, 
as the systematic approach that is needed at the community level to 
ensure that resources are being utilized in the most effective way 
possible and that every Veteran in that community is offered the 
resources he or she needs to end their homelessness. All homeless 
Veterans in a given community are impacted by the coordinated entry 
system given that its framework is designed to promote community-wide 
commitment to the goal of ending homelessness and utilizing community-
wide resources (including VA resources) in the most efficient way 
possible for those Veterans who are in most need. This includes the 
prioritization of resources for those Veterans experiencing chronic, 
literal street homelessness. The number of Veterans experiencing 
homelessness in the United States has declined by nearly half since 
2010. On a single night in January 2018, fewer than 40,000 Veterans 
were experiencing homelessness-5.4 percent fewer than in 2017.
    Since 2010, over 700,000 Veterans and their family members have 
been permanently housed or prevented from becoming homeless. As of 
December 19, 2018, 69 areas-66 communities and three states-have met 
the benchmarks and criteria established by the United States 
Interagency Council on Homelessness, VA, and the Department of Housing 
and Urban Development to publicly announced an effective end to Veteran 
homelessness.
    Efforts to end Veteran homelessness have greatly expanded the 
services available to permanently house homeless Veterans and VA offers 
a wide array of interventions designed to find homeless Veterans, 
engage them in services, find pathways to permanent housing, and 
prevent homelessness from occurring.

Opioid Safety & Reduction Efforts

    In October 2017, the President declared the opioid crisis in our 
country a public health emergency. Opioid safety and reduction efforts 
are a Department priority, and we have responded with new strategies to 
rapidly combat this national issue as it affects Veterans. Success 
requires collaboration among VA leadership and all levels of VA staff-
from medical centers to headquarters-Congress, and community partners 
to ensure we are working with Veterans to achieve positive, life-
changing results. The fact that opioid safety, pain care 
transformation, and treatment of opioid use disorder all contribute to 
reduction of suicide risk makes these efforts particularly important. 
The FY 2020 Budget includes $397 million, a $15 million increase over 
2019, to reduce over-reliance on opioid analgesics for pain management 
and to provide safe and effective use of opioid therapy when clinically 
indicated.
    VA's Opioid Safety Initiative has greatly reduced reliance on 
opioid medication for pain management, in part by reducing opioid 
prescribing by more than 50 percent over the past four years. Most of 
this progress is attributable to reductions in prescribing long-term 
opioid therapy by not starting Veterans with chronic, non-cancer pain 
on opioid therapy and, instead utilizing multimodal strategies that 
manage Veteran pain more effectively long-term such as acupuncture, 
behavioral therapy, chiropractic care, yoga, and non-opioid 
medications.
    We are committed to providing Veteran-centric, holistic care for 
the management of pain and for promoting well-being. We are seeing 
excellent results as sites across the country deploy this ``Whole 
Health'' approach. Non-medication treatments work as well and are often 
better than opioids at controlling non-cancer pain. We want to assure 
Congress-and Veterans on opioid therapy-that Veterans' medication will 
not be -decreased or stopped without their knowledge, engagement, and a 
thoughtful discussion of accessible alternatives. Our goal is to make 
sure every Veteran has the best function, quality of life, and pain 
control.

Women's Health

    VA has made significant progress serving women Veterans in recent 
years. We now provide full services to women Veterans, including 
comprehensive primary care, gynecology care, maternity care, specialty 
care, and mental health services. The FY 2020 Budget requests $547 
million for gender specific women Veterans' health care, a $42 million 
increase over 2019.
    The number of women Veterans using VHA services has tripled since 
2000, growing from nearly 160,000 to over 500,000 today. To accommodate 
the rapid growth, VHA has expanded services and sites of care across 
the country. VA now has at least two Women's Heath Primary Care 
Provider (WH-PCP) at all of VA's health care systems. In addition, 91 
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 65 locations. For severely injured Veterans, we also now 
offer in vitro fertilization services through care in the community and 
reimbursement of adoption costs.
    VHA is in the process of training additional providers so every 
woman Veteran has an opportunity to receive primary care from a WH-PCP. 
Since 2008, 5,800 providers have been trained in women's health. In 
fiscal year 2018, 968 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. This budget will 
also continue to support a fulltime Women Veterans Program Manager at 
every VHA health care system who is tasked with advocating for the 
health care needs 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 health care 
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.

National Cemetery Administration (NCA)

    The President's FY 2020 budget positions NCA to meet Veterans' 
emerging burial and memorial needs through the continued implementation 
of its key priorities: Preserving the Legacy: Ensuring ``No Veteran 
Ever Dies''; Providing Access and Choosing VA; and Partnering to Serve 
Veterans. The FY 2020 Budget includes $329 million for NCA's operations 
and maintenance account, an increase of $13.2 million (4.2 percent) 
over the FY 2019 level. This request will fund the 2,008 Full-Time 
Equivalent (FTE) employees needed to meet NCA's increasing workload and 
expansion of services, while maintaining our reputation as a world-
class service provider. In FY 2020, NCA will inter an estimated 137,000 
Veterans and eligible family members and care for over 3.9 million 
gravesites. NCA will continue to memorialize Veterans by providing 
383,570 headstones and markers, distributing 634,000 Presidential 
Memorial Certificates, and expanding the Veterans Legacy Program to 
communities across the country to increase awareness of Veteran service 
and sacrifice.
    VA is committed to investing in NCA's infrastructure, particularly 
to keep existing national cemeteries open and to construct new 
cemeteries consistent with burial policies approved by Congress. NCA is 
amid the largest expansion of the cemetery system since the Civil War. 
By 2022, NCA will establish 18 new national cemeteries across the 
country, including rural and urban locations. The FY 2020 request also 
includes $172 million in major construction funds for three gravesite 
expansion projects (Houston and Dallas, TX and Bourne, MA) and 
additional funding for the replacement cemetery in Bayamon, PR, the 
gravesite expansion project in Riverside, CA, and the new national 
cemetery in Western NY. The Budget also includes $45 million for the 
Veteran Cemetery Grant Program to continue important partnerships with 
States and tribal organizations. Upon completion of these expansion 
projects, and the opening of new national, State and tribal cemeteries, 
nearly 95 percent of the total Veteran population-about 20 million 
Veterans-will have access to a burial option in a national or grant-
funded Veterans cemetery within 75 miles of their homes.

Accountability

    The FY 2020 Budget requests direct appropriations for the Office of 
Accountability and Whistleblower Protection (OAWP) for the first time 
since it was established. The total request for OAWP in FY 2020 is 
$22.2 million, which is $4.5 million, or 25 percent higher than the 
2019 funding level. This funding level demonstrates VA's commitment to 
improving the performance and accountability of our senior executives 
through thorough, timely, and unbiased investigations of all 
allegations and concerns. This funding level will also enable OAWP to 
continue to provide protection of valued whistleblowers against 
retaliation for their disclosures under the whistleblower protections 
provisions of 38 U.S.C. Sec.  714. In FY 2018, OAWP assessed 2,241 
submissions, conducted 133 OAWP investigations, and monitored over 
1,000 referred investigations. These efforts are part of VA's effort to 
build public trust and confidence in the entire VA system and are 
critical to our transformation.
    The FY 2020 budget also requests $207 million, a $15 million 
increase over 2019, and 1,000 FTE for the Office of Inspector General 
(OIG) to fulfill statutory oversight requirements and sustain the 
investments made in people, facilities, and technology during the last 
three years. The 2020 budget supports FTE targets envisioned under a 
multi-year effort to grow the OIG to a size that is more appropriate 
for overseeing the Department's steadily rising spending on new complex 
systems and initiatives. The 2020 budget request will also provide 
sufficient resources for the OIG to continue to timely and effectively 
address the increased number of reviews and reports mandated through 
statute.
                               Conclusion
    Thank you for the opportunity to appear before you today to address 
our FY 2020 budget and FY 2021 AA budget request. VA has shown 
demonstrable improvement over the last several months. The resources 
requested in this budget will ensure VA remains on track to meet 
Congressional intent to implement the MISSION Act and continue to 
optimize care within VHA.
    Mr. Chairman, I look forward to working with you and this 
Committee. I am eager to continue building on the successes we have had 
so far and to continue to fulfill the President's promise to provide 
care to Veterans when and where they need it. There is significant work 
ahead of us and we look forward to building on our reform agenda and 
delivering an integrated VA that is agile and adaptive and delivers on 
our promises to America's Veterans.
    Thank you.

                                 
                     Prepared Statement of Joy Ilem
 JOINT STATEMENT OF THE CO-AUTHORS OF THE INDEPENDENT BUDGET: DISABLED 
 AMERICAN VETERANS, PARALYZED VETERANS OF AMERICA, VETERANS OF FOREIGN 
                                  WARS
``The President's Fiscal Year 2020 Budget Request for the Department of 
    Veterans Affairs''

    Chairman Takano, Ranking Member Roe, and members of the committee, 
the co-authors of The Independent Budget (IB)-DAV (Disabled American 
Veterans), Paralyzed Veterans of America (PVA), and Veterans of Foreign 
Wars (VFW)-are pleased to present our views regarding the President's 
funding request for the Department of Veterans Affairs (VA) for Fiscal 
Year (FY) 2020, including advance appropriations for FY 2021.
    In February, prior to the Administration's budget request, the IB 
released our comprehensive VA budget recommendations for all 
discretionary programs for FY 2020, as well as advance appropriations 
for FY 2021. \1\ The recommendations include funding to implement the 
VA MISSION Act of 2018 (P.L. 115-182) and other reform efforts. After 
reviewing the Administration's budget request for VA and comparing it 
to the IB recommendations, particularly in light of the requirements of 
the VA MISSON Act, we believe that the request falls short of meeting 
the needs of veterans seeking care through VA. Although the budget 
request provides a seven percent increase in the level of discretionary 
funding, when factoring in VA's own estimates of the cost of 
implementing the VA MISSION Act, the shift of $5.5 billion from 
mandatory to discretionary funding from the Choice program, and the 
increased cost for providing medical care due to inflation and other 
factors, VA will not have sufficient resources to meet the health care 
needs of America's veterans.
---------------------------------------------------------------------------
    \1\ The full IB budget report addressing all aspects of 
discretionary funding for VA can be downloaded at 
www.independentbudget.org.
---------------------------------------------------------------------------
    The Administration's request of $84 billion for Medical Care is $4 
billion less than the IB estimates is necessary to fully meet the 
demand by veterans for health care during the fiscal year. For FY 2020, 
the IB recommends approximately $88.1 billion in total medical care 
funding and approximately $90.8 billion for FY 2021. This 
recommendation reflects the necessary adjustments to the baseline for 
all Medical Care program funding in the preceding fiscal year, and 
assumes the Choice program is fully replaced at the beginning of FY 
2020 by the Veterans Community Care Program (VCCP).
    For FY 2020, the IB recommends $56.1 billion for VA Medical 
Services. This recommendation is a reflection of multiple components, 
including the current services estimate, the increase in patient 
workload, and additional medical care program costs. The current 
services estimate reflects the impact of projected uncontrollable 
inflation on the cost to provide services to veterans currently using 
the system. This estimate also assumes a 2.1 percent increase for pay 
and benefits across the board for all VA employees in FY 2020.
    Our estimate of growth in patient workload is based on a projected 
increase of approximately 90,000 new unique patients. These patients 
include priority group 1- 8 veterans and covered non-veterans. We 
estimate the cost of these new unique patients to be approximately $1.3 
billion.
    The IB believes there are additional projected medical program 
funding needs for VA totaling over $1.2 billion. Specifically, we 
believe there is a real need for funding to address an array of issues 
in VA's Long-Term Services and Supports (LTSS) program, including the 
shortfall in non-institutional services due to the unremitting waitlist 
for home and community-based services; to provide additional 
centralized prosthetics funding (based on actual expenditures and 
projections from the VA's Prosthetics and Sensory Aids Service); 
funding to expand and improve services for women veterans; funding to 
support the recently approved authority for reproductive services, to 
include in vitro fertilization (IVF); and initial funding to implement 
extending comprehensive caregiver support services to severely injured 
veterans of all eras.
    The Administration's request for VA Medical Services of $51.4 
billion is approximately $4.7 billion below the IB recommendation. To 
better understand the shortfall, it should be noted that the IB does 
not include anticipated receipts from VA's Medical Care Collections 
Fund in its recommendation. Although the Administration's request 
reflects an apparent increase of three percent, the IB believes that 
when taking into account the increased cost to maintain current 
services and anticipated increases in workload, as well as increased 
costs inside VA due to the VA MISSION Act that apparent increase will 
ultimately result in a shortfall.
    Of great concern to our members, the Administration's budget 
request estimates that VA will fail to meet the VA MISSION Act's very 
clear timetable for expanding its comprehensive caregiver support 
program to severely injured World War II, Korean War, and Vietnam War 
veterans and their family caregivers. Although we were pleased to hear 
at the Senate Committee on Veterans' Affairs hearing this past week 
that VA is still aiming to certify expansion by the October 1, 2019, 
deadline, we still have concerns as to whether VA will truly be able to 
meet the deadline, particularly in light of conflicting messages from 
VA and recent history in delayed implementation of IT solutions for 
this program. These men and women have waited nearly a decade for equal 
treatment and it is simply unacceptable to ask them to wait longer.
    As this Committee is aware, the VA Caregiver Support Program 
currently uses the IT system known as the Caregiver Application Tracker 
(CAT), which was rapidly developed due to time constraints on 
implementing the program and was not designed to manage a high volume 
of information as is required today. We are aware VA has requested a 
reprogramming of nearly $96 million in Medical Care funding to the IT 
Systems account, which includes just over $4 million to continue 
development and stabilization of CAT, while in its FY 2020 budget 
submission, VA is requesting $2.6 million to update the Caregivers Tool 
(CareT) to support the first phase of expansion. As this Committee is 
aware, VA notified Congress in April 2017 that CareT, which at that 
time was expected to fully automate the application and stipend 
delivery process for the program, experienced significant delays 
associated with external dependencies and lost prioritization among 
competing projects. As a result, a new contract had to be drafted to 
continue work pushing the delivery of CareT out one year to June 2018. 
Today, while the estimated certification date of CareT remains 
uncertain, there are important budgetary implications based on when 
certification occurs and phase one of the expansion begins, with full 
expectation that VA will issue interim final rules to expedite the 
process.
    In terms of funding, the Administration included $150 million to 
expand VA's comprehensive caregiver program, which is over $100 million 
less than the IB recommendation of $253 million to fully implement 
phase one of the caregiver expansion in FY 2020. The IB's 
recommendation is based on the Congressional Budget Office estimate for 
preparing the program, including increased staffing and IT needs, and 
the beginning of the first phase of expansion.
    For Medical Community Care, the IB recommends $18.1 billion for FY 
2020, which includes the growth in current services, estimated spending 
under the Choice program, and additional obligations under the VA 
MISSION Act of $3.7 billion. The Administration's FY 2020 request for 
$15.3 billion in discretionary funding appears to be a $5.9 billion 
increase in funding for Community Care. However, VA has indicated that 
$5.5 billion of that increase merely represents shifting $5.5 billion 
that would otherwise be necessary to pay for the Choice program, from 
mandatory funding. Considering that VA estimated the VA MISSION Act 
will require $2.6 billion in new funding for expanded access based on 
new access standards, expanded transplant care, and $271 million for 
urgent care, there appears to be a significant shortfall for VA 
community care programs.
    Furthermore, during VA's budget briefing on March 11, VHA officials 
stated that there would be no Medical Community Care funding required 
to implement the new wait time access standards, that VA would be able 
to fully meet those standards within VA facilities; therefore, not one 
veteran would get VCCP eligibility due solely to the wait time 
standard. However, VA has also stated that the current median wait time 
for primary care is 21 days, which would mean that approximately half 
of all veterans seeking primary care appointments today have a greater 
than 20-day wait time. Yet, VA's budget request assumes that they would 
achieve 100 percent compliance with the wait time standard through 
greater efficiency and an approximate 30 percent increase in VA primary 
care providers. We have serious doubts about whether this is realistic 
given the national shortage of primary care providers and the time 
needed to recruit, hire, and onboard new employees; and certainly, 
whether it is achievable by the first day of the next fiscal year, just 
over six months from today.
    The Administration's FY 2020 request for VA's construction programs 
of $1.8 billion dollars is a 44 percent reduction from FY 2019 funding 
levels, and a deeply disappointing retreat in funding to maintain VA's 
aging infrastructure. At the Senate Veterans' Affairs Committee hearing 
on March 26, 2019, in response to Senator Manchin's question about VA's 
``.44 percent decrease in funding levels for construction programs.,'' 
Secretary Wilkie stated that he estimates VA will need, ``.$60 billion 
over the next five years to come up to speed.'' This backlog is 
confirmed by VA's FY 2020 budget submission, which states that VA's, 
``.Long-Range SCIP plan includes 4,059 capital projects that would be 
necessary to close all currently-identified gaps with an estimated 
magnitude cost of between $62-$76 billion including activation costs.'' 
[Volume IV, FY 2020 Congressional Submission, Page 8.2- 47]. However, 
VA's FY 2020 budget request for Major & Minor Construction combined is 
just over $1.6 billion, significantly below the true need stated by the 
Secretary and identified by SCIP. At a time when VA is seeking to 
expand its capacity by hiring additional doctors, nurses, clinicians 
and supporting staff, it is absolutely critical that VA continue to 
invest in the infrastructure necessary for them to care for veterans.
    For major construction in FY 2019, VA requested and Congress 
appropriated a significant increase in funding for major construction 
projects- an approximate $700 million increase. While these funds will 
allow VA to begin construction on key projects, many other previously 
funded sites still lack the funding for completion. Some of these 
projects have been on hold or in the design and development phase for 
years. Additionally, there are outstanding seismic corrections that 
must be addressed. Thus, the IB recommended $2.78 billion in major 
construction, nearly $1 billion more than VA's total construction 
request.
    To ensure VA funding keeps pace with all current and future minor 
construction needs, the IB recommends Congress appropriate an 
additional $761 million for minor construction projects. It is 
important to invest heavily in minor construction because these are the 
types of projects that can be completed faster and have a more 
immediate impact on services for veterans. Previously, these changes 
fell under facilities similar to Non-Recurring Maintenance (NRM), but 
the IB recommends these specific modifications be under a different 
authority to ensure their priority.
    In addition, the Administration's FY 2020 Medical Facilities 
request of $6.1 billion, which includes critical NRM to ensure VA 
facilities have the space to provide care, is a $660 million cut 
compared to FY 2019 levels. The IB recommends $6.6 billion for FY 2020.
    The Administration's request of $762 million for Medical and 
Prosthetic Research is nearly $80 million below the IB recommendation 
of $840 million. The request represents a 2 percent cut, at a time when 
medical research inflation is estimated to be 2.8 percent. The VA 
Medical and Prosthetic Research program is widely acknowledged as a 
success, with direct and significant contributions to improved care for 
veterans and an elevated standard of care for all Americans. This 
research program is also an important tool in VA's recruitment and 
retention of health care professionals and clinician-scientists to 
serve our nation's veterans. This reduction would diminish VA's ability 
to provide the most advanced treatments available to injured and ill 
veterans in the future, one of VA's core missions.
    Overall, the IB believes that the Administration's FY 2020 budget 
request for VA will neither allow the Department to fully and 
faithfully implement the VA MISSION Act, nor will it fully meet the 
requirements to provide the health care, benefits, and services that 
veterans have earned. Below are some of the questions about VA's budget 
request that have not been answered.

      At its March 11 budget briefing, VA officials stated that 
the FY 2020 budget request was predicated on a carryover of 
approximately $3 billion from FY 2019 appropriations, but did not 
specify how much of it was unobligated. Specifically, how much 
``carryover'' is assumed in the FY 2020 budget request that could have 
been used to meet veterans' health care needs? What are the specific 
dollar amounts being carried over and from what specific accounts, and 
into what accounts and for what purposes will this carryover funding be 
used in FY 2020?
      As discussed above, VA officials indicated that there 
would be zero new dollars necessary for the Medical Community Care 
account as a result of the new wait time access standards proposed 
because VA assumes it will be able to meet those standards 100 percent 
of the time within VA facilities. VA indicated it will do this through 
workload recapture, greater efficiency, and a 30 percent increase in 
the total number of VA primary care providers. What new initiatives 
will VA undertake and what are the specific increases in productivity 
that each will achieve? What are VA's detailed plans and projections 
for increasing primary care providers by 30 percent, and how will these 
new providers be in place at the beginning of FY 2020?
      What factors did VA consider in reaching its decision to 
cut research spending for the emerging field of genomics research in FY 
2020 by two percent at a time when medical research inflation is 
estimated to be 2.8 percent?
      In the full budget documents made available on March 18, 
the Veterans Benefits Administration budget request seeks 
appropriations to support the exact same level of FTE for FY 2020 as it 
does in FY 2019. However, the Direct Labor estimate for the Disability 
Compensation program shows a decrease of 51 FTE in FY 2020. This small 
decrease in claims processors occurs at a time that the VA budget is 
projecting that number of pending claims for disability compensation 
will rise to over 450,000 by the end of FY 2020, almost a 50 percent 
increase in just the past three years. Why is VA requesting fewer 
claims processing staff in FY 2020 when its own data shows that the 
number of pending claims is rising dramatically?
      VA budget documents state that the Vocational 
Rehabilitation and Employment (VRE) program will meet and sustain the 
congressionally mandated goal of 1:125 counselor-to-client ratio. 
However, the latest data in the VA budget document also shows that from 
2016 to 2018, the number of VRE participants fell from 173,606 to 
164,355, more than a five percent decrease. During that same period, 
VRE's caseload also dropped from 137,097 to 125,513, an 8.4 percent 
decline. It would appear that VRE is able to meet the 1:125 goal by 
serving fewer veterans. Given how important and beneficial the VRE 
program is to disabled veterans-providing many of them with the ability 
to increase their economic independence-why are fewer veterans taking 
advantage of this program? Is the lack of counselors impacting veteran 
utilization? Has VRE instituted any new policies or practices that have 
deterred disabled veterans from seeking VRE services and what actions 
is VRE taking to increase awareness about the availability and benefits 
of VRE services?

    Lastly, the IBVSOs strongly oppose four legislative proposals 
included in the budget that would reduce benefits to disabled veterans 
that were earned through their service:

    1. Round-Down of the Computation of the Cost of Living Adjustment 
(COLA) for Service-Connected Compensation and Dependency and Indemnity 
Compensation (DIC) for Five Years:

    In 1990, Congress, in an omnibus reconciliation act, mandated 
veterans' and survivors' benefit payments be rounded down to the next 
lower whole dollar. While this policy was initially limited to a few 
years, Congress continued it until 2014. While not significant at the 
onset, the overwhelming effect of twenty-four years of round-down 
resulted in veterans and their beneficiaries losing billions of 
dollars.
    In last year's budget request, the Administration sought 
legislation to round-down the computation of COLA for ten years. This 
would have cost beneficiaries $34.1 million in 2019, $749.2 million 
over five years, and $3.1 billion over ten years.
    The Administration's new proposed budget for FY 2020 is seeking to 
round-down COLA increases from 2020 to 2024. The cumulative effect of 
this proposal levies a tax on disabled veterans and their survivors, 
costing them money each year. When multiplied by the number of disabled 
veterans and DIC recipients, millions of dollars are siphoned from 
these deserving individuals annually. All totaled, VA estimates it 
would cost veterans $34 million in 2020, $637 million over five years 
and $2 billion over ten years.
    Veterans and their survivors rely on their compensation for 
essential purchases such as food, transportation, rent, and utilities. 
Any COLA round-down will negatively impact the quality of life for our 
nation's disabled veterans and their families, and we oppose this and 
any similar effort. The federal budget should not seek financial 
savings at the expense of benefits earned by disabled veterans and 
their families.

    2. Clarify Evidentiary Threshold for Ordering VA Examinations:

    This proposal would increase the evidentiary threshold at which VA, 
under its duty to assist obligation in 38 U.S.C. Sec.  5103A, is 
required to request a medical examination for compensation claims. 
Section 5103A(d)(2) requires VA to ``treat an examination or opinion as 
being necessary to make a decision on a claim'' if the evidence of 
record, ``taking into consideration all information and lay or medical 
evidence . . . (A) contains competent evidence that the claimant has a 
current disability, or persistent or recurrent symptoms of disability; 
and (B) indicates that the disability or symptoms may be associated 
with the claimant's active military, naval, or air service; but (C) 
does not contain sufficient medical evidence for the Secretary to make 
a decision on the claim.''
    The Court of Appeals for Veterans Claims (CAVC), in McLendon v. 
Nicholson, 20 Vet.App. 79 (2006), determined that in disability 
compensation claims, VA must provide a VA medical examination when 
there is:

      Competent evidence of a current disability or persistent 
or recurrent symptoms of a disability, and
      Evidence establishing that an event, injury, or disease 
occurred in service or establishing certain diseases manifesting during 
an applicable presumptive period for which the claimant qualifies, and
      An indication that the disability or persistent or 
recurrent symptoms of a disability may be associated with the veteran's 
service or with another service-connected disability, but,
      Insufficient competent medical evidence on file for the 
secretary to make a decision on the claim. It notes that the 
requirement of (3) is a low threshold.

    We oppose this proposal as it would be inherently detrimental to 
the VA claims process for all veterans. The Administration asserts the 
holdings by the CAVC, specifically in McLendon v. Nicholson, are 
inconsistent and too low a bar when compared to 38 U.S.C. Sec.  
5103A(d)(2). However, that is not correct. As noted above, the 
statutory requirements for a VA examination are consistent with the 
CAVC's holding. The Administration's proposed legislation would 
intentionally raise the bar of the VA's Duty to Assist and allow the VA 
to hold veterans to a much higher threshold and result in fewer 
examinations with more claim denials. This would lead to more Higher 
Level Review requests, supplemental claims, and appeals directly to the 
Board of Veterans' Appeals. Ultimately, this will result in an 
increased number of veterans never receiving the benefits they earned.
    The Administration's proposal would reduce anticipated disability 
compensation to veterans by $233 million in 2020, $1.3 billion over 
five years, and $2.8 billion over ten years. We strongly oppose this 
attempt to limit the due process rights of veterans, particularly when 
the result will be billions of dollars in lost disability compensation 
for those who were injured or made ill in service.

    3. VA Schedule for Rating Disability (VASRD) Effective Dates:

    VA seeks to amend 38 U.S.C. Sec.  1155 so that when VASRD is 
readjusted, such changes would apply to any new or pending claims and 
may include action to decrease an existing evaluation. Under section 
1155, ``The Secretary shall from time to time readjust this schedule of 
ratings in accordance with experience. However, in no event shall such 
a readjustment in the rating schedule cause a veteran's disability 
rating in effect on the effective date of the readjustment to be 
reduced unless an improvement in the veteran's disability is shown to 
have occurred.''
    Currently, if a diagnostic code rating criteria changes, the 
veteran can only be granted an increased evaluation under the old 
rating criteria up to the date of the change to the new rating 
criteria. The new rating criteria must be applied from the date of the 
change. The Administration's proposal would eliminate a veteran's 
ability to receive an increased evaluation up to the date of the change 
and only apply the new criteria. This proposal would have a negative 
impact on veterans and would clearly be in contrast to 38 C.F.R. Sec.  
3.103, which states, ``Proceedings before VA are ex parte in nature, 
and it is the obligation of VA to assist a claimant in developing the 
facts pertinent to the claim and to render a decision which grants 
every benefit that can be supported in law while protecting the 
interests of the Government.''
    The Administration's proposed budget does not show any estimate of 
budgetary savings based on this legislative proposal and mentions only 
that it would make it easier for VA rating personnel to make decisions 
on veterans' claims. However, this proposal will eliminate any 
potential increased evaluations prior to the change of the rating 
criteria; thereby, lowering the earned benefit for affected disabled 
veterans. We oppose this proposal as it will have negative consequences 
on veterans.

    4. Elimination of Payment of Benefits to the Estates of Deceased 
Nehmer Class Members and to the Survivors of Certain Class Members:

    VA seeks to amend 38 U.S.C. Sec.  1116 to eliminate payment of 
benefits to survivors and estates of deceased Nehmer class members. If 
a Nehmer class member, per 38 C.F.R. Sec.  3.816, entitled to 
retroactive benefits dies prior to receiving such payment, VA is 
required to pay any unpaid retroactive benefits to the surviving spouse 
or subsequent family members. This proposed legislation would deny 
veterans' survivors and families' benefits that would have otherwise 
been due to their deceased veteran family member as a result of 
exposure to these toxic chemicals while in service. It is outrageous 
that the Administration would deny compensation payments due to a 
surviving spouse. We adamantly oppose this or any similar proposal that 
may be offered.
    The IBVSOs support VA's legislative proposal regarding Medical 
Foster Homes (MFH). This proposal would require the VA to pay for 
service-connected veterans to reside in VA approved MFHs.
    MFHs provide an alternative to long-stay nursing home (NH) care at 
a much lower cost. The program has already proven to be safe, 
preferable to veterans, highly veteran-centric, and half the cost to VA 
compared to NH care. Aligning patient choice with optimal locus of care 
results in more veterans receiving long-term care in a preferred 
setting, with substantial reductions in costs to VA. This proposal 
would require VA to include MFH in the program of extended care 
services for the provision of care in MFHs for veterans who would 
otherwise encumber VA with the higher cost of care in NHs.
    Many more service-connected veterans referred to or residing in NHs 
would choose MFH if VA paid the costs for MFH. Instead, they presently 
defer to NH care due to VA having payment authority to cover NH, while 
not having payment authority for MFH. As a result of this gap in 
authority, VA pays more than twice as much for the long-term NH care 
for many veterans than it would if VA was granted the proposed 
authority to pay for MFH. This proposal would give veterans in need of 
NH level care greater choice and ability to reside in a more home-like, 
safe environment, continue to have VA oversight and monitoring of their 
care, and preferably age in place in a VA-approved MFH rather than a 
NH. The proposal does not create authority to cover veterans who reside 
in assisted living facilities. MFH promotes veteran-centered care for 
those service-connected veterans who would otherwise be in a nursing 
home at VA expense, by honoring their choice of setting without 
financial penalty for choosing MFH.
    Thank you for the opportunity to submit our views on the 
Administration's budget request for VA. We firmly believe that unless 
Congress acts to substantially increase VA's funding for FY 2020, 
veterans will be forced to wait longer for care, whether they seek care 
at VA or in the community, leaving unfulfilled the promises made to 
veterans in the VA MISSION Act.

                                 
                 Prepared Statement of Larry L. Lohmann
    Chairman Takano, Ranking Member Roe, and Members of the Committee; 
on behalf of Brett P. Reistad, National Commander of the largest 
veteran service organization in the United States representing nearly 2 
million members; we welcome the opportunity to comment on specific 
funding programs of the Department of Veterans Affairs (VA) in the 
federal budget.
    The American Legion is a resolution-based organization directed and 
driven by active Legionnaires who dedicate their money, time, and 
resources to the continued service of veterans and their families. Our 
positions are guided by 100 years of advocacy and resolutions that 
originate at the grassroots level of the organization - local American 
Legion posts and veterans in every congressional district across the 
United States. The headquarters staff of The American Legion works 
daily on behalf of veterans, military personnel, and our communities 
through our roughly 20 national programs and thousands of outreach 
programs led by our posts across the country.
    As VA continues to serve the veterans of this nation, it is vital 
the Secretary has the necessary tools and resources to ensure they 
receive timely, professional, and courteous service - they have earned 
it. The American Legion calls on this Congress to ensure that funding 
for VA is maintained by implementing the president's budget request. At 
a time when most federal agencies are experiencing a decrease in their 
respective budgets, the hope of The American Legion is that VA, with 
assistance from these critical committees, receives a much-needed 
increase.
    Sustainability, accountability, information technology (IT) 
integration and updates, Electronic Health Records (EHR), facilities 
repair, construction, staff recruiting, and healthcare are paramount 
programs requiring adequate funding. In the 115th Congress, The 
American Legion testified on the need for increased funding for each of 
the aforementioned programs.
                    Implementing the VA MISSION Act
    ``The Budget fully supports implementation of the VA MISSION Act of 
2018 and provides veterans greater choice on where they receive their 
healthcare-whether at VA or through a private healthcare provider. The 
Budget consolidates all veterans' community care programs into a single 
program, reducing bureaucracy and making it easier for veterans to 
navigate their healthcare needs.''

    -A Budget for a Better America, Trump Administration's Proposed FY 
20 Budget

    The 2014 VHA Wait Time Scandal in Phoenix demonstrated to the 
veteran community the increased need for care in the community. 
Veterans desiring community care after the enactment of the Choice Act 
increased. The American Legion supported the Choice Program when it was 
added as a temporary emergency measure as part of the Veterans Access, 
Choice Accountability Act (VACAA) of 2014 because of our firsthand 
experience witnessing the need across the country. \1\
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    \1\ Veterans Access, Choice, and Accountability Act of 2014, Pub. 
L. No. 113-146, 38 U.S.C. 101
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    In 2014, The American Legion established a dozen Veterans Crisis 
Command Centers (VCCCs) in affected areas (Fulton et al., 2018). VCCCs 
were established from Phoenix to Fayetteville and The American Legion 
spoke to hundreds of veterans personally affected by the scheduling 
problems within VA. The Choice program provided an immediate short-term 
option, and provided an opportunity to learn how veterans utilized the 
program. At that time, The American Legion recommended gathering as 
much data as possible from veterans using the program to improve the 
ability of VA's other existing authorities for care in the community. 
\2\ Additionally, The American Legion supported the Veterans Choice 
Continuation Act, which continued the Veterans Choice Program (VCP) 
that was due to expire on August 7, 2017. Continuation of VCP ensured 
veterans within the VA healthcare system would continue to have the 
ability to access quality healthcare within their communities without 
interruption of services.
---------------------------------------------------------------------------
    \2\ Department of Veterans Affairs. ``Veterans Choice Program 
(VCP).'' Veterans Choice Program (VCP), 30 Jan. 2018, www.va.gov/
COMMUNITYCARE/programs/veterans/VCP/index.asp.
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    In 2018, a large percentage of veterans, many of which are proud 
members of The American Legion, voiced a preference to receive medical 
services closer to their homes. In response, Congress enacted the VA 
MISSION Act, a historic law that contains a number of policy priorities 
of The American Legion and other veteran stakeholders. \3\ VA MISSION 
Act, principally, reforms the Department of Veterans' Affairs care 
programs, including Choice, into a single Veterans Community Care 
Program (VCCP). MISSION Act requires VA to promulgate new access 
standards, released earlier this year, and to develop strategic plans 
with completed market assessments to provide care to veterans under the 
new VCCP.
---------------------------------------------------------------------------
    \3\ VA Mission Act Pub. L. No: 115-182
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    The budget includes $8.9 billion in 2020 and $11.3 billion in 2021 
for the VA Medical Care program to implement the MISSION Act, including 
access standards that expand Veterans' care options and reduce wait 
times for primary and specialty care. \4\ The American Legion supports 
the President in adequately funding the MISSION Act to support VA's 
implementation of a new consolidated community care program. We offer 
this support recognizing the president will continue to request, 
Congress must continue to appropriate, and VA must continue to properly 
allocate sufficient funding to maintain VA's existing healthcare 
infrastructure. Further, our support relies on the understanding VA 
must expand capacity in locations where demand for care justifies 
additional VA infrastructure.
---------------------------------------------------------------------------
    \4\ Department of Veterans Affairs ``Budget In Brief 2019.'' 
Department of Veterans Affairs (BiBs-8) www.va.gov/budget/docs/summary/
fy2020VAbudgetInBrief.pdf
---------------------------------------------------------------------------
                      Ensuring Proper VA Staffing
    ``Each day, more than 380,000 VA employees come to work for 
America's Veterans. These employees have a close connection with 
Veterans - over 33 percent are Veterans themselves. The 2020 Budget 
supports an increase of 13,805 Full-Time Equivalent Employees (FTE) 
above the 2019 estimated level to expand access to healthcare and 
improve benefits delivery.''

    -Department of Veterans Affairs - Budget in Brief 2020

    The American Legion has long expressed concern about staffing 
shortages at VA and Veterans Health Administration (VHA) medical 
facilities including physicians and medical specialist staffing. 
Unfortunately, no easy solutions exist for VHA to effectively and 
efficiently recruit and retain staff at VA healthcare facilities. It is 
important to understand that simply providing additional funding will 
not resolve the issue of staff shortages. The American Legion believes 
access to basic healthcare services offered by qualified primary care 
providers should be available locally, and by a VA healthcare 
professional, as often as possible at all times.
    While VA's Academic Residency Program made significant 
contributions in training VA healthcare professionals, upon graduation 
many of these healthcare professionals choose a career outside the VA 
healthcare system. The VA will remain unable to compete with the 
private sector without changes to current hiring practices. To this 
end, The American Legion supports legislation such as The VA Hiring 
Enhancement Act and initiatives such as establishing its own VA Health 
Professional University. Such initiatives address the shortcomings in 
recruitment and retention of highly qualified physicians \5\ and allow 
VA to train their medical healthcare professionals to serve as a 
supplement to VA's current medical residency program. \6\
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    \5\ The American Legion Resolution No. 115 (2016): Department of 
Veterans Affairs Recruitment and Retention
    \6\ American Legion Resolution No. 377: Support for Veteran Quality 
of Life: (Sept. 2016)
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    The American Legion understands filling highly skilled vacancies at 
premiere VA hospitals around the country is challenging. VA has a 
variety of creative solutions available to them beyond additional 
legislative action. One such idea involves aggressively seeking public-
private partnerships with local area hospitals. VA could expand both 
footprint and market penetration by renting space in existing hospitals 
enabling VA to leverage existing resources and foster comprehensive 
partnerships with the community. Further, VA could research the 
feasibility of incentivizing recruitment at level 3 hospitals by 
orchestrating a skills sharing program that might entice physicians to 
work at level 3 facilities if they were eligible to engage in a program 
where they could train at a level 1 facility for a year every 5 years 
while requiring level 1 facility physicians to spend some time at level 
3 facilities to share best practices. Currently, medical staff is 
primarily detailed to temporarily fill vacancies. This practice fails 
to incentivize the detailed professional to share best practices and 
teach, but rather to hold down the position until it can be filled by a 
permanent hire.
               Prioritizes Funding for Suicide Prevention
    Reducing deaths by suicide among the Nation's veterans continues to 
be VA's top clinical priority. The Budget provides essential resources 
for VA's suicide prevention programs and supports the expansion of key 
initiatives aimed at advancing VA's National Strategy for Preventing 
Veteran Suicide.

    -A Budget for a Better America, Trump Administration's Proposed FY 
20 Budget

    Suicide prevention is a top priority of The American Legion, The 
Department of Veterans Affairs (VA), and the Department of Defense 
(DoD). Last summer, the nation's largest organization of wartime 
veterans published a white paper report titled, Veteran Suicide. \7\ 
The American Legion is deeply concerned by the high suicide rate among 
servicemembers and veterans, which has increased substantially since 
2001. \8\ The suicide rate among 18-24-year-old male Iraq and 
Afghanistan veterans is particularly troubling, having risen nearly 
fivefold to an all-time high of 124 per 100,000, 10 times the national 
average. A spike also occurred in the suicide rate of 18-29-year-old 
female veterans, doubling from 5.7 per 100,000 to 11 per 100,000. \9\ 
These increases are startling when compared to rates of other 
demographics of veterans, whose suicide rates have remained constant 
during the same time period.
---------------------------------------------------------------------------
    \7\ The American Legion . Veteran Suicide: A White Paper Report. 
Indianapolis: The American Legion , 2018. ``Veterans Affairs & 
Rehabilitation Commission.'' (2018, July 12). www.legion.org/
commissions/veterans-affairs-rehabilitation-commission
    \8\ U.S. Department of Veteran Affairs. Suicide Among Veterans and 
Other Americans 2001-2014. 2017. ``Health Services Research & 
Development.'' www.hsrd.research.va.gov/publications/forum/spring18/
default.cfm?ForumMenu=Spring18-5
    \9\ Id.
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    VA has taken great strides to reduce veteran suicide. Of particular 
note, VA expanded the Veterans Crisis Line (VCL), responding to 500,000 
phone calls every year, as well as thousands of electronic chats and 
text messages. Since its launch in 2007, through September 2018, VCL 
staff dispatched emergency services to callers in crisis over 93,000 
times. \10\
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    \10\ Department of Veteran Affairs OIG. Healthcare Inspection: 
Evaluation of the VHA Veterans Crisis Line. 2018. Department of 
Veterans Affairs Office of Inspector General. ``Office Of Healthcare 
Inspections''. www.va.gov/oig/pubs/VAOIG-16-03985-181.pdf
---------------------------------------------------------------------------
    VA also hired hundreds of Suicide Prevention Coordinators (SPCs), 
mental health professionals that specialize in suicide prevention. SPCs 
are based in VA medical centers and local community-based outpatient 
clinics all over the country. Over 80 percent of the SPCs are 
conducting five outreach activities per month for at-risk veterans. 
\11\ These events provide opportunities for VA to connect to veterans 
who may have fallen through the cracks and are not currently seeking VA 
healthcare.
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    \11\ Department of Veteran Affairs OIG. Evaluation of Suicide 
Prevention Programs in VHA Facilities. 2017. Veterans Health 
Administration. (2009, June 10). Veterans Health Administration. 
www.va.gov/health/aboutvha.asp
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    The American Legion remains committed to working with Congress to 
reduce the high suicide rate among service members and veterans and is 
committed to finding solutions to help end this crisis. To ensure that 
all veterans are properly cared for at Departments of Defense and 
Veterans Affairs medical facilities, The American Legion, through 
Resolution No. 2 Suicide Prevention Program, has established a Suicide 
Prevention Program and aligned it under the TBI/PTSD Committee. \12\ 
This committee reviews methods, programs, and strategies that can be 
used to reduce veteran suicide. The work of this body will help guide 
American Legion policy and recommendations.
---------------------------------------------------------------------------
    \12\ National Executive Committee Of The American Legion Resolution 
No. 20 , ``Suicide Prevention Program.'' archive.legion.org/bitstream/
handle/20.500.12203/9286/2018S020.pdf?sequence=1&isAllowed=y
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    President Donald Trump signed an executive order last month 
establishing a new task force aimed at empowering military veterans and 
ending the suicide epidemic among them. \13\ The order, titled the 
``President's Roadmap to Empower Veterans and End a National Tragedy of 
Suicide,'' or (PREVENTS), will require top officials from multiple 
government agencies to coordinate a strategy to tackle the issue of 
veterans suicide and release recommendations to the president within 
the next 365 days. The American Legion believes this group led by 
Secretary Wilkie is a step forward, but we still have questions about 
how it will be executed and where the resources to support it will come 
from.
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    \13\ Exec. Order 13,861, 84 FR 8585 (2019)
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    Congress must ensure sufficient resources are available for 
effective VA suicide prevention efforts. One death by suicide is one 
death too many. Funding for the aforementioned programs must be 
provided as well as money for new programs, including those to 
effectively treat individuals with previous suicide attempts, to deploy 
new interventions, and to identify those at higher risk of suicide. 
President Trump has called for a 9.5 percent increase in VA spending in 
2020, up to a total of $216 billion. The American Legion appreciates 
the serious attention paid to this issue by the White House and urges 
Congress to appropriate these funds.
                    Provides Critical Funding for IT
    ``In 2020, OIT is requesting $4.343 billion, an increase of $240.0 
million (5.8 percent) over the 2019 enacted budget. This requested 
increase will support critical investments to Veteran-focused 
development, IT modernization and transformational efforts.''

    -Department of Veterans Affairs - Budget in Brief 2020

    Department of Veterans Affairs (VA) Information Technology (IT) 
infrastructure has been an evolving technological necessity over the 
past 40 plus years, sometimes leading the industry, and sometimes 
trailing. Leading the field in 1978, VA doctors developed an electronic 
solution to coordinate and catalog patients healthcare long before 
their private sector colleagues, who were slow to follow, while some 
private physicians still refuse to automate today. The American Legion 
has been intrinsically involved with VA's IT transformation from the 
inception of Veterans Health Information and Technology Architecture 
(VistA) to being a pioneer partner in the concept and integration of 
the fully electronic disability claims process, as well as through the 
new telehealth project, Atlas. Atlas will enable remote examinations in 
selected American Legion posts.
    IT automation is expensive to implement and expensive to maintain, 
especially while working on legacy equipment. As in all digital space, 
IT infrastructure advances so quickly that most IT infrastructure is 
outdated by the time it is fully implemented, and VA's IT 
infrastructure is no different. This is the cost of doing business in a 
technologically advancing society. With this in mind, companies are 
turning to rented cloud-based resources and Software as a Service (SAS) 
to mitigate costs. These services have a lower up-front investment and 
negate the need for hardware maintenance and software upgrades in many 
cases.
    IT is inextricably intertwined into many of the services we take 
for granted, such as; telephone systems, appointment scheduling, 
procurement, building access, safety controls, and much more. 
Maintaining an up-to-date system is not a luxury, it is a necessity. 
The American Legion supports the continued effort by VA to update their 
systems. The president's Budget provides $4.3 billion for essential 
investments in IT to improve the online interface between the veterans 
and the Department. This includes an increase of more than $200 million 
to recapitalize aging network infrastructure, to expedite VA's 
transition to the cloud, and to support emerging VA MISSION Act of 2018 
IT requirements. \14\
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    \14\ A Budget for a better America, Promises Kept. Taxpayers first. 
``Fiscal Year 2020 Budget of the U.S Government.'', www.whitehouse.gov/
wp-content/uploads/2019/03/budget-fy2020.pdf
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    The American Legion continues to call on Congress to consider 
funding that enables VA to tie all of their IT programs together. This 
should be a seamless program capable of processing claims, managing 
veterans' healthcare needs, integrating procurement needs so that VA 
leaders and Congress can analyze annual expenditures versus healthcare 
consumption. Additionally, patient information must be integrated into 
their profiles ensuring seamless transition between the Department of 
Defense and VA.
             Electronic Health Record Modernization (EHRM)
    ``The EHR is a high-priority initiative that would ensure a 
seamlessly integrated healthcare record between the Department of 
Defense and VA, by bringing all patient data into one common system.''

    -A Budget for a Better America, Trump Administration's Proposed FY 
20 Budget

    The American Legion, through resolution, has long endorsed and 
supported the Department of Veterans Affairs (VA) in creating a 
Lifetime Electronic Health Records (EHR) system. Additionally, The 
American Legion has encouraged both DoD and the VA to either use the 
same EHR system, or, at the very least, systems that were 
interoperable.
    The American Legion recognizes the advantages of a bi-directional 
interoperable exchange of information between agencies. Collaborating 
with DoD offers potential cost savings and opportunities for VA. 
Opportunities include capitalizing on challenges DoD encounters 
deploying its own Cerner solution, applying lessons learned to 
anticipate and mitigate issues, and identifying potential efficiencies 
for faster and successful deployment. The American Legion supports the 
president's Budget including $1.6 billion as part of a multiyear effort 
to continue implementation of a new EHR system. The EHR is a high-
priority initiative that ensures a seamlessly integrated healthcare 
record between the Department of Defense and VA, by bringing all 
patient data into one common system, as such we call on Congress to 
fund it accordingly.
                           Medical Facilities
    During FY 2012, VA unveiled the Strategic Capital Investment 
Planning (SCIP) program. This ten-year capital construction plan was 
designed to address VA's most critical infrastructure needs. Through 
the plan, VA estimated the ten-year costs for major and minor 
construction projects and non-recurring maintenance would total 
approximately 60 billion over ten years.
    The American Legion is supportive of the SCIP program which 
empowers facility managers and users to evaluate needs based on patient 
safety, utilization, and other factors. While it places the onus on 
these individuals to justify the need, these needs are more reflective 
of the actuality as observed by our members and during our visits. VA 
has taken this process and effectively neutered it through budget 
limitations thereby underfunding the accounts and delaying delivery of 
critical infrastructure.
    While failing to meet these needs, facility managers will be forced 
to make do with existing aging facilities. While seemingly saving money 
in construction costs, VA will be expending money maintaining 
deteriorating facilities, paying increased utility and operational 
costs, and performing piecemeal renovation of properties to remain 
below the threshold of major or minor projects.
    This is an inefficient byproduct of budgeting priorities. The 
reality remains that the SCIP program is unlikely to be funded at 
levels necessary to accomplish the ten-year plan. Therefore, this 
account must be increased to meet the short-term needs within the 
existing facilities.
                 Addresses Infrastructure Deficiencies
    VA requests $1.2 billion for Major Construction operations, a 
decrease of $942 million (43 percent) over 2019 and similar substantial 
decreases in Minor Construction from $800 million to $399 million (50 
percent).

    -Department of Veterans Affairs - Budget in Brief 2020

    Since 2003, The American Legion's Veterans Affairs and 
Rehabilitation Commission members conduct a series of site visits to VA 
medical facilities and regional offices. While on site, Legionnaires 
visit with veterans, their families, and VA administrators and 
employees to discuss successes, challenges, and limitations at each 
site. Included in these System Worth Saving (SWS) reports are 
observations and challenges concerning infrastructure. In the 2018 
System Worth Saving report, The American Legion noted multiple 
infrastructure issues with a number of facilities around the country, 
including Fort Harrison, Montana; Manchester, New Hampshire; Denver, 
Colorado; and Durham, North Carolina. \15\
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    \15\ The American Legion, 2018 System Worth Saving, www.legion.org/
sites/legion.org/files/legion/publications/
50VAR0718%20SWS%20Executive%20Summary.pdf
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    Unfortunately, the types of issues found in these facilities are 
not isolated incidents and are too often found in VA facilities all 
around the country. For more than 100 years, our nation's solution to 
care for those who have defended us has been to build a network of care 
facilities across the country. The VA system currently boasts more than 
1,750 facilities with more than 5,600 buildings.
    The current process to manage this network of facilities is the 
Strategic Capital Investment Planning program (SCIP). SCIP identifies 
VA's current and projected gaps in access, utilization, condition, and 
safety. The SCIP planning process develops data for VA's annual budget 
requests. These infrastructure budget requests are divided into several 
VA accounts: Major Construction, Minor Construction, Non-Recurring 
Maintenance (NRM), Enhanced-Use Leasing, Sharing, and Other Investments 
and Disposal. The VA estimates costs at approximately $60 billion. \16\
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    \16\ Fiscal Year 2020 Budget for Veterans' Programs and Fiscal Year 
2021 advance Appropriations Request, 116th Cong. (2019) Secretary, 
Robert Wilkie
---------------------------------------------------------------------------
    The American Legion is very concerned about the lack of funding in 
the Major and Minor Construction accounts. Based on VA's SCIP plan, 
Congress underfunded these accounts and the president's budget does not 
propose enough. Clearly, if this underfunding continues VA will never 
fix its identified deficiencies within its ten-year plan. At current 
rates, it will take VA almost sixty years to address current 
deficiencies. VA currently has 24 partially funded major construction 
projects that need to be put on a clear path to completion and numerous 
additional projects that are in the design phase and have already 
received large expenditures in planning time, resources, and fees.
    The American Legion also understands there is a discussion to refer 
to SCIP in the future as a ``planning document'' rather than an actual 
capital investment plan. Under this proposal, VA will still address the 
deficiencies identified by the SCIP process for future funding requests 
but rather than having an annual appropriation, SCIP will be extended 
to a five-year appropriation, similar to the appropriation process used 
by the Department of Defense as its construction model. Such a plan 
will have huge implications on VA's ability to prioritize or make 
changes as to design or project specifications of its construction 
projects. The American Legion is against this five-year appropriation 
model and recommends Congress continue funding VA's construction needs 
on an annual appropriations basis.
    The American Legion recommends Congress adopt the 10-year action 
plan created by the SCIP process. Congress must appropriate sufficient 
funds to pay for needed VA construction projects and stop underfunding 
these accounts.
                Modernizes the Veteran Appeals Process.
    ``The Budget provides sufficient resources for the Board of 
Veterans Appeals and the Veterans Benefits Administration to implement 
the Veterans Appeals Improvement and Modernization Act of 2017, a new 
streamlined framework that will provide quicker decisions on new 
veteran compensation appeals and resolve the remaining legacy appeals 
inventory. The new framework will provide veterans with increased 
options to resolve their appeals and improve the timeliness of appeals 
decisions.''

    -A Budget for a Better America, Trump Administration's Proposed FY 
20 Budget

    The American Legion currently holds power of attorney on more than 
1.3 million claimants. We spend millions of dollars each year defending 
veterans through the claims and appeals process, and our success rate 
at the Board of Veterans Appeals (BVA) continues to hover around 75 
percent. Until President Trump signed the Veterans Appeals Improvement 
and Modernization Act of 2017 (Appeals Modernization Act or AMA) at The 
American Legion's National Convention in Reno, Nevada, VA had a complex 
claims and appeals system. \17\
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    \17\ Veterans appeals Improvement and Modernization Act of 2017, 
Pub. L. No: 115-55.
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    This ``legacy'' system divided jurisdiction amongst VA's three 
administrations and the Board of Veterans' Appeals (BVA). This 
confusing and complex process eventually led to extensive wait times 
and created a backlog. At the time, it was estimated it would take over 
nine years to resolve the over 200,000 case backlog. \18\
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    \18\ VA Debt Management Brief, Office Of Management, ``Department 
of Veterans Affairs Debt Management and Collections'' drive.google.com/
file/d/0B70--mGYT1tJETzZGWUZKYzdGXzg/view
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    Recognizing this indefensible state of affairs, The American Legion 
worked with other stakeholders, VA, and Congress to develop the Appeals 
Modernization Act. The law created a new system with three review 
options:

      A ``higher-level review'' by a more senior claims 
adjudicator
      A ``supplemental claim'' option for new and relevant 
evidence
      An ``appeal'' option for review by the Board of Veterans' 
Appeals

    Now, claimants may choose the option that best suits their needs. 
This new framework reduces the time it takes to review, process, and 
make a final claim determination, all while ensuring veterans receive a 
fair decision. Additionally, the Appeals Modernization Act framework 
includes safeguards to make sure claimants receive the earliest 
effective dates possible for their claims.
    The Appeals Modernization Act became fully effective earlier this 
year. The AMA sets forth specific elements that VA must address in its 
implementation. The American Legion believes working together with VA 
and Congress is vital to ensuring the success of the new appeals 
system. VA must provide stakeholders and Congress clear metrics to 
measure the progress and success of appeals and claims reform and 
strengthen Congress's ability to hold VA accountable for meeting these 
metrics. The American Legion supports the funding in the president's 
budget and urges Congress to appropriate this money and use its 
oversight authority to make sure stakeholder voices continue to be 
heard.
                 Vocational Rehabilitation & Employment
    The Vocational Rehabilitation and Employment (VR&E) Program 
provides comprehensive services and assistance enabling veterans with 
service-connected disabilities and employment handicaps to achieve 
maximum independence in daily living, become employable, and maintain 
suitable employment. After a veteran is found to be entitled to VR&E, a 
vocational rehabilitation counselor helps the veteran identify a 
suitable employment goal and determines the appropriate services 
necessary to achieve their goal.
    Once a veteran's claim has been adjudicated through the appeals 
process, the next step is approval and access to utilize the VR&E 
program. However, if the processing rate of adjudicating claims is 
increased and no investment into the VR&E program is made, The American 
Legion fears the unintended consequence of increasing the applicant 
pool for VR&E without increasing support staff will cause concern.
    Between FY11 and FY16, VR&E applicants rose from 65,239 to 112,115, 
creating increasing workloads for VR&E counselors tasked with 
developing employment goals and services for beneficiaries. The 
American Legion recognized the escalating problems associated with 
VR&E, and at our 2016 National Convention enacted Resolution No. 345: 
Support for Vocational Rehabilitation and Employment Program Hiring 
More Counselors and Employment Coordinators \19\.
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    \19\ American Legion Resolution No. 345: archive.legion.org/
bitstream/handle/123456789/5663/2016N345.pdf?sequence=1&isAllowed=y
---------------------------------------------------------------------------
    The combination of the increased output of claims and appeals 
without increasing the number of program counselors in the Vocational 
Rehabilitation and Employment program has the potential to accelerate 
the challenge into a crisis for veterans enrolled in the program.
    The American Legion is thankful and proud to have worked closely 
with this committee and others in Congress to modernize the appeals 
process and is appreciative that the president's budget requests the 
funding necessary to keep up with a streamlined appeals process. We 
also encourage this committee to consider and take into account the 
impending need to increase funding for the VR&E program, so we can 
assist veterans in finding quality employment.
            Increases Access to Burial and Memorial Benefits
    ``The Budget includes $329 million, a 4.2-percent increase from the 
2019 enacted level, to expand veteran access to memorial benefits, 
deliver premier services to veterans' families, and provide perpetual 
care for more than 3.9 million gravesites.''

    -A Budget for a Better America, Trump Administration's Proposed FY 
20 Budget
                 National Cemetery Administration (NCA)
    No aspect of the VA is as critically acclaimed as the National 
Cemetery Administration (NCA). In the 2016 American Customer 
Satisfaction Index, the NCA achieved the highest ranking of any public 
or private organization, again. \20\ In addition to meeting this 
customer service level, the NCA remains the highest employer of 
veterans within the federal government and remains the model for 
contracting with veteran-owned businesses.
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    \20\ ACSI Benchmarks for U.S Federal Government 2016, ACSI 
Benchmark for U.S Federal Government www.theacsi.org/acsi-benchmarks-
for-u-s-federal-government-2016
---------------------------------------------------------------------------
    One of the NCA's strategic goals is to provide reasonable access 
(within 75 miles of a veteran's residence) to a burial option in a 
national or Department of Veterans Affairs (VA)-funded state or tribal 
veterans' cemetery for 95 percent of eligible veterans. Currently, the 
NCA reports that they have reached 92 percent of this access standard. 
\21\ Congress must provide sufficient major construction appropriations 
to permit NCA to accomplish this goal and open five new cemeteries in 
the coming five years. Moreover, funding must remain to continue to 
expand existing cemetery facilities as the need arises.
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    \21\ National Cemetery Administration. (2008, April 29). ``National 
Cemetery Administration.'' www.ea.oit.va.gov/EAOIT/docs/NCA--LRP.pdf
---------------------------------------------------------------------------
    While the costs of fuel, water, and contracts have risen, the NCA 
operations budget has not received a significant increase in the past 
three budgets. Unfortunately, recent audits have shown cracks beginning 
to appear. Due predominantly to poor contract oversight, several 
cemeteries inadvertently misidentified burial locations. Although only 
one or two were willful violations of NCA protocols, the findings 
demonstrate a system nearly ready to burst.
    To meet the increased costs of fuel, equipment, and other resources 
as well as ever-increasing contract costs, The American Legion believes 
a small increase is necessary. In addition, we urge Congress to 
adequately fund the construction program to meet the burial needs of 
our nation's veterans.
                      State Cemetery Grant Program
    The NCA administers a program of grants to states to assist them in 
establishing or improving state-operated veterans' cemeteries through 
VA's State Cemetery Grants Program (SCGP). Established in 1978, this 
program funds nearly 100% of the costs to establish a new cemetery, or 
expand existing facilities. For the past two budgets, this program has 
been budgeted $45 million to accomplish this mission.
    New authority granted to VA funds Operation and Maintenance 
Projects at state veterans cemeteries to assist states in achieving the 
national shrine standards VA achieves within national cemeteries. 
Specifically, the new operation and maintenance grants have been 
targeted to help states meet VA's national shrine standards with 
respect to cleanliness, height, and alignment of headstones and 
markers, leveling of gravesites, and turf conditions. In addition, this 
law allowed VA to provide funding for the delivery of grants to tribal 
governments for Native American veterans. Yet we have not seen the 
allocation of funding increased to not only meet the existing needs 
under the construction and expansion level but also the needs from 
operation and maintenance and tribal nation grants. Moreover, as these 
cemeteries age, the $5 million limitations must be revoked to allow for 
better management of resources within the projects.
                    Better Care for Female Veterans
    VA is anticipating and preparing for the increase in the number of 
women Veterans as well as for the accompanying complexity and longevity 
of their treatment needs.

    -Department of Veterans Affairs - Budget in Brief 2020

    In 2018, women Veterans comprised over 15 percent of active duty 
military forces and 19 percent of National Guard and Reserves. The 
number of women serving is growing, composing an increasingly large 
share of the military and veterans' populations. \22\ Women veterans 
now comprise about 10 percent of the total veteran population, and more 
than 7 percent of the veterans using VA healthcare services. \23\ The 
2015 Department of Veterans Affairs Women Veterans Report not*ed that 
the total population of women veterans is expected to increase at an 
average rate of about 18,000 per year for the next 10 years. \24\
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    \22\ Women Veterans 2015, The Past, Present and Future of Women 
Veterans, ``Women Veterans' Report.'' www.va.gov/vetdata/docs/
specialreports/women--veterans--2015--final.pdf
    \23\ Id.
    \24\ Women Veterans 2015, The Past, Present and Future of Women 
Veterans. ``Women Veterans' Report.'' www.va.gov/vetdata/docs/
specialreports/women--veterans--2015--final.pdf
---------------------------------------------------------------------------
    VA needs to be prepared for a significant increase of younger 
female veterans, as those who served in the War on Terror separate from 
active service. Never before have so many women servicemembers been 
routinely assigned to combat zones. They sustain the same types of 
injuries as their male counterparts. The number of women enrolled in 
the VA system is expected to grow by 33 percent over the next three 
years.VA must ensure women veterans receive gender-specific healthcare 
to meet their needs across the entire network. The diverse population 
of women veterans using VA care require knowledgeable providers in 
women's health to deliver comprehensive primary care services, 
including mental health, gender-specific care, and referrals for 
reproductive healthcare needs. Finding ways to ensure that these 
veterans are welcome and receive the services they deserve is vital to 
The American Legion.
    VA needs to develop a comprehensive health-care program for female 
veterans that extend beyond reproductive issues. Bills like the Deborah 
Sampson Act and the Women Veterans Access to Quality Care Act are a 
step in the right direction. Provider education needs improvement. 
Furthermore, as female veterans are the sole caregivers in some 
families, services, and benefits designed to promote independent living 
for combat-injured veterans must be evaluated, and needs such as child-
care must be factored into the equation. Additionally, many female 
veterans cannot make appointments due to the lack of child-care options 
at VA medical centers. Since the 2011 survey, The American Legion has 
continued to advocate for improved delivery of timely, quality 
healthcare for women using VA. The American Legion is encouraged that 
the president's budget recognizes the need for additional funding in 
this critical area, and has proposed an increase of $42 million almost 
8 percent over last year's authorization levels.
                            Medical Services
    Over the past two decades, VA has dramatically transformed its 
medical care delivery system. Through The American Legion visits a 
variety of medical facilities throughout the nation during our System 
Worth Saving Task Force, we see firsthand this transformation and its 
impact on veterans in every corner of the nation.
    While the quality of care remains exemplary, veteran healthcare 
will be inadequate if access is hampered. Today there are over 20 
million veterans in the United States. \25\ While 8.3 million of these 
veterans are enrolled in the VA healthcare system, a population that 
has been relatively steady in the past decade, the costs associated 
with caring for these veterans has escalated dramatically.
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    \25\ United States Department of Veterans Affairs, ``Profile of 
Veterans': 2017" www.va.gov/vetdata/docs/SpecialReports/Profile--of--
Veterans--2017.pdf
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    Since 2010, VA enrolment has increased from 8.3 million to over 9 
million \26\. During the same period, inpatient admissions increased 
from 662 thousand to 764 thousand. Outpatient visits also increased 
from 80.2 to 109 million. Correspondingly, cost to care for these 
veterans increased respectively. The increase during these years is a 
trend that dramatically impacts the ability to care for these veterans.
---------------------------------------------------------------------------
    \26\ Department of Veterans Affairs, Veterans Health 
Administration, Office of the Assistant Deputy Under Secretary for 
Health for Policy and Planning. Prepared by the National Center for 
Veterans Analysis and Statistics
---------------------------------------------------------------------------
    While FY 2010 numbers seemingly leveled off - to only 3 percent 
annual growth - will adequate funding exist to meet veteran care needs? 
If adequate funding to meet these needs isn't appropriated, VA will be 
forced to either not meet patient needs or shift money from other 
accounts to meet the need.
    Even with the opportunity for veterans from OIF/OEF to have up to 5 
years of care following their active duty period, we have not seen a 
dramatic change in overall enrollee population. Yet The American Legion 
remains concerned that the population estimates are dated and not 
reflective of the costs. If current mandatory healthcare mandates for 
veterans remain and with the Vietnam Era Veterans continuing to retire 
and needing healthcare that may no longer be provided by their 
employers, VA medical care will become enticing for a veteran 
population that might not have utilized those services in the past.
    In order to meet the increased levels of demand, even assuming that 
not all eligible veterans will elect to enroll for coverage, and keep 
pace with the cost trend identified above, there must be an increase to 
account for both the influx of new patients and increased costs of 
care.
                Military and Veteran Caregiver Services
    The Budget also supports the VA MISSION Act of 2018's expansion of 
the Caregivers program to include eligible veterans who incurred or 
aggravated a serious injury in the line of duty before September 11, 
2001. Expansion of the Caregivers program would coincide with new 
information technology (IT) updates necessary to effectively manage the 
program.

    -Department of Veterans Affairs - Budget in Brief 2020

    The struggle to care for veterans wounded in defense of this nation 
takes a terrible toll on families. In recognition of this, Congress 
enacted, and President Barack Obama signed into law, the Caregivers and 
Veterans Omnibus Health Services Act of 2010. The unprecedented package 
of caregiver benefits authorized by this landmark legislation included 
training to ensure patient safety, cash stipends to partially 
compensate for caregiver's time and effort, caregiver health coverage, 
and guaranteed periods of respite to protect against burnout.
    The comprehensive package, however, was still not available to most 
family members who are primary caregivers to severely ill and injured 
veterans. Congress opened the program only to caregivers of veterans 
severely injured, either physically or mentally, in the line of duty on 
or after Sept. 11, 2001.
    Finally, VA will begin to extend eligibility for the Program of 
Comprehensive Assistance for Family Caregivers to severely injured 
veterans of all eras, through a phased approach. First, VA must submit 
to Congress certification that the IT system relied upon by the program 
is prepared to accommodate a higher workload. Once the system is 
prepared, VA will begin processing applicants injured on or before May 
7, 1975, in addition to those injured after September 11, 2001. Two 
years after this expansion, the program will accept all veterans 
severely injured in all eras.
    The American Legion has long advocated for expanding eligibility 
and ending the obvious inequity that Caregivers and Veterans Omnibus 
Health Services Act of 2010 created. Simply put, a veteran is a 
veteran! All veterans should receive the same level of benefits for 
equal service. As affirmed in American Legion Resolution No. 259: 
Extend Caregiver Benefits to Include Veterans Before September 11, 
2001, The American Legion supports the expansion to include all 
veterans who otherwise meet the eligibility requirements. \27\
---------------------------------------------------------------------------
    \27\ American Legion Resolution No. 259 (2016): Extend Caregiver 
Benefits to Include Veterans Before September 11, 2001
---------------------------------------------------------------------------
    The American Legion believes that providing expanded support 
services and stipends to caregivers of veterans to all eras is not only 
possible but also budgetary feasible and the right thing to do. We urge 
this committee and the U.S. Congress to allocate the required funding 
to continue and expedite the expansion of the caregiver program to all 
eras of conflict and veterans who should be in this program. The 
president's FY20 Budget requests $720 million for the Caregiver Support 
Program, a $213.5 million (42 percent) increase over the 2019 level, to 
support over 27,000 caregivers through the Caregiver Support Program. 
The American Legion supports this proposal.
                Ensuring Quality Care to Rural Veterans
    ``The budget maintains the strong level of funding for rural health 
projects at $270 million. As a complement to telehealth, VA is 
committed to improving the care and access for Veterans in 
geographically rural areas.''

    -Department of Veterans Affairs - Budget in Brief 2020

    The American Legion's System Worth Saving task force travels the 
country to evaluate VA medical facilities and ensure they are meeting 
the needs of veterans. From June 2017 to April 2018, the task force has 
been conducting site visits to VA medical facilities and town hall 
meetings to receive feedback from local veterans who utilize VA to 
receive their healthcare.
    The Task Force, in its 18th program year, is focusing on VA's 
accomplishments and progress over the past decade and a half, current 
issues and concerns, and VA's five-year strategic plan for several 
program areas. These areas of focus are VA's budget, staffing, 
enrollment/outreach, hospital programs (e.g. mental health, intensive 
care unit (ICU), long-term services and support, homelessness programs) 
information technology and construction programs.
    During each site visit, a town hall meeting is hosted by an 
American Legion Post. The town hall meetings have consistently 
illustrated that veterans are worried VA has turned a deaf ear to their 
concerns and is intentionally ignoring their complaints. We have seen 
firsthand where VA has closed intensive care departments, downgrading 
emergency departments to urgent care clinics, or has proposed to closed 
or reconfiguring hospital services under the guise of ``realigning 
services closer to where veterans live.''
    The American Legion urges Congress to evaluate VA's plan in rural 
areas and to stop VA from closing hospitals and community-based 
outpatient clinics unless existing requisite community services are 
meet or exceed that VA currently provides to veterans.
    In addition to ensuring improvements to infrastructure in rural 
areas, Congress must support increased funding to support telehealth. 
As the largest integrated healthcare system in the United States, the 
VA provides telehealth at more than 900 sites across the country in 
over 50 areas of specialty care. In 2017, 45 percent of Veteran who 
received care via telehealth lived in rural areas, yet many Veterans 
are limited from this option due to lack of availability of reliable 
connectivity or technology.
    The American Legion, Veterans of Foreign Wars, the U.S. Department 
of Veterans Affairs (VA) and Philips have partnered to bring VA 
healthcare to veterans through VA's ``Anywhere to Anywhere'' program. 
This program will allow veterans to be examined by a doctor in a 
familiar setting, their American Legion posts.
    Through Project Atlas, Philips will install video communication 
technologies and medical devices in selected American Legion posts to 
enable remote examinations through a secure, high-speed internet line. 
Veterans will be examined and advised in real time through face-to-face 
video sessions with VA medical professionals, who may be located 
hundreds or thousands of miles away. The program enables the ``Anywhere 
to Anywhere'' VA initiative to benefit veterans who would otherwise 
need to travel to receive care.
    The president's proposed budget requests $1.1 billion for the total 
Telehealth program, an increase of $105 million above the 2019 level. 
In 2021, VA is requesting $1.7 billion, an increase of $623 million 
above the 2020 level. The American ardently supports this initiative 
and urges Congress to appropriate funds to bring affordable VA 
Healthcare to veterans in rural areas through this program.
                      Assisting Homeless Veterans
    ``VA requests $1.8 billion for homeless programs, maintaining the 
significant funding provided in 2019 and increasing funds by $179 
million above the 2018 level, to provide the type of resources most 
needed where they are most needed across the country.''
    The American Legion strongly believes that homeless veteran 
programs should be granted sufficient funding to provide supportive 
services such as, but not limited to: outreach, healthcare, 
rehabilitation, case management, personal finance planning, 
transportation, vocational counseling, employment, and education. In 
that vein, we support the proposed funding in the president's budget 
and urge Congress to appropriate the funds.
    Furthermore, The American Legion continues to place special 
priority on the issue of veteran homelessness. With veterans making up 
approximately 9% of our nation's total adult homeless population, there 
is plenty of reason to give this issue special attention. Along with 
various community partners, The American Legion remains committed to 
seeing VA's goal of ending veteran homelessness come to fruition. Our 
goal is to ensure that every community across America has programs and 
services in place to get homeless veterans into housing (along with 
necessary healthcare/treatment) while connecting those at-risk veterans 
with the local services and resources they need. We hope to see that 
with the expansion of assistance afforded to homeless veterans and 
their dependents, there will also be an increase in funding to support. 
We estimate that an additional $10 million annually will be sufficient 
to accomplish this goal.
                             Mental Health
    Post-traumatic stress disorder and traumatic brain injury are the 
signature wounds of today's wars. Both conditions are increasing in 
number, particularly among those who have served in Operation Iraqi 
Freedom and Operation Enduring Freedom. The President's request for a 
4.7 percent increase in funding will provide find much-needed funding 
dedicated to this area. While Veterans who served in Iraq and 
Afghanistan make up only a small percentage of VA's patient population 
they require a disproportionate amount of VA specialized mental health 
services. There are nearly 3.5 million veterans who served after 
September 11, 2001. The need for specialized mental health services 
will only grow.
    In July 2010, VA took significant strides towards assisting 
veterans suffering from PTSD. The liberalization of regulations relaxed 
the need for veterans to provide proof of a PTSD stressor; instead, 
veterans only needed to prove a ``fear of hostility.'' Further, since 
2012, VA has increased staffing of new mental health providers, made 
efforts to improve wait times for mental health services, and removed 
numerous barriers to care.
    While The American Legion acknowledges advancements in this area, 
we also know there is significant room for improvement. From 
development of PTSD claims, through compensation and pension (C&P) 
examinations, to ultimate adjudication, The American Legion accredited 
representatives routinely see errors throughout the process. 
Furthermore, if a veteran seeks service connection for a physical 
condition that manifested secondary or was aggravated by PTSD, veterans 
routinely are faced with a difficult journey.
    VA has hired more than 3,900 new mental health providers yielding a 
net increase in VA mental health staff of over 1,000 providers, since 
July 2017. However, during that time there has been a massive influx of 
veterans into the system, with a growing need for psychiatric services. 
With over 1.5 million veterans separating from service in the past 
decade, nearly half have not utilized VA for treatment or evaluation. 
The American Legion is deeply concerned about nearly 750,000 veterans 
who are slipping through the cracks unable to access the healthcare 
system they have earned through their service.
    The American Legion believes VA must focus on head injuries and 
mental health without sacrificing awareness and concern for other 
conditions afflicting servicemembers and veterans. As an immediate 
priority, the VA must ensure staffing levels are adequate to meet the 
need. The American Legion also urges Congress to invest in research, 
screening, diagnosis, and treatment of PTSD and TBI.
    The American Legion recently published in, The Road Home, we 
believe VA must continue to search for the most effective treatment 
programs for veterans with comorbidities of PTSD, and TBI with 
substance use disorder (SUD) and chronic pain. \28\ We should also seek 
to develop treatment options including Complementary and Alternative 
Medicine (CAM) for veterans who are newly diagnosed. Providers in VA 
must take care to prevent at-risk veterans from becoming dependent on 
alcohol or drugs used to ``self-medicate.''
---------------------------------------------------------------------------
    \28\ The Road Home American Legion, TBI/PTSD Committee 
www.legion.org/sites/legion.org/files/legion/publications/
60VAR0818%20The%20Road%20Home%20-%20TBI-PTSD.pdf
---------------------------------------------------------------------------
    Through Resolution No. 160 Complementary and Alternative Medicine, 
Congress is urged to provide oversight and funding VA for innovative, 
evidence-based, CAM in treating various illnesses and disabilities. The 
president's proposed budget requests $9.4 billion for Veterans' mental 
health services, an increase of $426 million (4.7 percent) above 2019. 
The American Legion supports this action. Additionally, The American 
Legion remains committed to working with the VA in any way possible to 
move the VA toward their goal of becoming a fully integrated paperless 
system. \29\
---------------------------------------------------------------------------
    \29\ The American Legion Resolution No. 160 (2016): Complementary 
and Alternative Medicine
---------------------------------------------------------------------------
                     Medical Support and Compliance
    The Medical Support and Compliance account consist of expenses 
associated with administration, oversight, and support for the 
operation of hospitals, clinics, nursing homes, and domiciliaries. 
Although few of these activities are directly related to the personal 
care of veterans, they are essential for quality, budget management, 
and safety. Without adequate funding in these accounts, facilities will 
be unable to meet collection goals, patient safety, and quality of care 
guidelines. The American Legion has been critical of programs funded by 
this account. We remain concerned patient safety is addressed at every 
level.
                 State Veteran Home Construction Grants
    Perhaps no program facilitated by the VA has been as impacted by 
the decrease in government spending than the State Veteran Home 
Construction Grant program. This program is essential in providing 
services to a significant number of veterans throughout the country at 
a fraction of the daily costs of similar care in private or VA 
facilities. As the economy rebounds and states are pivoting towards 
resuming essential services, taking advantage of depressed construction 
costs, and meeting the needs of an aging veteran population, greater 
use of this grant program will continue. As our baby boomer population 
continues to transition into retirement, many more of these veterans 
are retiring to state veteran homes due to their excellent reputation 
for care and cost. The popularity of these retirement options will 
cause any surplus of space to become consumed. The American Legion 
encourages Congress to increase the funding level of this program.
                    Medical and Prosthetic Research
    The American Legion believes VA research must focus on improving 
treatment for medical conditions unique to veterans. Because of the 
unique structure of VA's electronic medical records (VISTA), VA 
Research has access to a great amount of longitudinal data incomparable 
to research outside the VA system. Because of the ongoing wars of the 
past decade, several areas have emerged as ``signature wounds'' of the 
Global War on Terror, specifically Traumatic Brain Injury (TBI), 
Posttraumatic Stress Disorder (PTSD), and dealing with the effects of 
amputated limbs.
    Much media attention has focused on TBI from blast injuries common 
to Improvised Explosive Devices (IEDs) and PTSD. As a result, VA 
devoted extensive research efforts to improve the understanding and 
treatment of these disorders. Amputee medicine has received less 
scrutiny but is no less a critical area of concern. Because of 
improvements in body armor and battlefield medicine, catastrophic 
injuries that in previous wars would have resulted in loss of life have 
led to substantial increases in the numbers of veterans who are coping 
with loss of limbs.
    As far back as 2004, statistics were emerged indicating amputation 
rates for US troops were as much as twice that from previous wars. By 
January of 2007, news reports circulated noting the 500th amputee of 
the Iraq War. The Department of Defense's response involved the 
creation of Traumatic Extremity Injury and Amputation Centers of 
Excellence, and sites such as Walter Reed have made landmark strides in 
providing the most cutting-edge treatment and technology to help 
injured service members deal with these catastrophic injuries.
    America's disabled veterans depend on VA maintaining its reputation 
as the leader in prosthetics care and service. VA has a reputation in 
the United States and around the world of providing the best possible 
prosthetic care to its disabled veterans. However, The American Legion 
remains concerned that once these veterans transition away from active 
duty status to become veteran members of the communities, there is a 
drop-off in the level of access to these cutting edge advancements. 
Ongoing care for the balance of their lives is delivered through the VA 
Healthcare system, and not through concentrated active duty centers.
    Reports indicate the state of the art technology available at DoD 
sites is sometimes not available through a VA Medical Center. With so 
much focus on ``seamless transition'' from active duty to civilian life 
for veterans, this is one critical area where VA cannot afford to lag 
beyond the advancements reaching service members at DoD sites. If a 
veteran can receive a state of the artificial art limb at the new 
Walter Reed National Military Medical Center (WRNMC) they should be 
able to receive the exact same treatment when they return home to the 
VA Medical Center in their home community, be it in Gainesville, Battle 
Creek, or Fort Harrison.
    American Legion contact with senior VA healthcare officials has 
concluded that while DoD concentrates their treatment in a small number 
of facilities, the VA is tasked with providing care at 152 major 
medical centers and over 1,700 total facilities throughout the 50 
states as well as in Puerto Rico, Guam, American Samoa and the 
Philippines. Yet, VA officials are adamant their budget figures are 
sufficient to ensure a veteran can and will receive the most cutting 
edge care wherever they choose to seek treatment in the system.
    The American Legion remains concerned about the ability to deliver 
this cutting edge care to our amputee veterans, as well as the ability 
of VA to fund and drive top research in areas of medicine related to 
veteran-centric disorders. There is no reason VA should not be seen at 
the world's leading source for medical research into veteran injuries 
such as amputee medicine, PTSD, and TBI.
    The American Legion urges Congress to ensure appropriations are 
sufficient to meet the prosthetic needs of all enrolled veterans. We 
believe the VA must continue to protect all funding for prosthetics and 
sensory aids. The VA must maintain a dedicated, centralized funding 
prosthetic budget to ensure the continuation of timely delivery of 
quality prosthetic services to the millions of veterans who rely on 
prosthetic and sensory aids' devices and services to recover and 
maintain a reasonable quality of life. The American Legion is skeptical 
of the reduction of funding for FY 20 from FY 19 in the president's 
proposed budget and urge Congress to, at a minimum, maintain funding.
                  Medical Care Collections Fund (MCCF)
    In addition to the aforementioned accounts which are directly 
appropriated, medical care cost recovery collections are included when 
formulating the funding for VHA. Over the years, this funding has been 
contentious because they often include proposals for enrollment fees, 
increased prescription rates, and other costs billed directly to 
veterans. The American Legion has always ardently fought against these 
fees and unsubstantiated increases.
    Beyond these first party fees, VHA is authorized to bill healthcare 
insurers for nonservice-connected care provided to veterans within the 
system. Other income collected into this account includes parking fees 
and enhanced use lease revenue. The American Legion remains concerned 
that the expiration of authority to continue enhanced use leases will 
greatly impact not only potential revenue but also delivery of care in 
these unique circumstances. We urge Congress to reauthorize the 
enhanced use lease authority with the greatest amount of flexibility 
allowable.
    It would be unconscionable to increase this account beyond the 
previous levels that were not met. To do so without increasing co-
payments or collection methods would be counterproductive and mere 
budget gimmickry. While we recognize the need to include this in the 
budget, The American Legion cannot condone a budget that penalizes the 
veteran for administrative failures.
                   Advance Appropriations for FY 2020
    The Veterans Health Administration (VHA) manages the largest 
integrated health-care system in the United States, with 152 medical 
centers, nearly 1,400 community-based outpatient clinics, community 
living centers, Vet Centers and domiciliary serving more than 9 million 
veterans every year. The American Legion believes those veterans should 
receive the best care possible.
    The needs of veterans continue to evolve, and VHA must ensure it is 
evolving to meet them. The rural veteran population is growing, and 
options such as telehealth medicine and clinical care must expand to 
better serve that population. Growing numbers of female veterans mean 
that a system that primarily provided for male enrollees must now 
evolve and adapt to meet the needs of male and female veterans, 
regardless whether they live in urban or rural areas.
    An integrated response to mental healthcare is necessary, as the 
rising rates of suicide and severe post-traumatic stress disorder are 
greatly impacting veterans and active-duty servicemembers alike.
    If veterans are going to receive the best possible care from VA, 
the system needs to continue to adapt to the changing demands of the 
population it serves. The concerns of rural veterans can be addressed 
through multiple measures, including expansion of the existing 
infrastructure through CBOCs, MISSION Act initiatives, improvements in 
telehealth and telemedicine, improved staffing and enhancements to the 
travel system, and other innovative solutions.
    Patient concerns and quality of care can be improved by better 
attention to VA strategic planning, concise and clear directives from 
VHA, improved hiring practices and retention, and better tracking of 
quality by VA on a national level.
    And finally, mandatory funds must be included in Advanced 
Appropriations along with full discretionary funding of all VA 
accounts. Veterans and dependents having their compensation and 
disability checks delayed because Congress refuses to pass an annual 
budget before being forced to close the federal government is 
reprehensible. Pass full advanced appropriations now.
                              Round-Downs
    In the president's proposed budget the VA seeks multiple Cost of 
Living Adjustment (COLA) round-downs. VA seeks to amend 38 U.S.C. 
Sec. Sec.  1104(a) and 1303(a) to round-down COLA computations for 
Dependency and Indemnity Compensation (DIC) from 2020 to 2024 and amend 
38 U.S.C. Sec. Sec.  3015(h) and 3564 to round-down COLA computations 
for Education Programs from 2020 to 2029.
    The American Legion, through Resolution No. 164, Oppose Lowering 
Cost-of-Living Adjustments, opposes these round-downs. The effect of 
the proposed round-down would serve as a tax on disabled veterans and 
their survivors, costing them money each year. Veterans and their 
survivors rely on their compensation for cost-of-living for essential 
purchases such as transportation, rent, utilities, and food. The 
American Legion is opposed to any COLA round-down as it will negatively 
impact the quality of life for our nation's veterans and their 
families. The Administration should not seek to balance the budget on 
the backs of veterans.
                               Conclusion
    Implementing the VA MISSION Act will require more resources than 
have been provided through regular appropriations in FY19 and it will 
cause care appropriation needs by the VA for future fiscal years. 
MISSION Act changes how VA purchases health services for veterans from 
community providers, is projected to increase veterans' enrollment in 
the VA healthcare system, and increase veterans' utilization and 
reliance on VA as a direct provider of care. Any and all future funding 
levels must reflect this as part of the plan, not wait until VHA is in 
crisis.
    Greater emphasis needs to be placed on VA's hiring and incentives, 
and if additional resources are needed to secure key providers like 
psychologists and physician's assistants, then VHA must be provided 
with the funding needed to make those critical hires. That is the long-
term key to ensuring that veterans get the care they need in a timely 
fashion in the system that is designed to treat their unique wounds of 
war.
    For Caregivers, older veterans' participation is unlikely to 
fluctuate, caregivers of older veterans likely will. Younger veterans 
tend to rely consistently on a spouse or a parent for care. Older 
veterans are less likely to have a spouse still capable of the physical 
demands of providing daily care. VA must be able to accommodate 
rotating caregivers, providing adequate and relevant training needed to 
sustain their veteran and maintain the caregivers own health as well.
    VA must continue to research the most effective treatment programs 
for veterans with post-traumatic stress disorder (PTSD), military 
sexual trauma (MST), and Traumatic Brain Injury (TBI), as well as 
researching biomarkers and complementary and alternative medicine to 
include cannabis.
    Individuals affected by homelessness should not have to choose 
between staying with their dependents or obtaining needed resources 
from a homeless shelter. Funds must be allocated to supporting veterans 
affected by homelessness who are also caring for others.
    The American Legion thanks this committee for the opportunity to 
elucidate the position of the nearly 2 million veteran members of this 
organization. For additional information regarding this testimony, 
please contact Mr. Larry Lohmann, Senior Associate of The American 
Legion Legislative Division at (202) 861-2700 or [email protected].
                               References
    Fulton, L. V., & Brooks, M. S. (2018). An Evaluation of 
Alternatives for Providing Care to Veterans. Healthcare (Basel, 
Switzerland), 6(3), 92. doi:10.3390/healthcare6030092

                                 
                        Questions For The Record

    House Committee Members To: Department of Veterans Affairs (VA)
Questions for the Record from Rep. Lee

    Question 1: According to the Fiscal Year 2020 President's Budget 
request, the Department of Veterans' Affairs is requesting $1.1 billion 
for telehealth services - a $105 million or 10.5 percent increase over 
the 2019 current estimate. How does the Department intend to use the 
$105 million budget increase to ensure open and competitive telehealth 
acquisitions and fair consideration of commercial-off-the-shelf 
telehealth solutions?

    VA Response: Telehealth funding supports several aspects of VA's 
Telehealth program including providers' salaries, telehealth support 
staff salaries, training, implementation, evaluation, and technology 
acquisitions. When additional telehealth technology is needed, VA will 
leverage, where applicable, existing VA telehealth contract vehicles 
that VA established through the open and competitive Federal 
Acquisition Regulation process.

Questions for the Record from Rep. Cunningham

    Question 1a: ``Hospitals and medical clinics, like the Ralph H. 
Johnson VA Medical Center in my district, are facing increased 
instances of flooding. These events can be extremely disruptive to 
healthcare operations, even isolating the hospital from the community 
it serves and delaying emergency responders. Will the VA make funding 
accessible to address flooded access roads that service these medical 
facilities?

    VA Response: Funding is available through the Non-Recurring 
Maintenance program to address infrastructure issues such as flooded 
access roads as long as the road is VA owned and operated.

    Question 1b: Does the VA have a strategic plan to address increased 
flooding from tidal influences, precipitation, and hurricane storm 
surge at its medical centers across the country?''

    VA Response: The Veterans Health Administration (VHA) complies with 
the VA Physical Security Design Manual, which was most recently revised 
in January 2015, for all new and existing facilities. The manual 
addresses both manmade and natural disasters, including hurricane surge 
and other natural events. The manual states that no new facilities 
shall be constructed in the 100-year flood plain and addresses the 
housing of equipment and construction materials in existing facilities 
that may be in the 100-year flood plain.

Questions for the Record from Rep. Cisneros

    Question 1: I understand from a VSO that they are concerned about 
the proposed $234 million offset to standardize and enhance VA 
Compensation and Pension benefit programs, listed under ``mandatory and 
Receipt Proposals'' on page 130 (PDF controls) of the proposed budget. 
Will this proposed initiative result in the reduction of Individual 
Unemployability (IU) benefits or other benefits veterans depend on to 
make ends meet?

    VA Response: The heading ``Standardize and Enhance VA Compensation 
and Pension Benefit Programs'' includes the following legislative 
proposals from the 2020 Budget:

 
------------------------------------------------------------------------
                                                 Cost/(Savings) to VA in
                Proposal Title                   FY 2020 ($ in Millions)
------------------------------------------------------------------------
1) Clarify Evidentiary Threshold for Ordering                    ($233)
                               VA Examinations
     2) Prohibition of Entitlement to VA's IU                      ($7)
        Benefit for Individuals Serving in the
                             Reserve Component
3) Reissue VA Benefit Payments to all Victims                        $6
                           of Fiduciary Misuse
------------------------------------------------------------------------
                         Total Cost/(Savings)                    ($234)
------------------------------------------------------------------------

    Summaries of these legislative proposals can be found on pages 15-
17 of Volume 1 of VA's 2020 Budget. The proposal to clarify the 
evidentiary threshold for ordering VA examinations would result in a 
savings associated with a reduction in the number of medical exams 
completed and would not represent a reduction in benefits to Veterans. 
The proposal to prohibit entitlement of IU for individuals serving in 
the reserve component would prohibit an individual from receiving IU 
while concurrently performing duties in the reserve components and 
receiving active service pay from such duty.

Questions for the Record from Rep. Peterson

    Question 1: Mr. Secretary, I have two new, skilled-nursing veterans 
home project proposals in my district that will greatly benefit 
underserved rural veterans. One is in Bemidji and the other is in 
Montevideo. Each home has raised enough state and local funds to be 
listed under Priority Group 1.
    For Fiscal Year 2019, the VA received $150 million and there were 
not enough funds to provide grant offers to all proposals under 
Priority Group One.
    In your proposal for FY 2020, the VA's budget only requests $90 
million for the extended care grant program.
    How will you make sure that the need for these two veteran home 
projects in my district will be accounted for in your FY 2020 budget 
request?

    VA Response: VA acknowledges that increase in requests for State 
Home construction funding; however, State Home construction grant 
funding must compete with other VA programs and needs for funding 
priorities. The process for awarding State Home construction grants is 
established in title 38 United States code, part 59. The statute 
outlines the process for prioritizing state projects and gives the 
highest priority to life or safety projects. These are projects to 
remedy a condition, or conditions, at an existing facility that have 
been cited as threatening to the lives or safety of one or more 
residents or program participants in the facility. The statute also 
requires that VA fund projects in the order of the list and that VA 
funding not exceed 65 percent of the total project cost. In this 
process, by law there is no flexibility or alternative financing 
mechanisms for awarding grant funds to states.

    Question 2: Mr. Secretary, when will you let me know how these two 
veteran home projects rank compared to other grant requests?
    VA Response: To be included on the VA priority list, initial grants 
applications are due to VA by April 15th of the prior fiscal year. 
Additionally, project budgets and certifications of state matching 
funds are due to VA by August 1st of the prior fiscal year. VA approves 
the project application and creates preliminary ranking of all state 
projects based on project type, application date, type of renovation, 
and the need for Veterans beds within the state. Life and safety 
projects are ranked above all others. The Fiscal Year 2020 State 
Veterans Home Construction Grant priority list is expected to be 
released by the second quarter of FY 2020.

    Question 3: Mr. Secretary, will you and your department be willing 
to provide me with updates on your review progress for the two veteran 
home project proposals in Bemidji and Montevideo?

    VA Response: All States are provided with updates on the status of 
their requests as part of the annual State Home Construction Grant 
priority list notification process.

                                 
                   Materials Submitted For The Record

      Letter From Elaine Luria To: Department Of Veterans Affairs
    April 1, 2019

    The Honorable Robert Wilkie
    Secretary
    Department of Veterans Affairs
    810 Vermont Avenue, N. W.
    Washington, D.C. 20420

    Dear Secretary Wilkie:
    Thank you for your commitment while testifying before the Senate 
Veterans' Affairs Committee on March 26, 2019, to not recommend an 
appeal of the U.S. Court of Appeals for the Federal Circuit's decision 
in Procopio v. Wilkie. As you know, Blue Water Navy Veterans have 
waited decades to receive benefits for diseases related to herbicide 
exposure during their service in the Republic of Vietnam. The Blue 
Water Navy Vietnam Veterans Act, H.R. 299, enjoys broad bipartisan 
support as we collectively work to compensate these veterans. I applaud 
this step by VA toward recognizing Blue Water Navy Veterans as eligible 
for the same benefits as their fellow Vietnam veterans.
    On February 27, 2019, you testified before the House Veterans' 
Affairs Committee. At that hearing, I asked whether you intended to 
extend Priority Group 6 VA healthcare benefits to Blue Water Navy 
Veterans. You replied that you assumed so. but would consult your 
attorneys and provide me with a complete answer. In light of your 
recommendation against appeal of Procopio, I am following up on a 
response to my question.
    To reiterate, Procopio v. Wilkie detennined that a servicemember 
present within the 12 nautical mile territorial sea of the Republic of 
Vietnam between January 9, 1962, and May 7, 1975, is entitled to a 
presumption of herbicide exposure for purposes of VA disability 
benefits. Do you intend to treat this class of veterans as equally 
eligible for Priority Group 6 VA healthcare benefits based on service 
within the Repubic of Vietnam?
    Please provide a response to this request by April 12, 2019. If you 
have questions or require additional infonnation, please contact Julie 
Turner, Counsel for the Subcommittee on Disability Assistance and 
Memorial Affairs, at 202-225-6603 or [email protected].

    Sincerely.

    Elaine Luria
    Chair
    Subcommittee on Disability Assistance and Memorial Affairs
    Committee on Veterans' Affairs
                                 

   Letter From Chairman Takano and David P. Roe, Ranking Member To: 
                     Department Of Veterans Affairs

    March 21, 2019

    The Honorable Robert Wilkie
    Secretary
    U.S. Department of Veterans Affairs
    810 Vermont Avenue, NW
    Washington, DC 20420

    Dear Mr. Secretary:

    We are aware that the U.S. Digital Service (USDS) recently 
prepared an analysis regarding development of information 
technology (IT) systems to support implementation of the 
Community Care requirements of the Mission Act. \1\ It is our 
understanding that USDS has prepared similar reports about 
other Department of Veterans Affairs (VA) systems over the last 
five years, including an ongoing report about implementation of 
systems to support the Caregiver Program.
---------------------------------------------------------------------------
    \1\ U.S. Digital Service, USDS Discovery Sprint Report Mission Act: 
Community Care (Mar. 1, 2019).
---------------------------------------------------------------------------
    In order to assist with the Committee's oversight of 
implementation of information technology at VA, we request that 
you provide complete and unredacted copies, including any 
attachments or appendices, of any USDS report, memorandum, or 
analysis pertaining to any VA IT systems prepared in the last 
five years. We also request that you disclose any ongoing 
analysis by USOS and the expected date of completion. We 
request that these reports be provided to the Committee no 
later than close of business on March 28, 2019.
    Please provide the documents in electronic, soft-copy 
format. Do not alter the documents in any way, including but 
not limited to applications of redactions or a water mark. Only 
relevant documents and tangible things should be provided as 
part of the submission. Also provide the contact information 
for the individual(s) responsible for assembling the 
submission. This/These individual(s) shall certify and attest 
to the accuracy of the submission.
    Thank you for your assistance. Should you have any 
questions about this request, please contact Sarah Garcia, 
Majority Staff Director, Subcommittee on Technology 
Modernization at [email protected] or Bill Mallison, 
Minority Staff Director, Subcommittee on Technology 
Modernization at [email protected].

    Sincerely,

    Mark Takano, Chairman

    David P. Roe, Ranking Member
                                 

         Letter From Robert L. Wilkie To: Mark Takano, Chairman

    March 29, 2019

    The Honorable Mark Takano Chairman
    Committee on Veterans' Affairs
    U.S. House of Representatives Washington, DC 20515

    Dear Mr. Chairman:

    This is a response to your March 21, 2019, letter to the 
Department of Veterans Affairs (VA) requesting copies of any 
U.S. Digital Service (USDS) reports pertaining to VA 
information technology (IT) systems prepared in the last 5 
years, in addition to information related to any ongoing 
analysis by USDS of VA IT systems and the expected date of 
completion. It is my understanding that USDS is a component of 
the Office of Management and Budget (0MB) within the Executive 
Office of the President. As such, your request for USDS 
reports, in addition to information related to ongoing USDS 
assessments, should be directed to 0 MB.
    It also has come to my attention that on March 19, 2019, 
the Committee sent a letter to Ms. Marcy Jacobs, Executive 
Director of Digital Services at VA, requesting that she appear 
on Tuesday, April 2, 2019, before a full 'Committee oversight 
hearing, to testify on behalf of VA on the implementation of IT 
systems to support the Maintaining Internal Systems and 
Strengthening Integrated Outside Networks (MISSION) Act of 
2018. As I have expressed to you before, VA is committed to 
being as transparent as possible with Congress, Veterans, and 
the American people. However, respectfully, Ms. Jacobs is not 
the most appropriate witness to address theVA's IT 
systems.Instead, as an accommodation to the Committee's 
exercise of legitimate oversight responsibility on this 
important subject, I will make available Mr. James Gfrerer, 
Assistant Secretary for Information and Technology and Chief 
Information Officer, to answer any questions the Committee has 
in connection with the implementation of IT systems to support 
the MISSION Act when he appears on April 2, 2019, before the 
Full Committee.

    Sincerely,

    Robert L. Wilkie

                                 [all]