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








 
                  U.S. DEPARTMENT OF VETERANS' AFFAIRS


                  BUDGET REQUEST FOR FISCAL YEAR 2021

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

                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                      THURSDAY, FEBRUARY 27, 2020

                               __________

                           Serial No. 116-58

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
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                  U.S. GOVERNMENT PUBLISHING OFFICE 
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                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tennessee, 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 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                         C  O  N  T  E  N  T  S

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                      THURSDAY, FEBRUARY 27, 2020

                                                                   Page

                           OPENING STATEMENTS

The Honorable Mark Takano, Chairman..............................     1
The Honorable David P. Roe, Ranking Member.......................     3

                               WITNESSES

The Honorable Robert Wilkie, Secretary, U.S. Department of 
  Veterans Affairs...............................................     6

        Accompanied by:

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

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

    Mr. Jon Rychalski, Assistant Secretary of Management/CFO, 
        U.S. Department of Veterans Affairs

Mr. Adrian Atizado, Deputy National Legislative Director, 
  Disabled American Veterans, On behalf of the Independent Budget    43

        Accompanied by:

    Mr. Carlos Fuentes, Director, National Legislative Service, 
        Veterans of Foreign Wars, On behalf of the Independent 
        Budget

    Mr. Morgan Brown, National Legislative Director, Paralyzed 
        Veterans of America, On behalf of the Independent Budget

Ms. Melissa Bryant, National Legislative Director, The American 
  Legion.........................................................    45

                                APPENDIX
                    Prepared Statements Of Witnesses

The Honorable Robert Wilkie Prepared Statement...................    53
Mr. Adrian Atizado Prepared Statement............................    64
Ms. Melissa Bryant Prepared Statement............................    70


                  U.S. DEPARTMENT OF VETERANS' AFFAIRS



                  BUDGET REQUEST FOR FISCAL YEAR 2021

                              ----------                              


                      THURSDAY, FEBRUARY 27, 2020

                     Committee on Veterans' Affairs
                              U.S. House of Representatives
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:06 a.m., in 
room 210, House Visitors Center, Hon. Mark Takano (chairman of 
the committee) presiding.
    Present: Representatives Takano, Brownley, Lamb, Levin, 
Brindisi, Rose, Pappas, Luria, Lee, Cunningham, Cisneros, 
Peterson, Sablan, Allred, Underwood, Roe, Bilirakis, Bost, 
Dunn, Bergman, Banks, Barr, Meuser, Watkins, Roy, and Steube.

           OPENING STATEMENT OF MARK TAKANO, CHAIRMAN

    The Chairman. Good morning. I call this hearing to order. A 
quorum is present.
    Pursuant to Committee Rule 4 and House Rule XI, Clause 2, 
the chair may postpone further proceedings today and, without 
objection, the chair is authorized to declare a recess at any 
time.
    Thank you, Secretary Wilkie, and your team for coming in to 
discuss the Department of Veterans Affairs budget request for 
Fiscal Year 2021. I also want to welcome our Veterans Service 
Organization (VSO) partners and look forward to hearing their 
views on our second panel.
    Despite a requested 12-percent increase for VA's budget, I 
am deeply concerned this request ignores a much worse reality. 
This budget could lead to less food on the plates of struggling 
veteran families, no new housing vouchers for homeless 
veterans, and millions of veterans cutoff from key support 
programs. This 12-percent increase comes at the expense of 
significant cuts to critical domestic programs that veterans, 
especially those in crisis, depend on.
    One point seven million veterans rely on Medicaid, but the 
President's budget would cut Medicaid by $900 billion over the 
next 10 years. More than half of all veterans, approximately 
9.3 million, rely on Medicare, but the President's budget would 
cut Medicare by $500 billion over the next 10 years. Over 
600,000 disabled veterans receive Social Security disability 
insurance a year, but the President's budget would cut Social 
Security benefits by at least $24 billion. Nearly 1.3 million 
veterans live in households that participate in Supplemental 
Nutrition Assistance Program (SNAP), but the President's budget 
would cut SNAP by $182 billion over the next 10 years. As of 
January 2019, there are 37,085 homeless veterans and Department 
of Housing and Urban Developments (HUD's) rental assistance 
program would be cut by $3.5 billion.
    Additionally, the President proposed we slash almost $700 
million from the Center for Disease Control 2021 budget, the 
very agency on the front lines of the coronavirus response. 
Meanwhile, the Centers for Disease Control and Prevention (CDC) 
warned this week that there will likely be an outbreak of the 
coronavirus in the United States. The President requested a 
separate, supplemental response, but it is wholly inadequate 
and would actually raid the funds set aside for other life-
threatening public health emergencies such as Ebola.
    As the Nation responds to the coronavirus outbreak, we 
cannot forget our veterans. They will not be immune to this 
virus and, under VA's fourth mission, it is our responsibility 
to ensure VA is prepared. While I am pleased that this budget 
places significant investments in mental health care for 
veterans, a top priority for this committee, VA and the 
President--it is a top priority for this committee, VA, and the 
President, I am alarmed that resources are directed outside the 
VA into grant programs and the PREVENTS Task Force instead of 
being used to explicitly support veterans in crisis. As demand 
for VA mental health services continues to grow, we need to 
ensure VA programs are fully funded before this money is 
directed elsewhere.
    I also emphasized in my remarks yesterday during the VSO 
hearing that I have made reducing veteran suicide my No. 1 
priority and that is why the committee adopted a comprehensive, 
evidence-based framework to address the crisis of veteran 
suicide from every angle. Our approach takes into account 
multiple factors that could reduce veteran suicide, everything 
from lowering economic burdens to increasing access to care and 
improving crisis intervention for those at higher risk.
    While funding has increased to reduce veteran homelessness, 
a factor that may lead to suicide, HUD faces significant cuts 
itself and for the fourth straight year HUD has zeroed out any 
new U.S. Department of Housing and Urban Development-Veterans 
Affairs Supportive Housing (HUD-VASH) vouchers, and I can tell 
you from experience representing my constituents in Riverside 
County that these vouchers are essential to ending 
homelessness. This program is a partnership between VA and HUD, 
and HUD provides the housing assistance and VA provides the key 
wraparound services. It does no good to only fund the VA 
services side of the partnership, veterans need housing 
provided by these HUD vouchers and for the--while we need these 
both to work for HUD-VASH, the program, to reduce veteran 
homelessness. Both VA and HUD need to be fully funded.
    VA also increased its budget for gender-specific women 
veterans health care by 9 percent, but its funding for hiring 
and training the clinicians and staff who run the women's 
health program is far below what is needed according to the 
independent budget. The chronic under-resourcing of women's 
health at VA is an indication of the greater cultural issue of 
fully valuing women veterans and, if we want to have an honest 
conversation about suicide prevention, we need to address the 
culture of sexual violence against women at VA. Currently, VA 
does not even require mandatory bystander intervention training 
for all employees, contractors, vendors, and volunteers.
    When Congress passed the MISSION Act in June 2018, tens of 
thousands of pre-9/11 veterans and their caregivers won a hard-
fought battle for equality with their post-9/11 counterparts, a 
battle that took nearly a decade; however, VA's inability to 
meet congressionally mandated time lines has prevented these 
veterans and their families from accessing these services.
    The budget requests $1.19 billion for 2021, which is a $485 
million increase over last year's funding levels for the 
program. However, to date, VA has not released the regulations 
outlining changes to the caregiver program that were authorized 
by the MISSION Act. Without finalized regulations published, it 
is unclear how accurate VA's budget request for this program 
is, potentially further breaking an already broken promise.
    The budget also requests additional employees to help with 
Blue Water Navy claims processing, but ignores funding for 
claims and treatment for other herbicide-exposed veterans 
despite extensive and credible evidence that their conditions 
are related to Agent Orange exposure. I sent a letter to 
President Trump with 77 of my House colleagues to ensure four 
diseases were added to the presumptions list. Senate Democrats 
and VSO leaders have called for the same inclusion, but there 
has been no response from this Administration. I was 
disappointed to see that the Secretary did not even address 
this injustice in his prepared remarks. That and the fact that 
this budget does not request any funding for these additional 
diseases signals that this Administration is not making 
progress on this matter. These veterans have already waited too 
long.
    Despite all of these increases, the President's budget 
would hurt veterans by slashing programs that ensure essential 
needs are met. When you consider it in its entirety, this 
budget is a cruel document that cuts housing, food security, 
health care, and key assistance that millions of veterans 
depend on.
    Now, instead, I suggest that we have to work together to 
ensure that we can keep the promises that we have made to our 
veterans and ensure that our budget reflects humane values.
    That concludes my opening remarks and, with that, I 
recognize Dr. Roe for 5 minutes for his opening statement.

       OPENING STATEMENT OF DAVID P. ROE, RANKING MEMBER

    Mr. Roe. Thank you, Mr. Chairman. I think it is fair to say 
that you and I view this budget through a very different set of 
lenses.
    When I came to Congress 11 years ago, the Department of 
Veterans Affairs' budget was $97.7 billion, which supported 
just over 260,000 employees, and that is medical benefits and 
cemeteries and health care, as it does today. Today, we are 
examining a VA budget request that totals $243.3 billion, 
almost a quarter of a trillion dollars, that would fund more 
than 400,000 VA employees, much larger than the U.S. Navy. That 
is an increase of $145 billion, almost 150 percent, and 140,000 
full-time employees, approximately 65 percent.
    Since 2017 alone, VA's budget has grown by $60 billion and 
VA's staff has grown by more than 50,000, and as you can see in 
the graphs behind me here. Increased government spending 
certainly does not always equate to improved government 
services, sometimes quite the opposite. However, this 
tremendous investment in our Nation's veterans has more than 
paid off under this President. Not only is VA more well-funded, 
well-staffed than ever before, but it is unquestionable that 
veterans are better served. I hear it every day when I go home 
now. Compared to President Trump's first day in office, 
veterans today have more access to care, more choices in care, 
more control over their care than any other time in history. 
Veteran unemployment has reached near-record lows. Veterans are 
expressing significantly greater trust in the VA. Veterans are 
able to use their GI Bill benefits whenever they choose. 
Veterans are getting their appeals for disability compensation 
decided faster and more efficiently.
    I remember we were in the Cannon Building in my first term, 
General Shenseki said we have a million backlog disability 
claims, we have 100,000 homeless veterans, and I applaud him 
for trying to get this number down. Dr. Lawrence, hopefully, in 
his remarks, will tell us where that is. It is rather 
remarkable what has happened for disability claims. Veterans 
are getting more support during their transition out of the 
military, veterans are able to go to urgent care clinics in 
their neighborhoods instead of traveling to VA hospitals for 
things like just a cold or a sprained ankle or whatever, 
something minor.
    Veterans who served in the Blue Water Navy during the 
Vietnam war are finally receiving the benefits they have 
earned. Let me tell you, that was the work of bipartisan on 
both sides of the aisle, they got that done. It was not easy, 
it was fully paid for, it is done; we should take a victory lap 
for that.
    Fewer veterans are homeless. A hundred thousand when I came 
here, which was unconscionable, now down to the numbers 
somewhere in the 30,000's. By the way, there are 10,000 unused 
HUD-VASH vouchers, 10,000 right now that have not been used 
that should be. Fewer veterans are dependent on opioids, which 
is great. The widow tax that financially penalized surviving 
spouses of disabled veterans has been repealed. Caregivers of 
seriously injured pre-9/11--that is my generation--veterans 
will soon receive the same support that caregivers of post-9/11 
veterans receive.
    VA has begun the process of modernizing its electronic 
health record and achieving true interoperability with the 
Department of Defense. VA has become one of the six best places 
to work in the Federal Government from number 17, the worst. 
Poor-performing employees are being held accountable. 
Whistleblowers have additional avenues to report concerns and 
be protected from retaliation.
    I could go on and on and on. Just look at the charts behind 
me, which are available on the minority website. That is 
certainly not to say our work is over, it is far from it, it 
will never be completely done, but it is to say that the 
staunchest critics of this President are being disingenuous 
when they claim that he has not put veterans first and that his 
policies have not led to clear improvements in the lives of 
veterans and their families, as I believe the previous 
Administration did.
    As for the work still ahead of us, many of the 
accomplishments I have mentioned earlier, which are listed in 
the graphs behind me, will require the ongoing leadership and 
oversight of this committee and our partners in VA and in the 
veterans service organizations.
    I remain particularly concerned about the State of VA 
medical facilities across the country, which is why I fought so 
hard to include the Asset and Infrastructure Review (AIR) as 
part of the MISSION Act 2 years ago. AIR is the most 
transformational, yet least discussed, aspect of the MISSION 
Act. It has the potential to permanently change the way VA 
delivers care across the country and help veterans, 
particularly those in rural, remote, and minority communities 
who are not being well served by the crumbling infrastructure 
that exists throughout the VA health care system.
    Just yesterday I had a State veterans service officer in my 
office, along with their organization, from Montana. A very, 
very rural area. The newest facility in the State is a hospital 
that has half their beds are full and many veterans have travel 
miles and miles. We can look at that new hospital and partner 
with them to help the local community and help veterans. That 
State veterans service officer told me that they opened an 
office in their community right there where they worked so 
veterans would not have to drive 65 miles for mental health 
services one way and 65 miles back and many times in a 
snowstorm. It is used 5 days a week. Those are the things we 
need to be doing for our veterans and we are.
    Veterans in the 21st century deserve to have access to the 
high-quality care close to their homes in facilities that were 
designed and built to provide modern medicine, not the ones who 
are relics of years long ago and that exist in neighborhoods 
where veterans no longer live.
    Change is not easy, I got that, especially for a health 
care system as antiquated and entrenched as VA, but AIR 
presents an incredible opportunity to preserve the VA for 
future generations of veterans. We cannot let this pass us by.
    But perhaps no greater challenge remains than preventing 
veteran suicide. I completely agree with the chair on what his 
primary object is, to help lower that, I could not agree more. 
If the number of veterans who died by their own hands every 
year in--that died in combat instead, there would be a 
worldwide outcry and calls for action, as we are doing now with 
the coronavirus. We should be doing that with the 6,000 
veterans and active duty who commit suicide each other. Those 
men and women are dying on a different battlefield and far too 
long their deaths have been accepted as inevitable, they are 
not. Incredible efforts have been invested in ending this 
crisis, but those efforts have failed and they will continue to 
fail until we are collectively brave enough to challenge the 
status quo, connect with the majority of veterans who are 
outside the VA's reach, and provide them with the support and 
care that they need where they are without requiring them to 
come to us first just because that is how we have always done 
it. I know that this President and this Secretary agree with me 
on that point and I appreciate their leadership and their 
commitment to doing so.
    Clearly, great progress has been made. You could be 
forgiven for not being aware of just how much, because when it 
comes to veterans we seldom talk about their triumphs as loudly 
as we talk about their trials. That does a real injustice to 
them and is a narrative that I would like to overturn in my 
final year on this committee. For now I will simply say that 
whenever we, as a grateful nation, have invested in the brave 
men and women who fought in the defense of our freedoms it has 
paid dividends not just for them, but also for our country and 
our future. This budget is a wise investment in our future and 
I wholeheartedly support it.
    I thank all of our witnesses for being here and, Mr. 
Chairman, I yield back.
    The Chairman. Thank you, Ranking Member Dr. Roe.
    Appearing for us today is Hon. Robert Wilkie, Secretary of 
United States Department of Veterans Affairs. We have Dr. 
Richard Stone, Executive in Charge of the Veterans Health 
Administration; Dr. Paul Lawrence, Under Secretary for 
Benefits; Mr. Jon Rychalski, Assistant Secretary of Management 
and Chief Financial Officer. We look forward to hearing your 
testimony today.
    Secretary Wilkie, I now recognize you to present your 
statement.

                   STATEMENT OF ROBERT WILKIE

    Secretary Wilkie. Thank you, Mr. Chairman, and thank you, 
Dr. Roe. I appreciate, again, this is my second time as 
Secretary, I made an appearance talking about programs as the 
acting, sitting under the picture of an old friend of mine from 
many years ago, Walter Jones, the late Walter Jones, Sr., so it 
is good to be back.
    I want to pick up on something that Dr. Roe said that I am 
in wholehearted agreement with. The Department of Veterans 
Affairs looks nothing like it did a few years ago. A few years 
ago, there were incredible stories of failures and excuses. 
Today, we are not only leading the country in innovation and 
modernized systems, but, above all, we have satisfied veterans.
    VA has implemented the most far-reaching transformational 
programs since the GI Bill was signed by President Roosevelt in 
June 1944. We have put in place just in the last year and a 
half the Colmery Act, the MISSION Act, the Blue Water Navy Act. 
That is a record of achievement that I think most Federal 
departments would be proud of. What makes me most proud is our 
ability to make these sorts of changes without missing a beat 
when it comes to serving America's veterans.
    In the last few years, I have heard a great deal of debate 
about the MISSION Act being a gateway to privatization. Well, 
last year, we completed almost 60 million internal appointments 
in the Department of Veterans Affairs, that is an increase in 
1.7 million internal appointments even as we sent 2.8 million 
to outside care under MISSION. Ninety percent of our veterans 
across the country, according to the surveys, trust the care 
they get at VA. Surveys continue to show that we are 
competitive with the private sector on wait times and quality. 
Much of this improvement has happened because we have brought 
back accountability to VA and released more than 8,000 staff 
who were not performing.
    As Dr. Roe said, 2 years ago we were sitting at 17 out of 
17 in terms of best places to work; today, we are at sixth. One 
of the reasons for that, other than accountability, is what we 
call the high-reliability organization. I have made it clear 
that VA is a bottom-up organization where people at every end 
of the strata have a say in how their work is performed, they 
have a say in how their leaders perform their work, and I think 
that has gone a long way to improving morale amongst our staff 
and, if morale amongst our staff is high, the care for veterans 
is much better.
    In addition, our staff continues to innovate and improve 
the quality of veterans' lives. It was the Department of 
Veterans Affairs that brought America the first cardiac 
pacemaker and the first liver transplant, now we are leading 
the way on cancer treatment. Precision oncology promises new 
ways to attack cancer by not attacking the patient. In Northern 
California, in Palo Alto, we just put on line one of the first 
5G hospitals in the United States that will allow us to deliver 
telesurgery services remotely to veterans across the country. 
It is telehealth, as Dr. Roe pointed out, that will allow us to 
reach those veterans, particularly those veterans in the 
Western United States and in the Pacific Islands, where we can 
diagnose patients remotely without forcing them to encounter 
long journeys.
    Now, we have several challenges on the horizon, as the 
chairman pointed out. Next week, I expect the caregiver 
regulations to be published in the Federal Register, fulfilling 
a promise that I made to Senator Murray that the program itself 
would not change until we actually had regulations in place and 
an IT system that is ready to go for all veterans.
    I take this personally. Some of you have heard me talk 
about my experiences growing up as the son of a combat soldier 
from Vietnam. My mother was a caregiver. My father passed away 
about a year and a half ago and when I last saw my mother at 
the end of last year she did tell me about the suffering that 
he engaged in, which we think was from chemical poisoning, 
which is why I place particular emphasis, as the chairman does, 
on getting the presumptions for Agent Orange right. I have seen 
it happen in my family. That is a promise to you that I am 
doing everything as diligently as I can to make sure that we do 
not go through what those veterans went through so many years 
ago and that we set the pace for the future for those veterans 
who have come since Vietnam.
    We are closer on the electronic health records. I did 
inform the committee that I delayed the rollout by a few weeks 
because we were not ready to train on a system that was not 100 
percent ready for those who would be using it. I think this is 
also an example of the change in morale at VA. I gave the 
practitioners on the ground in eastern Washington the power to 
tell me, Mr. Secretary, it is not ready to go, and I was not 
going to have thousands and thousands of practitioners practice 
on a system that was not ready.
    I am very gratified at the progress that we have made. I 
think we are in a much better place than many of the private 
sector hospitals were who engaged in this development many 
years ago; the Mayo Clinic, Children's Hospital. I think we are 
in a very good place to finally deliver that long-gone promise 
that when a young man or woman comes in to a military entrance 
processing station they have an electronic record that is built 
for the rest of their lives, so people like my father never 
carry around an 800-page record for the decades that they lived 
after they left military service.
    As the chairman noted, in a few weeks we will present the 
PREVENTS Task Force report for a nationwide plan to work with 
State, local, and tribal groups to identify veterans who are at 
risk of suicide.
    In addition to what the chairman said, that I take very 
seriously, we are offering more services to women than ever. 
Women like what they see, more and more are enrolling at VA. As 
of last year, 41 percent of all American women veterans are 
enrolled at VA, that is compared with 48 percent of all male 
veterans. Last year, 84 percent of all women veterans surveyed 
said they trusted the care that they received VA. We have a 
zero tolerance policy for all of that behavior that makes women 
uncomfortable.
    I will leave you with one more initiative that we are 
pursuing that is important to me. I have been accused of being 
an amateur historian and I plead guilty. The most spiritual 
speech ever given by an American President was the second 
inaugural address of Abraham Lincoln that would have been 
presented 150 years ago next week, where he laid out his vision 
for what was then known as the Veterans Bureau, I have asked 
that that address be placed in all of our cemeteries to remind 
us of that sacred bond that the country has with those who have 
shared, as some on this dais have shared, the incommunicable 
experience of war. I can think of no better way to set in place 
what we should be about than having Mr. Lincoln's words 
available to all of those who are coming to visit those 
veterans in their final resting place.
    Mr. Chairman, I thank you for your courtesy.

    [The Prepared Statement Of Robert Wilkie Appears In The 
Appendix]

    The Chairman. Thank you, Mr. Secretary, for your testimony. 
I now recognize myself for 5 minutes for questions and I will 
begin, Mr. Secretary, with this topic of electronic health 
record modernization.
    Very simply, is the new time line for the electronic health 
record modernization go-live July 2020?
    Secretary Wilkie. Well, that certainly is a goal that I 
would like to achieve. You and I discussed on the phone the 
reasons that I delayed the training on the system. Two weeks 
ago was always the date that I had chosen to make sure we would 
be ready, I am confident that we will be. I am also confident 
that Seattle will be on line later in the year.
    Dr. Stone is actually more on the ground on that than I am 
and I think he can fill in the blank on some of the issues that 
I have missed.
    The Chairman. Well, just before Dr. Stone, are you saying 
it will or will not be July 2020?
    Secretary Wilkie. Well, that is my goal.
    The Chairman. It is your goal----
    Secretary Wilkie. Yes.
    The Chairman.--right.
    Secretary Wilkie. Yes.
    The Chairman. Are you reasonably--do you think it is 
possible?
    Secretary Wilkie. I am confident that we can fulfill our 
mandate.
    The Chairman. The go-live will be July 2020, we are on 
track for that?
    Secretary Wilkie. Well, I would hope that it would be 
earlier, but I am focused on making sure----
    The Chairman. July----
    Secretary Wilkie.--we are on a glide path to get there.
    The Chairman. July 2020, if not earlier, we are on a glide 
path. I mean, look, we have always said on this committee 
that--and I think, you know, Ms. Lee has also said, we would 
rather get it right, but we also just want you all to be 
transparent with us and just tell us, you know, what you need.
    Secretary Wilkie. I would also say, as a way of 
complimenting, this committee has done things that I have not 
experienced in my other positions in the Department of Defense 
with other committees. You have graciously recognized the 
complexity of this program. It is the most complex program the 
Federal Government has undertaken and you have given me 
gracious opportunities and great leeway to fulfill your 
mandate.
    The Chairman. Well, look, I think--I hear what you are 
saying, that we are on track to go live by July 2020, it could 
happen earlier. I certainly hope that you will tell us if there 
will be more significant----
    Secretary Wilkie. Yes, sir.
    The Chairman.--delays beyond that. Okay?
    Secretary Wilkie. Yes, sir.
    The Chairman. I do want to get on to some other questions, 
though. Is the rationale for the delay development?
    Secretary Wilkie. The rationale was that, when I reviewed 
it, the two portions of the program that were not ready for our 
clinicians were programs that are incredibly important, 
particularly to the west, travel and community care, those 
programs were not ready. We have a great relationship with our 
private sector partner, we have a great relationship with the 
Department of Defense, but I was not satisfied, and I promised 
you and Dr. Roe that, if I was not satisfied, we would not 
launch. We are working on those interfaces right now.
    One of the highlights of our effort is that--and I should 
invite you to come see it--we have created the equivalent of 
what we in the Air Force call an air operations center that is 
working around the clock----
    The Chairman. Well, we were told----
    Secretary Wilkie.--to work this problem.
    The Chairman.--we were told that before--we were told 
before it was changed management and workflow, and then a 
capabilities issue.
    Dr. Stone. Mr. Chairman, if I may, it is development. There 
is about a thousand work processes that need to be written; 
those are substantially completed, but once you finish those 
work processes you have got to set that electronic medical 
record into a number of interfaces that plug into the rest of 
the system. There are 73 interfaces, 19 are completed as of 
today, and that is why we are delayed. This is development.
    The Chairman. Thank you, Dr. Stone.
    I want to move on to COVID-19 preparedness, coronavirus, 
and the supplemental funding request that is now before the 
Congress. Does VA need supplemental appropriations to prepare 
for a major coronavirus outbreak, including procurement of 
additional protective equipment, training for VA employees and 
deployment of VA employees as part of disaster emergency 
medical personnel system teams?
    Secretary Wilkie. Not at this point, Mr. Chairman. As you 
know from earthquakes that have hit California, we are a 
foundational response for the United States health care system 
when it comes to emergencies like this. We train for them year-
round, because when hurricanes hit, when earthquakes hit, we 
are the responding force. We are testing our processes as we 
speak, we are making sure our supply chain is full. Right now I 
do not see a need for us----
    The Chairman. What about staffing and funding for the 
Office of Emergency Management?
    Secretary Wilkie. We are set, right now we are set.
    The Chairman. Dr. Stone, do you agree with that?
    Dr. Stone. I do, I do. Now, if this develops into a 
pandemic in which portions of the American health care system, 
we are going to have a different discussion, but at this time 
as we take a look at the planning and what was outlined 
yesterday in the presser that was sent out, as well as a brief 
yesterday from the White House, we see ourselves as well 
prepared.
    Secretary Wilkie. Let me get you a brief on our emergency 
preparedness.
    The Chairman. Yes, I just want to make sure that--we have 
this opportunity in this supplemental to--I just want to make 
sure you all have thought this through on what you might need. 
I mean, we saw what happened when just one person in Houston 
that they thought might have it, but I do not think that he did 
have it, but the reaction throughout that area.
    I have gone over time. I want to recognize Dr. Roe for his 
5 minutes.
    Mr. Roe. Thank you. Just, Mr. Chairman, to dovetail in what 
you are talking about, you are absolutely right. I have noticed 
this for years in practicing medicine, what scared patients is 
the unknown. What you have to do, we have to get accurate 
information to people about this particular virus and what it 
does and what it can do. I think, if it is a 24-hour news 
cycle, you can get people completely worked up about this.
    We have the resources in this country, as opposed to many 
countries. Dr. Stone may want to share his experience with 
someone in France to show you how different it will be here 
about how we handle these. We are the best in the world at this 
and we will get through this just fine, I feel very confident 
that we can.
    I also feel, Mr. Chairman, that we in the Congress, 
whatever the number is, we are arguing about a number, we will 
provide the resources to take care of the American people. I 
have no doubt about that, that is not going to be an argument. 
When we figure out what that is, and we have to rely on the 
people who do this, we will provide those resources.
    I want to ask a couple of questions. One, Dr. Lawrence, I 
want to start with you, because the thing that we hear in our 
offices back home more is how long--why is it taking so long to 
get my disability claim adjudicated, would you please just give 
us a rundown on where that is right now after Mr. Bost passed, 
I guess now, Mike, it has been 3 years ago that that bill 
passed.
    Mr. Lawrence. Sure. As you recall and you alluded to, in 
2013, the backlog of claims peaked at 611,000. Those were 
claims over 125 days and they were taking 6 or more months to 
process. Right now, the backlog this morning is a little north 
of 72,000; in November, it hit an all-time low of 64,000. We 
processed claims last quarter, the period of October 1st 
through December 31st, in an average of 91 days. There are some 
that are more complicated that take longer, no claim, no two 
claims are exactly the same, but this is a significant 
reduction. Compared to the same quarter at the beginning of 
Fiscal Year 2019, we processed 12 percent more claims with the 
same people.
    We are providing faster service for veterans and more 
consistent results, so we are doing more with the resources you 
have provided us.
    Mr. Roe. Well, thank you for that. I know that I have heard 
constituent after constituent talk about--and especially with 
the rapid appeals modernization went on--about claims that had 
been out for years that got adjudicated in 2 or 3 or 4 months, 
and these veterans are very appreciative.
    Another thing very quickly I want to go to I think is one 
of the most--a very important component of the MISSION Act, 
which is the AIR Act. I would like to know exactly the status 
of the market assessments right now and that will form the 
basis of the recommendations to the AIR commission.
    Secretary Wilkie. Yes, sir. We have conducted market 
assessments in six or seven Veterans Integrated Services 
Networks (VISNs), that is a component of the 96 market 
assessments that we are doing that look at our services, our 
footprint, our partnerships, everything from building new 
facilities to leasing other facilities. I have a report date of 
January 2022 to the Congress. I will continue to ensure that we 
do this as rapidly as possible so I can actually get ahead of 
that report date. I think it is absolutely vital.
    We have never really had a complete inventory of what VA 
has and where VA is, and I do think that this is a key 
component for our future; without it, we will again be moving 
into the future blind, and I am very supportive of that part of 
the MISSION Act.
    Mr. Roe. I hope that the Congress has the courage to carry 
out what--because it is critical for the future. We can not 
keep just throwing money at a problem, there is a more 
efficient way to do it, and it is just the way health care is 
provided today.
    This was in yesterday's Washington Times, which I thought 
was very concerning, temporary doctors fill increasing 
shortages at health care facilities. We have a very good 
synopsis of what I have been saying now for years, that we have 
a shortage and in the next 10 years we are going to have to 
learn to do things more efficiently and better, both in the 
private sector and in the VA sector. I think this is one of the 
reasons that the AIR Act is so important to use the--and the 
MISSION Act, to use the best assets of both the private sector 
and the VA sector. I think as a shared responsibility we can 
take the best care of our veterans in that way.
    My time has expired. I yield back.
    The Chairman. Thank you, Dr. Roe.
    Ms. Brownley, you are recognized for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chairman. Good morning, Mr. 
Secretary. I am going to try really hard to get three questions 
in, so we will see how I do.
    The first question is around women veterans. I think you 
recently referenced that there are 780,000 women veterans in 
the VA; however, the budget represents--or references 545,000, 
roughly, unique women veterans. Can you confirm that the 
distinction is between enrolled women and actual veteran 
patients?
    Secretary Wilkie. Right, there is a difference between 
enrollees and patients, and that is the same for men as well.
    Ms. Brownley. Okay. In some other testimony the VA said 
that in Fiscal Year 2019 the number of unique women veterans 
grew to 821,000. It just seems to me that the population--I am 
a little confused, but that population is not totally 
represented in the budget?
    Dr. Stone. Congresswoman, there are 780,000 enrolled women 
veterans, 510,000 active users, growing to 548,000 active users 
in the 2021 budget. About 8 percent growth, about 9 percent 
increase in the budget.
    Ms. Brownley. Okay. We also know that women veterans 
represent the fastest growing sub-population of veterans and, 
you know, we are continuing to try to keep pace with that. 
Since Fiscal Year 2000 women veterans have more than tripled 
and are currently 30 percent of net new users of VA health care 
are female, yet the budget is only reflecting only about a 9 
percent increase in Fiscal Year 2020. Do you think there is 
adequate sums of money here to meet the need?
    Secretary Wilkie. That is for gender-specific care. We have 
a much larger budget for medical treatment that both men and 
women would need, because the conditions cut across gender 
lines.
    Ms. Brownley. Well, again, my data tells me that there is 
about 76 percent of women veterans now are assigned to a 
trained women's health primary care provider, which is still 
under where we aspire too.
    Secretary Wilkie. Well, right now we have at least two 
dedicated women's health care providers in all of our VA 
facilities. We have hired just I think in the last year 7,000 
providers and nurses, we have trained them just on women-
specific issues. It is something that is absolutely vital if we 
are going to provide those questions.
    Ms. Brownley. Thank you, sir. Now I want to go to the 
caregiver program and I think you mentioned that the 
regulations will be published next week. I am going to take 
your word for that, the buck stops with you, Mr. Secretary. 
Assuming we will be reviewing those next week, where are we 
with regards to the new IT system for processing caregiver 
program applications?
    Dr. Stone. The program is progressing well. The IT system 
has come online and we have moved most of the existing 20,000 
families that are on this system. The second phase that will be 
exercised next month is the ability to pay claims or to pay the 
benefit on an automated basis instead of handwriting that 
number of checks each month. Then the third piece will be the 
automated intake of new applicants.
    We are quite optimistic that by this summer the program 
will be ready for the Secretary to certify for expansion.
    Ms. Brownley. You are saying the summer of 2020 you will be 
able to accept applications electronically?
    Dr. Stone. That is exactly where we would like to be. 
Please remember, this is a very complex regulation of more than 
200 pages of regulation, and we do anticipate a robust response 
to the proposed regulation.
    Ms. Brownley. Can I just get your commitment then, if we 
fall off of that mark that you will let us know, so that we can 
stay abreast of that, I would appreciate it.
    The last question is the issue around sexual harassment 
within VA facilities. Just in reviewing the budget, I know, Mr. 
Secretary, you have initiated a program, Stand Up to Stop 
Harassment, and just looking at the budget I can not really 
identify resources dedicated to that program and I am just 
curious if you could further articulate a little bit more with 
regards to funding, including advertising materials and videos, 
so that we are really getting this information out at every 
corner of VA facilities.
    Dr. Stone. We have instituted a program called Stand Up to 
Stop Harassment. We have instituted about a half million 
dollars--or we put about a half million dollars into the budget 
to generate products that will train not only our employees, 
but also our volunteers and those coming through. You will also 
see in our lobbies pictures up about demonstrating respect for 
fellow veterans. All of those are present within the budget.
    Secretary Wilkie. I would add to that, we are engaging in a 
new bystander training program. It is one thing to put up a 
poster, but we need those people who are in that facility to be 
trained. About 7, 8 months ago, I put in place a similar 
program that I put in place at the Department of Defense and 
that is a task force that looks at culture, it looks at the way 
we report these things. Dr. Stone has brought into his 
immediate office a senior-level official who focuses on nothing 
but that. That is part of this great cultural change that the 
active duty and the veterans component has to go through it.
    Ms. Brownley. Well, I thank you for that and obviously we 
are looking for persistence in this endeavor.
    I am way over my time and I yield back.
    The Chairman. Thank you, Ms. Brownley.
    Mr. Bilirakis, you are recognized for 5 minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman, I appreciate it. 
Mr. Secretary, thank you for your service and you truly are 
making a difference. I see it locally in the Tampa Bay area, 
but nationwide----
    Secretary Wilkie. Thank you, sir.
    Mr. Bilirakis.--and I appreciate your service.
    The first question is, there have been some--Mr. Secretary, 
there have been some who have said the President's budget 
request is cutting services to homeless veterans by not 
requesting additional HUD-VASH vouchers. Is it true that there 
are over 10,000 HUD-VASH vouchers or 10 percent of all the HUD-
VASH vouchers that Congress funded last year that are not being 
used?
    Secretary Wilkie. That is true. Most of them are unused 
because they are in very high-cost areas that we have not been 
able to meet the rents. I have been in contact with--and I 
think I have mentioned this to the chairman--leadership 
particularly in Los Angeles. We are working with them to find 
some way to get around this problem, more transitional homes 
for veterans homelessness. We are expanding the facilities that 
we have, particularly in Southern California. Yes, that is 
true, we have 10,000 that have not been used.
    Mr. Bilirakis. Yes, and we did have a hearing in Southern 
California with Congressman Levin and that is what we heard as 
well, and I think even in my area the cost of living is very 
high. I would appreciate you working on that and thank you for 
doing that. It is unfair, would you agree, that the 
Administration is being criticized for not requesting new 
vouchers when there are more than 10,000 vouchers available?
    Dr. Stone. Sir, I understand your point. As part of this 
budget, we have added $30 million for additional caseworkers to 
work those. It is specifically our problem is in very high-cost 
communities where we just can not get the participation of 
enough private owners to participate in this, but we are adding 
additional resources just because of the complexity of having 
to work each case.
    Secretary Wilkie. I would add the success story--and Dr. 
Roe mentioned the decrease from hundreds of thousands to the 
38,000--just in the last 2 fiscal years we have managed to find 
homes for 125,000 veterans and their families. The way this 
will continue to work, though, is that we have to enhance our 
partnerships with the private sector, with charities, with non-
governmental organizations, so they can help us go where we do 
not go to find those veterans who are on the street.
    Mr. Bilirakis. Getting the additional case managers will 
help you do that; correct?
    Secretary Wilkie. Yes.
    Mr. Bilirakis. It is a smart move. I mean, this is a 
priority of this Administration, obviously it is a priority of 
this committee as well.
    Okay. Mr. Secretary, I have seen in The American Legion's 
testimony, which we will hear on a second panel, that VA should 
consider public-private partnerships with community hospitals 
to increase VA's market penetration in under-served areas by 
renting space in existing facilities. Now, we do not need that 
in my area, but in other parts of the country I think it is 
necessary. I also strongly believe that we can leverage the 
already existing framework of community health centers to 
increase VA's footprint.
    Would you support these concepts and--well, just give me 
your opinion on that, because I think it is important, 
particularly with the community out centers. That is all over 
the country, they do such a wonderful job, and it would make a 
veteran's life a lot easier to travel there as opposed to going 
to a hospital, which may be hundreds of miles away. Yes, 
please.
    Secretary Wilkie. That is the beauty of MISSION. In fact, I 
never remember the entire acronym, but the part, the words, the 
letters that I do remember are integrated network. MISSION 
allows the veterans the choice to find those community 
providers. There are about 880,000 community providers across 
the country that could be community hospitals or doctors or 
nurse practitioners.
    Our goal is to get veterans to the care that is most 
advantageous to them.
    Mr. Bilirakis. Thank you very much. Doctor, do you want to 
add something?
    Dr. Stone. No, not in addition to what the Secretary said.
    Mr. Bilirakis. Okay. Thank you very much and, again, thank 
you for your service. I am telling you, I hear it from veterans 
everywhere that you are truly making a difference. God bless 
you.
    Thank you and I yield back, Mr. Chair.
    The Chairman. Thank you, Mr. Bilirakis.
    Mr. Lamb, you are recognized for 5 minutes.
    Mr. Lamb. Thank you, Mr. Chairman. Mr. Secretary, 
everybody, thank you for joining us today.
    Mr. Secretary, thank you for everything you are doing, but 
especially for starting off today by mentioning your father and 
his service in Vietnam and what he went through, because I 
really just want to focus for a second on the men and women who 
are out there right now with hypothyroidism, hypertension, 
Parkinson's symptoms, and bladder cancer, those four conditions 
that have still not been added to the presumptive list. I will 
just State up front that this is an injustice, it is an insult 
to these men and women.
    I believe that the responsibility lies at Office of 
Management and Budget (OMB), I do not believe it lies with the 
four of you. From what I can see as publicly available, the 
Secretary wanted to add it back in 2017, then-Secretary 
Shulkin, OMB turned him down pretty clearly; the reasons are 
not clear, but they have turned him down. I just want to 
confirm your understanding of a few facts, though.
    Do I have it right that, if you take these four conditions 
as a whole, there are probably around 190,000 veterans who 
would receive benefits under those four conditions and then 
that number would grow over time?
    Secretary Wilkie. I think it would as to the growth. I 
would have to look at the actuary tables, because the 
population is----
    Mr. Lamb. Right.
    Secretary Wilkie.--beginning to leave us.
    Mr. Lamb. 190,000 veterans who, as you say, are beginning 
to leave us, suffering from these incredibly serious 
conditions. I mean, just Parkinson's alone, the drugs can cost 
thousands and thousands of dollars for people every single 
year. The estimate I have seen publicly reported is that adding 
these four conditions would cost about 11 to $15 billion over 
time; does that sound familiar?
    Mr. Rychalski. Eleven to 15 billion over 5 years?
    Mr. Lamb. Eleven to 15 billion over 5 years.
    Mr. Rychalski. Correct.
    Mr. Lamb. That is correct, Okay. That is what OMB has 
rejected due to the cost; is that correct?
    Secretary Wilkie. I can not tell you what their reasoning 
is today.
    Mr. Lamb. It is a fact that OMB has rejected it?
    Secretary Wilkie. That has been replaced with a 
recommendation.
    Mr. Lamb. The thing is that, I mean, I think that their 
case has been couched in terms of protecting the taxpayers, 
making sure we can actually pay for the things we promise 
veterans, which all sounds nice in the abstract, but the exact 
same OMB is promoting and requesting a budget that asks for $22 
billion of an increase this year alone as VA as a whole. It is 
not as if they are pinching pennies throughout the VA, it is 
not as if they are pinching pennies throughout the government, 
we now have over a trillion dollars of budget deficit. This is 
about choices. If these four conditions going on the 
presumptive list would mean 11 to $15 billion over 5 years, 
that is in fact less than VA's overall budget request increase 
this year alone; correct?
    Secretary Wilkie. That is----
    Mr. Lamb. Just the math, it is a mathematical question.
    Secretary Wilkie.--yes, the math is correct. The 
distribution probably would not work dollar-for-dollar, given 
other needs that we would have.
    Mr. Lamb. Yes, and no one is saying that there are not 
other needs, but this is about making choices. You know, when 
we passed the expansion of community care, the MISSION Act, one 
of the things that we called attention to was the conflict 
between mandatory and discretionary spending that that would 
create, and we were very concerned about it. As you noted, 
people were concerned about privatization of the VA.
    I will commend you for how you have executed MISSION Act so 
far. This year went smoothly in my district, from what I can 
see, and the Administration has continued to request more money 
to fund MISSION Act so that that did not happen, but, again, it 
was about choices. The Administration's response at that time 
was, basically, do not worry, we are going to make sure 
veterans get the money that they deserve; we are going to take 
care of these people if we send them out into the community, we 
are going to pay, we are going to find a way. That is now not 
happening with the people who are suffering from these four 
conditions. As you said, they are starting to leave us. The 
clock is ticking for them, the clock is not ticking as much for 
a 35-year-old who might want to get medical care in the 
community, but that is who OMB and the Administration is 
choosing and that is what is wrong. I know you are working hard 
for these veterans and you are making the case, I can tell.
    Please, do not give up and try to convince these people 
over there that this is not about saving money. Our government 
sprayed them with Agent Orange, we are the ones that did it to 
them.
    Dr. Stone. Congressman, none of the decisions that we have 
recommended to the Secretary or have been recommended to OMB 
have been based on how much this costs.
    Mr. Lamb. Thank you.
    Dr. Stone. It has to do with the science and the science, 
unfortunately, is difficult. The National Academy of Science 
went over these four conditions and----
    Mr. Lamb. It is.
    Dr. Stone.--unfortunately, they----
    Mr. Lamb. My time is about--it is impolite to cut you off, 
my time is about to expire, but I just want to reiterate that 
the level of evidence related to these four conditions is 
similar to the conditions that are already on the presumptive 
list, they are not novel or unique in that respect. Science can 
differ, but you also have to add into it that it is similar to 
how we have done it in the past and, again, the clock is 
ticking. At a certain extent it becomes who bears the burden, 
the government or the veteran, and I believe it should be the 
government.
    Mr. Chairman, I yield back.
    Secretary Wilkie. I know you are over your time, sir, but I 
will give you my commitment, because it is personal, that the 
Vietnam soldiers have particular meaning to me. That was the 
world I was born into and I take your passion seriously.
    The Chairman. Thank you, Mr. Lamb. Mr. Secretary, I 
appreciate your responses to Mr. Lamb on this issue. I agree 
with him that I think--I do not see you gentlemen responsible 
for these four conditions not being listed on the presumptive 
list. This is something I hope that we can resolve quickly.
    I now recognize Mr. Bost for 5 minutes.
    Mr. Bost. Thank you, Mr. Chairman. I want to thank you all 
for being here as well and what all you are doing.
    Dr. Lawrence, as you know, the VA recently faced challenges 
responding to legislative requirements like those under the 
Forever GI Bill that Congress passed to enhance education 
benefits for our veterans, servicemembers, families, and 
survivors. How would you assess the Veterans Benefits 
Administration's (VBA's) state of preparedness today, 
particularly from an informational technology perspective, and 
if you would require--if you were required to carry out 
implementation of additional legislative provisions, what 
challenges would you still face?
    Mr. Lawrence. As you know, part of what got us through the 
journey through the GI Bill in calendar year 2019 was the old 
technology and the inability to respond agile to the new 
requirements passed in the Forever GI Bill. The assessment 
coming out of that, which was completed successfully on 
December 1st and we are in the process of truing up per the 
Secretary's guidance, is that the technology is very, very old, 
making it very difficult for us to provide veterans world-class 
service that they are used to with the private sector, as well 
as limiting the possibilities that additional changes to the GI 
Bill will be done cheaply, if at all.
    There is a real sense the time is near to not just continue 
to upgrade this old technology, but to really rethink the 
acquisition of new commercial off-the-shelf software and 
implement it in such a way that going forward we will not face 
the same problems.
    Mr. Bost. If you were provided with additional funding for 
IT, what would your priorities be?
    Mr. Lawrence. Sure. We have done a preliminary assessment, 
but I will give you a broad assessment. We would purchase three 
commercial off-the-shelf packages, one called Customer 
Relationship Management, so when veterans call up we know 
everything about them when we are on the phone. This happens 
when you interact with a bank or insurance company now. We will 
purchase high-tech computing power to do calculations. This 
happens when you take a dependent off your insurance company 
and they tell you the reduction or the addition. We will have 
sufficient data capacity, so we can have all the information 
from the schools and the veterans, so that it is all right 
there.
    These are commercial off-the-shelf acquisitions, companies 
that exist that do this all the time now. With additional 
funding, that is what we would do. The implementation of this 
should take between 18 to 24 months. We have MITRE presently 
studying this exactly as to how it would be done, so that we 
could do this when the resources are available.
    Mr. Bost. That is what I wanted to get on the record, so we 
knew, you know, the efficiencies we can move forward with the 
proper investments.
    My next question is for Dr. Stone. You have spoken about S. 
3084, that is a bill that passed out of the Senate in January 
that would correct a technical error in the law that impacts 
leaders working in senior executive positions throughout the VA 
and within the VA health care system, and it is actively making 
it harder for VA to recruit and retain the necessary talent to 
serve veterans. I have been working to get the bill passed out 
of the House as soon as possible. Could you please briefly 
summarize what the advantage of having this passed would do for 
you?
    Dr. Stone. Congressman, 10 years ago there was an error 
made in two sections of the law that allowed us to pay Senior 
Executive Service (SES) equivalents a market rate. We 
discovered this as part of the last pay raise, it placed us in 
a very difficult position. That in essence states in one 
section of the law we may have overpaid those senior leaders. I 
have 30 active senior leaders, these are the people that had my 
pharmacy program, had our suicide prevention program, these are 
the key working leaders of this organization.
    The problem we have got as this sits is that I can not do 
anything with those employees. We will trigger additional 
potential debt for them unless we lower their salaries. In 
addition, we can not promote any of them, we can not move them 
someplace else; I can not hire, they can not retire. This is an 
extraordinary morale killer for 30 of our key leaders and we 
would hope that your efforts would result in continued 
movement.
    Secretary Wilkie. I would add to that, and the chairman and 
Dr. Roe have worked on this in the past, we have a larger issue 
and that is remaining competitive when it comes to paying 
doctors and nurses, particularly in high-end specialties. It is 
my desire to break out of the compartments that have existed in 
terms of the Federal pay scale for well over 100 years. This 
committee has given us authorities for loan forgiveness, it has 
given us authority for moving expenses, it has given us some 
authorities to raise salaries beyond what they would normally 
be, but that is an issue that is going to reach a point that we 
will have to come back and have a much longer discussion.
    Mr. Bost. Thank you, Mr. Secretary.
    My time has expired and, with that, I yield back, Mr. 
Chairman.
    The Chairman. Thank you, Mr. Bost.
    Mr. Levin, you are recognized for 5 minutes.
    Mr. Levin. Thank you, Mr. Chairman. Mr. Secretary, to you 
and your team, I thank you for being here with us and on behalf 
of my communities in San Diego and Orange County we thank you 
for your service to our veterans.
    I wanted to follow up as chair of the Economic Opportunity 
Subcommittee on one topic that my friend, the ranking member, 
Mr. Bilirakis brought up and that is the HUD-VASH program. 
Specifically, we have heard testimony in our recent 
subcommittee hearings on the difficulty in hiring and retaining 
case managers that are critical to operating the program. 
Studies have shown how effective HUD-VASH is at reducing 
veteran homelessness, but obviously without sufficient case 
managers veterans can not access the vouchers and that is 
certainly true, as was indicated before.
    What is the VA doing to address the case management 
staffing issue? I heard the 30 million that you brought up 
before, but understanding the key challenges, recruitment and 
retention, and offering a competitive salary for these case 
managers. Do we need to adjust the pay scale for HUD-VASH case 
managers and, if so, what would that require?
    Dr. Stone. I think we have got room to move higher. Our 
problem primarily is in high-cost areas, as I mentioned before. 
It is not just the cost of housing, it is the cost of living 
for that employee to stay in. We could use relief in our Title 
38 authority for those social workers.
    One of the success stories that we have had in Los Angeles 
is to make that HUD-VASH voucher social worker part of an 
overarching team integrated with the rest of the medical care 
team. Much of the issues of our persist homeless veteran really 
relate to chronic, severe mental illness, as well as drug 
abuse, and the full integration of those programs has resulted 
in much higher job satisfaction. Although one of the 
frustrations is, we can bring people into long-term domiciliary 
care, but after 6 months or so when we have got people drug-
free and under good control transitioning out is very 
frustrating into the community, especially in high-cost markets 
like you represent.
    Mr. Levin. Thank you for that. We look forward to working 
with you in a bipartisan way on trying to figure this out, 
whether it be the fair market calculation, ensuring that the 
voucher is commensurate with the actual cost of living in a 
particular area, or the eligibility criteria, we have 
legislation to expand that, and then the case managers, making 
sure that their salaries are competitive. Let us know how we 
can work with you.
    The other thing that we have done this year is we have made 
several visits to Muskogee, Oklahoma--and it is good to see you 
again, Dr. Lawrence--for the GI Bill call center regional 
processing office. We repeatedly heard the need for funding and 
you went into that a little bit, but I was amazed that one such 
system is now over 50 years old, it is still in operation, and 
it seems to me that the budget request does not reflect 
everything that you need and instead we seem to be left in this 
cycle of band-aids and IOUs for a system that is desperately in 
need of a revamp.
    Mr. Secretary, obviously, I hope you would consider 
education services IT a priority and, if so, how can we better 
reflect that priority given that VA, as my friend Mr. Lamb 
said, had their own budget increased, one of only two Federal 
agencies? How can we better reconcile the needs for the GI Bill 
IT infrastructure?
    Secretary Wilkie. It is actually an issue beyond just the 
GI Bill and is one that Ms. Lee has been very involved in, and 
that is a look at our entire IT infrastructure readiness. I 
will admit that VA has been underfunded on the IT front 
throughout the last several decades, we were right at the 
bottom. That is a bipartisan criticism, both Republic and 
Democrat administrations. Raising that IT infrastructure 
profile is absolutely the key. Moving things to the cloud, 
getting people away from actually having to touch a claim, that 
is what we are working on. Dr. Lawrence, as you said, has done 
an incredible job at Muskogee, but we have a much larger issue 
than just the GI Bill and we are working to correct that.
    Mr. Levin. Thank you for that, Mr. Secretary. Again, thank 
you to the whole team. I do hope, while this is an election 
year, things get a little crazy, that we are able to find those 
areas of common ground where we can work together in service of 
our veterans. I know that Mr. Bilirakis and I share that ideal 
in our subcommittee and we look forward to addressing these and 
related issues.
    Thank you, again, and I will yield back to the chairman.
    Secretary Wilkie. Thank you, sir.
    The Chairman. Mr. Bergman--thank you, Mr. Levin--Mr. 
Bergman, you are recognized for 5 minutes.
    Mr. Bergman. Thank you, Mr. Chairman. Thanks to everybody 
for being here.
    You know, we all sometimes hear the term we are not in a 
sprint, we are in a marathon. I would suggest to you this is 
not a marathon, this not even an ultra marathon. More 
appropriately, I could maybe categorize this as a never-ending, 
multi-generational relay race in which the baton is passed from 
generation to generation, whether that generation be human or 
technology, because as we hear what all of you have done on the 
technology side is we advance everything from the Electronic 
Medical Record (EMR) to other digital technologies as we do our 
business processes, but also the generation of veterans, 
whether they be World War II, Korea, Vietnam, Desert Shield, 
Desert Storm, Operation Iraqi Freedom (OIF), Operation Enduring 
Freedom (OEF), and going forward. Thank you for all the effort, 
both here on the committee side, but also on your side, to 
understand what is the baton we are actually passing, because 
in some cases it is going to be technology, but we can never 
forget the human side of that.
    Mr. Secretary, I have got a couple of rapid-fire, yes-or-no 
kind of things here, so these would be--okay. When this request 
was released earlier this month, Chairman Takano alleged that, 
despite significant increases in VA funding overall and for 
mental health care, and suicide prevention in particular, this 
budget would, quote, ``direct resources outside VA into grant 
programs and the PREVENTS Task Force instead of being used to 
explicitly support veterans in crisis at VA.'' Is that 
assertion true?
    Secretary Wilkie. I do not agree with it, no, sir.
    Mr. Bergman. Okay. Is it true that most of VA's suicide 
prevention resources and efforts support suicidal or at-risk 
veterans inside the VA health care system?
    Secretary Wilkie. Yes, sir. If I can go beyond the yes or 
no, the reason that is because, something that the chairman has 
identified, 60 percent of those who take their lives we do not 
see. Yes, the majority of the funds are going internally 
because we are not touching those folks out there.
    Mr. Bergman. Right. Then is it true, despite tremendous 
growth in mental health and suicide prevention funding, 
staffing, and programs within VA medical facilities, that 20 
servicemembers and veterans die by suicide every day and that 
14 of those, as you just articulated, had not sought VA care in 
the 2 years prior to their death?
    Secretary Wilkie. That is correct.
    Mr. Bergman. Okay. Is it true, based on VA's experience 
with Choice and now with the MISSION Act, that expanding access 
in the community leads to increased reliance on VA care, not 
reduced utilization or capacity?
    Secretary Wilkie. I agree with you, yes, sir.
    Mr. Bergman. Okay. Now, you have equated the success VA has 
had with respect to reducing the number of veterans who are 
homeless with the success VA hopes to have with respect to 
reducing the number of veterans who die by suicide to increase 
the success through the Improve Act.
    Secretary Wilkie. Yes, sir.
    Mr. Bergman. Could you please respond to those who argue 
that these two crises are, I will call them, mutually 
exclusive? Homelessness and suicide are so different that the 
same approach could not and will not be effective in both 
cases?
    Secretary Wilkie. They are part of the same continuum. The 
solutions for homelessness where we have reduced to 38,000 have 
involved us getting into the community with partners to find 
those people who are homeless, those veterans that we do not 
see and we do not have the resources to go out and touch, that 
is the formula we need for suicide, in my opinion.
    I will give you an example, the State of Alaska, the most 
veterans per capita in any State, more than half have no 
contact with us. I have to go to the Federation of Natives in 
Alaska and ask them right now, without me giving them any 
financial support, to go out and please help us find those 
veterans we do not see in the wilderness.
    Mr. Bergman. Okay, thank you.
    Dr. Stone, just one quick one here. VHA has requested $270 
million for the Office of Rural Health, ORH. ORH is authorized 
to develop and implement innovative and successful programs to 
improve care and services for veterans who reside in rural 
areas of the United States. How is ORH using its ability to 
innovate on behalf of our rural and remote veterans who might 
benefit from next-generation programs, are we utilizing any new 
technologies?
    Dr. Stone. Yes. This office has been one of the most 
creative and innovative offices within VHA as we seek to reach 
the remote and isolated veteran, whether it is helping us in 
partnerships with companies like Walmart or helping us with our 
Phillips partnership where we are placing self-contained units 
that allow us to do remote visits in VSOs around the Nation, 
this office has allowed us to really fund creative and 
innovative ideas and really bring in partnerships like the 
major carriers that have helped us with the contact with 
veterans without costing text lines and cost against the 
veteran.
    Mr. Bergman. Thank you. I see I am over my time. I guess, 
as I listen to you talk and starting with the analogy of the 
baton, I guess each time we pass that baton, if we are doing it 
right, it is going to be a better baton, a more capable baton 
that we pass along to better serve our veterans.
    Thank you, Mr. Chairman, and I yield back.
    The Chairman. Thank you, General Bergman.
    Mr. Brindisi, you are recognized for 5 minutes.
    Mr. Brindisi. Thank you, Chairman and Ranking Member, and 
thank you all on the panel for your service to our Nation's 
veterans.
    First off, I do want to add my voice to those who are 
calling for the VA to add additional diseases for the 
presumptive list for service connection based on Agent Orange 
exposure. Secretary Wilkie, I wanted to ask you a question, 
because last week the Under Secretary for Memorial Affairs, 
Randy Reeves, came to my district at my invitation to discuss 
the creation of a State veterans cemetery in New York. As you 
know, New York is one of the few states left that does not have 
a State veterans cemetery, so I appreciate him coming. The 
district I represent in particular has about 56,000 veterans 
right now who are underserved by a State veterans cemetery or 
access to any veterans cemetery, national or State. We had a 
good meeting and at that time Under Secretary Reeves informed 
us that expansion projects are a top priority for them and then 
National Cemetery Administration (NCA) works through new 
construction grants which meet the statutory requirements.
    I just want to ask, is your budget request enough to meet 
the needs of all top-priority sites, both expansions and new 
constructions?
    Secretary Wilkie. For the top-priority sites that we have, 
and some of those are in New York, some are as far away as Utah 
and Wyoming, yes. I actually had this discussion with Leader 
Schumer about the concept of the cemetery in your district. We 
are going to make sure that the State of New York has every 
access to the grants that we give to help states on that. You 
are right, that many veterans, it is a gaping hole in service.
    Mr. Brindisi. Thank you. I want to put a plug in for Under 
Secretary Reeves, he really has done a great job and I can 
think of no person I would rather see overseeing that program 
rather than him. He was fantastic when he came up to the 
district. So thank you for having him come up.
    I also want to ask, Secretary, about State veteran home 
construction grants. Your proposed budget includes level 
funding for State veteran home construction grants and we have 
one such home in my district in Oxford New York. I understand 
there has been a backlog of State grant requests and Congress 
appropriated additional funds to address this backlog in fiscal 
years 2018 and 2019. Can you tell us what this backlog looks 
like now and how many of these grant requests already have 
State matching funds lined up?
    Secretary Wilkie. I will have to get back with you on 
that--oh, no--Jon?
    Mr. Rychalski. I think in 2018 we received a plus-up that 
pretty much brought the new construction backlog down to about 
70 million. We do have in service a static request now. Most of 
the--so I think the backlog has gone up from about 90 million 
to about right around 300 million, but most of that is for 
renovation, not for new construction. I think we eliminated 
most of the construction with the plus-up, so that is sort of 
where we are today.
    Mr. Brindisi. Okay.
    Dr. Stone. If I could add, sir, we have 154 State veterans 
homes that we are in partnership with. The Association of State 
Directors was in town here this week, we have been talking to 
them and discussing what the future is. We know that over age 
75 there are 2 million veterans today, that will grow in the 
next decade to 3 million. We need the 20,000 beds that are in 
the State homes, we need to expand that. We have in our chronic 
living facilities about 45,000 beds, we need much more than 
that. What you will see from us over the next 6 to 12 months is 
the development of an elder care strategic plan and a cognitive 
decline strategic plan that really begins to garner how to 
approach this.
    This also ties in to the rollout of the caregiver program, 
because most of those veterans would rather stay at home if 
they possibly could and it is why all of this fits together.
    Mr. Brindisi. Are you studying where across the country 
that the needs are right now?
    Dr. Stone. Yes, we are. As part of the AIR Commission, we 
have taken a look at where the demand is. One of the things we 
recognize, in spite of the very significant decline in veterans 
in the Northeast and the Northwest, those that are staying are 
substantially challenged and are engaging with us at remarkable 
rates.
    Mr. Brindisi. Is that something, when you have the 
conclusions of those results, can you share that with us?
    Dr. Stone. They will come here, yes.
    Mr. Brindisi. Okay, all right. Then just finally, Dr. 
Stone, again, thank you for coming up to the district to visit 
the clinic in Bainbridge, New York. I appreciate your concern 
with service to rural veterans. I just want to talk just 
generally about the budget and do you think there is enough in 
there to address the needs of veterans who are living in rural 
areas? What more can we be doing?
    Dr. Stone. I think there is enough in here and we are 
comfortable with the budget. The movement of veterans has got 
to be tackled in the AIR Commission. You and I have had this 
discussion as we wandered around that great town of Bainbridge 
and met its citizen, and I appreciate the time you have spent 
and your passion for this. How we approach the future lay-down 
of this system is going to require a recognition of the 
evolution of how we deliver health care in America. You know, 
we have grown to 2.6 million telephonic or face-to-face video 
visits last year, about 20 percent of our veterans will be 
working off of video visits and they have some of the highest 
satisfaction rates of any of our visits.
    I appreciate the ongoing dialog that you and I are having 
on this. I am not sure we are going to come to complete 
agreement, but we both want the same thing and that is the care 
of the American veteran.
    Secretary Wilkie. I would give one more statistic. In 
Fiscal Year 2019, more than 900,000 veterans had at least one 
episode of telehealth care, I hope that is bigger, that grows. 
I will tell you, my focus has been on rural and Native 
populations, they serve in numbers greater than any other 
communities in the country.
    Mr. Brindisi. Thank you all very much.
    The Chairman. Thank you, Mr. Brindisi.
    Mr. Roy, you are recognized for 5 minutes, but if you need 
to get settled, I can call on someone else.
    Mr. Roy. I will go ahead and defer to someone, if you do 
not mind, one round.
    The Chairman. I will call Mr. Banks.
    Mr. Roy. Thank you, Mr. Chairman.
    Mr. Banks. Thank you, Mr. Chairman.
    Mr. Secretary, I was encouraged to see the President's 
budget proposal for the Office of Information and Technology 
reflect the conversations that we have been having, both on the 
committee and in the VA, about the importance of IT as the 
platform for more responsive, high-quality services for 
veterans. The $540 million increase, which works out to about 
12 percent, is absolutely warranted.
    What will this funding level enable you to do in terms of 
particular IT systems and the veteran-facing programs that they 
support?
    Secretary Wilkie. It will allow us to focus and, in 
addition to the infrastructure readiness program, it actually--
it gives us a map as to where we need to be. It focuses on 
infrastructure, on cloud migration, decommissioning legacy 
systems, which you have heard some of my colleagues talk about. 
I think the most important thing--and Ms. Lee and I have had a 
conversation about this as well--is recruiting the cyber 
workforce. I will admit that VA has been underfunded in IT, so 
the challenge is to catch up in those deficits, and that will 
impact caregiver and Colmery as well.
    Mr. Banks. Let me turn to Electronic Health Record (EHR) 
for a moment. I am interested in your thought process behind 
the new July 2020 date that you have already talked about a 
little bit for the initial go-live in Spokane. How do you plan 
to use these additional 4 months to improve the system, most 
importantly by pulling key capabilities forward into the 
initial capabilities set?
    Dr. Stone. I think you have hit the two key points. There 
is a capability set, sir, that are in the capabilities, set 1, 
that has to be developed and delivered by the vendor, but 
should we use the couple of months extra to take pieces that 
are in capability, set 2, and draw them forward? Most 
importantly, online prescription refill. 11,000 times a month 
the Spokane market veterans refill online prescriptions. We 
were going to lose that capability in capability set 1, set up 
a call center, do it all manually to impact that, but as we 
take these couple of months extra the debate has been is the 
interface well enough developed for our computerized pharmacies 
to draw the capability forward, and that is a recommendation 
that we hope to be able to recommend to the Secretary in what 
we call capability set 1.1.
    Mr. Banks. Okay, that is helpful.
    Mr. Secretary, I do have to say I am struggling a little 
bit with the size of the remained--with the requested EHR 
increase. It is a $1.1 billion increase over this year and a 
$400 million increase over the most recent Fiscal Year 2021 
cost estimate that I have seen.
    Let me say up front, I absolutely support the $90 million 
increase to accelerate the implementation of the scheduling 
system, but I have a hard time seeing how VA could even spend 
an $850 million increase for infrastructure upgrades. I wonder, 
Mr. Secretary, if you could unpack that for me a little bit?
    Dr. Stone. If I may, sir, with permission of the Secretary. 
You see about $685 million in the budget for infrastructure 
development. We are moving from ancient cabling in these old 
buildings to 5E or 6 cabling. This is the majority of the 
improvement in the cabling of the building. Second, the control 
of heating and cooling in our switching stations in old 
buildings is about a 2 and a half billion dollar cost over the 
next 3 years, and that is what you are seeing in much of that 
increase.
    Secretary Wilkie. The greatest challenge, and Dr. Stone 
touched on it, is ancient buildings. I am spending millions and 
millions of dollars building closets right now to house 
equipment, because the facilities, some of which are 100 years 
old or older, cannot accept the kind of infrastructure that we 
need to get these programs online.
    Mr. Banks. Mr. Secretary, with the time that I have left, I 
want to emphasize the importance of accelerating the scheduling 
system, as I noted a moment ago. I was disappointed with the 
original 5-year schedule and the fact that your budget speeds 
it up to 4 years is definitely an improvement. Beyond words on 
a page, this means that VA medical centers in Indiana and Ohio 
are going to have a modernized appointment scheduling system in 
place next year. That is a big win and I very much appreciate 
that leadership.
    With that, Mr. Chairman, I yield back.
    The Chairman. Thank you, Mr. Banks.
    I now recognize Mr. Pappas for 5 minutes.
    Mr. Pappas. Thank you very much, Mr. Chairman. Thank you to 
our panel for your commitment, your unwavering commitment to 
our veterans, I really appreciate it.
    Mr. Secretary, I appreciated your comments about MISSION 
Act and I know in my district we are seeing already the ways in 
which MISSION is improving outcomes for our veterans and 
opening doors of care, quality care for veterans across our 
State. That of course only will continue to work if our 
provider networks are adequate and our networks will only be 
adequate if those providers are paid in a timely fashion. I am 
here to tell you that there is palpable frustration in the 
provider community in my own State. That has ebbed and flowed, 
frankly, over a number of years as we have seen different 
iterations of community care, so this is nothing new, but the 
hospital association in my State estimates $134 million in 
outstanding claims unpaid for community care.
    We had a hearing 2 weeks ago in the Oversight and 
Investigation Subcommittee and Dr. Matthews told us that there 
are more than two million aged claims in the VA system that she 
hopes to address by the end of this fiscal year. That is 
absolutely important, but in addition to that, we know that a 
number of the contractors with VA, these third party 
administrators, also have, you know, to be able to come to the 
table here to help solve this problem.
    I am wondering if we have your commitment to address this, 
to deal with these legacy claims, to make sure that our 
providers are paid in an appropriate and efficient manner, and 
that we can allow MISSION Act to flourish?
    Secretary Wilkie. Absolutely. Without it, MISSION act does 
not work.
    I can tell you that since MISSION came online we have 
adjudicated 11 million claims just from MISSION and disbursed 
about 3 and a half billion dollars, but the legacy and catching 
up with the legacy is absolutely vital or we will start seeing 
a reduction in that 880,000 number when it comes to partners 
that we have.
    Dr. Stone. Sustainment of the delivery system and the 
contracts that we have with providers, we have taken a look at 
a number of rural areas. We have a higher penetration with our 
third party administrators of contracted providers than does 
Medicare in many of the markets, we can only sustain that if we 
pay people on time.
    What Dr. Matthews related to you last week in testimony is 
exactly where we want to be. I can tell you that in this month 
alone we have reduced our backlog by 200,000 and so I am 
pleased at the direction that she is going. It is a promise we 
made to the Secretary to really correct this. It is one of the 
most frustrating areas for all of us, but part of this has to 
do with growth, part of this has to do with just getting rid of 
antiquated processes and moving to what needs to be done, and 
that is pay people in a timely manner.
    Mr. Pappas. There are a number of issues certainly at work 
here, from authorizations to IT systems, and, you know, we can 
really get down in the weeds on this issue.
    One of the things I wanted to find out from you today, if 
you feel that the budget is right-sized for community care and 
that we have adequate staffing within VA to be able to work 
with these providers on this issue.
    Dr. Stone. We do feel that the burn rate of dollars in this 
year's budget, as well as future years' budget, are right; 
however, we have got a lot of new benefits and 3 months from 
now I may be up here giving you a different answer, but right 
now we look to be right on target of our burn rates for 
community care. Yes, we are staffed appropriately and have 
brought in adequate contractor support to support us with the 
processing of claims.
    Mr. Pappas. My subcommittee has also done hearings on 
whistleblowers and the Office of Accountability and 
Whistleblower Protection (OAWP). I know there is a significant 
increase in this budget proposal for OAWP and I am wondering if 
you could talk about your commitment to seeing improvements in 
this office, ensuring that, you know, the voices of these 
whistleblowers will be protected, so that they can help improve 
outcomes for our veterans.
    Secretary Wilkie. We are. There is a 26 and a half million 
dollar increase in the request for OAWP and that also means we 
are bringing in more investigators. They received about 2900 
complaints last year and right now there are 167 investigations 
going on. That is absolutely key.
    The addition to that is, I am not simply relying on OAWP 
for accountability. We have released over 8,000 people, people 
who were not fulfilling their mandate. We approach this from 
different angles as well.
    Mr. Pappas. Great. Well, thank you for your commitment, 
your work, and I yield back, Mr. Chairman.
    The Chairman. Thank you, Mr. Pappas.
    Mr. Roy, you are recognized----
    Mr. Roy. I thank the chairman----
    The Chairman.--for 5 minutes.
    Mr. Roy.--I thank the witnesses for being here today. Thank 
you, Mr. Secretary.
    Yesterday, I had the privilege of going over to 
Administration for Strategic Preparedness and Response (ASPR) 
over at U.S. Department of Health and Human Services (HHS) to 
visit with them about what is going on with the coronavirus and 
it has been raised a couple times in here, but I am correct, 
right, that the VA has a presence over there as well in 
ensuring that we are doing what we need to do----
    Secretary Wilkie. Yes.
    Mr. Roy.--in coordination to deal with the coronavirus?
    Secretary Wilkie. Yes, we do.
    Mr. Roy. They are active part of that discussion and 
debate?
    Secretary Wilkie. We are part of the task force.
    Mr. Roy. That is good. Let me ask you a quick question, 
because I have got limited time. Are you familiar in general 
terms with the overall budget submitted by the President? I 
know, obviously, specific to VA, but in broad terms?
    Secretary Wilkie. In broad terms, yes, sir.
    Mr. Roy. Well, the reason I ask is because there were some 
charges made earlier about what is happening to the other parts 
of the budget and we are here, obviously, to talk about the VA 
budget, we want to make sure it is robust to accomplish the 
objectives. As I often say when I am in the district, I am 
proud to represent Fort Sam Houston, I represent Army Futures 
Command, about 80,000 odd veterans, and outside of Military 
City USA, San Antonio, and, you know, what I am talking about, 
I talk about that we want to make sure that our men and women 
in uniform have a clear mission, the tools to carry it out, and 
the care when they get home. We want to make sure that is done 
here and we are talking about the entirety of the budget.
    Would you agree, at least based on your understanding of 
the budget, that what the President's budget submitted would 
balance in 15 years, within a 15-year window?
    Secretary Wilkie. That is my understanding, yes, sir.
    Mr. Roy. That in doing so it does assume certain growth 
rates, 3 percent growth rates and relatively low interest 
rates? In other words, it is still pretty aggressive. In order 
to balance in 15 years, you have to have a massive economic 
growth in order to achieve that objective. Is that a fair 
statement?
    Secretary Wilkie. Yes, absolutely.
    Mr. Roy. In other words, we have a massive problem to deal 
with right now. We are racking up $110 million of debt an hour, 
we have got over a trillion dollars a year that we are piling 
on, and we have got $23.4 trillion of debt. Do those numbers 
sound roughly correct?
    Secretary Wilkie. Yes.
    Mr. Roy. Are you aware of any budget being yet proposed by 
the House Democrat majority?
    Secretary Wilkie. I have got to be honest, I have not 
followed that, no, sir.
    Mr. Roy. Okay. Well, I will tell you, I have not seen one. 
I was just walking over to Oversight and ran into some of my--
we could not go to a budget hearing this morning, we had 
Director Vought in a couple weeks ago, no one on the Budget 
Committee is talking about a budget being presented by House 
Democrats. I am rather intrigued by all the complaints about 
what is going on. When we talk about cuts in Medicare, I am 
looking at the numbers presented by the President's budget, 
$722 billion for Medicare in 2021, going up to $1.269 trillion 
in 2030, increasing every year in between. Social Security, 
$1.1 trillion 2021, up to $1.9 trillion in 2030, increasing 
every ear. Medicaid, 448 to 607, increasing every year.
    What we have are savings measures being put in place on the 
margins to not impact benefits that are, frankly, in line with 
proposals put forward by the OMB under President Obama. Does 
that sound right to you based on what you understand the 
President has put forward or can you comment?
    Secretary Wilkie. I can not. I did not follow budgets in 
the last Administration.
    Mr. Roy. Okay. Well, that is what my understanding is, 
having served on the Budget Committee and asking these 
questions of Members that have come before the committee, that 
these are the numbers. When I hear the-sky-is-falling rhetoric 
about what we are doing with respect to cuts in other areas, I 
want to be honest, okay, because there are not cuts going on to 
Medicare, Social Security, coming from the budget and the 
President. The budget put forward by the President, frankly, in 
my view, is not aggressive enough in what we need to do for the 
fiscal health of this country. We need to do a better job to 
figure out how to get the balance. Our kids and grandkids 
deserve better than $23.4 trillion of debt and climbing.
    I would put all of that in context to say that we are here 
with a robust budget for the VA, in the context of a budget 
that was proposed by the President that balances in 15 years. I 
would like to hear from my colleagues on the other side of the 
aisle something where we are working together to try to achieve 
that or improve upon it.
    Let me ask----
    Secretary Wilkie. I would----
    Mr. Roy.--something--do you have a comment?
    Secretary Wilkie. No, I would just say that this budget, I 
argue, reflects confidence in the direction that the VA is 
headed. We are in a position that this Department has not been 
in decades. Confidence, the satisfaction of those veterans who 
use us, modernization of all of our programs, so this is a 
validation of the good work that all of our people are doing.
    Mr. Roy. Well, I appreciate that and I have got limited 
time left. Let me ask one last question. With respect to Choice 
and MISSION, I am a big proponent of what we are trying to do 
there in community care, you know, upwards of 33 million now 
served through those programs. It is great, I get a lot of 
positive feedback, but the one problem we get whenever I talk 
to veterans is health records and the clunkiness of sort of 
moving in and out of the system and going to community care. 
What can you say about this budget and specifically--it is a 
pretty big jump in the technology dollars and so forth--what 
can you do to tell us that you are going to solve the problems 
that many of our veterans are facing using health records to 
move in and out of the system to use community care? Thank you.
    Dr. Stone. We are on schedule, sir, and with the chairman's 
forbearance, I would say we are on schedule to roll out the 
health information exchange, which brings 225 vendors and 
systems of health services into an integrated, interoperable 
electronic records system within the next 6 to 8 weeks.
    Secretary Wilkie. Interoperability is the key.
    Mr. Roy. Thank you.
    The Chairman. All right, thank you, Mr. Roy.
    I now recognize Ms. Lee for 5 minutes.
    Ms. Lee. Thank you, Mr. Chair. Thank you all for being here 
and, before I get into my questions, I just want to briefly 
talk about the postponement of the Electronic Health Record 
Modernization (EHRM) project and I think we have all had those 
discussions on how we anticipated that this was happening. I 
think from an oversight point of view you take a serious risk 
in terms of, you know, being okay with postponing. I just hope 
that we continue to have a transparent update, especially as 
the health information exchange goes live, I would like to have 
an update at that point, as well as on June 5th when you have 
your----
    Secretary Wilkie. Yes, ma'am.
    Ms. Lee.--mandate, your assessment date on that.
    Then, finally, just highlighting that giving your 
practitioners the power to come to you and the freedom to be 
able to say we are not ready, also again understanding there is 
a certain balance as well of at some point you just have to 
sort of rip the band-aid off and move with what you have. 
Understanding that ultimately the veteran's care is important, 
making sure we are just in constant conversation about that, 
and understanding what is going on would be greatly 
appreciated.
    I want to talk about the VA infrastructure modernization. 
It is a Department-wide investment, each administration and 
office in the VA has to play the same role in assessing the 
needs and whether some level of contribution is required. For 
instance, in the case of funding infrastructure for EHRM, the 
maintenance and regular refresh of that infrastructure and 
related physical infrastructure investments, Office of 
Electronic Health Record Modernization (OEHRM), Office of 
Information and Technology (OIT), and Veterans Health 
Administration (VHA) have a responsibility. However, there is 
little to no transparency in the budget that was submitted that 
clearly lays out how much of an investment is expected to be 
made and where the money is coming from and, without that 
transparency, there is no way to assess that the $1.2 billion 
OEHRM investment in infrastructure is going to get us where we 
need to be.
    The question is, at least in the case of EHRM, did OEHRM, 
VHA, and OIT sit down and hammer out the infrastructure 
investments, including refreshing that infrastructure during 
the implementation period, and nonrecurring maintenance, and 
come up with a number and a plan?
    Mr. Rychalski. Ma'am, I can answer that. The answer is, 
yes, they did. In fact, we made a transition from the 
infrastructure piece being partially funded by IT and partially 
funded for EHRM, putting it all in EHRM. They have teams doing 
infrastructure assessments and the modeling of the costs are 
based upon those models. We can actually walk the budget 
numbers much more granular to actually the specific sites.
    Ms. Lee. Great. I would just like to see the number and the 
plan.
    Mr. Rychalski. Yes, ma'am.
    Ms. Lee. I want to go on and talk about the budget includes 
the $1.18 billion for infrastructure readiness for EHRM and 
additionally $1.85 billion in nonrecurring maintenance. How 
much of that $1.18 billion infrastructure improvement would be 
needed, is needed outside of EHRM to fully modernize VA's 
infrastructure? Just really put it more simply, if there was 
not the EHRM project, how much of this would be needed to bring 
the VA to an acceptable level of technology?
    Mr. Rychalski. I can answer that as well, and I would say 
all of it and that is infrastructure. I think as the Secretary 
mentioned, to upgrade communication closets and when you see 
some of them, you know, you would be truly shocked. In fact, 
there was one anecdote that after the upgrade, I think it was 
in Spokane, the infrastructure upgrade with the technology, 
they were able to change login times from something like 30 
minutes to like 15 seconds. I mean, it is really--it is that 
significant.
    Ms. Lee. Okay, great. Just one final thing. On the VA's 
Integrated IT and Operations-Electronic Health Record 
Modernization (ITOP-EHRM) alignment, the Department plans a 
full transition to eradicate the cumulative technical debt in 4 
years, which I completely appreciate. Based on this alignment 
plan, a significant number of systems, especially the end 
points upgraded in 2021, would be scheduled for replacement in 
2025. Looking forward, will OIT be absorbing the cost of future 
updates, upgrades, refreshes of technology that was originally 
funded through OEHRM or VHA?
    Mr. Rychalski. We are looking actually at a different model 
where we shift to sustainment of certain things being borne by 
the user, we have a working capital fund. I guess, if we could 
take that as a to be determined (TBD), we are looking at 
various models of how to fund sustainment and then the refresh 
going forward. As it exists today, OIT would, but I am not sure 
that that will be the case going forward.
    Ms. Lee. Okay, great.
    Mr. Rychalski. Thank you.
    Ms. Lee. All right. Thank you very much.
    The Chairman. Thank you, Ms. Lee.
    Mr. Meuser, you are recognized for 5 minutes.
    Mr. Meuser. Thank you, Mr. Chairman. Thank you all very 
much, Secretary, Under Secretaries. Thank you also for your 
significant progress over the last several years. It has really 
been quite remarkable, quite frankly. A few years ago, we were 
talking about all the issues facing the various VA hospitals 
and the administration as a whole, and now we are talking about 
if the funding is in the right arenas so as these improvements 
can continue.
    Just a quick list that I have here of some of the progress 
and successes. Significantly improved veterans' trust in the 
VA, were there surveys done in that regard?
    Secretary Wilkie. Yes, sir, we survey our veterans. We also 
survey our employees and why that is important--and I preach 
customer service, but I start off with customer service 
internally--if you do not have employees who are enthusiastic 
about coming to work, they are not going to give service to 
those they are supposed to serve. We have all employee surveys. 
That is why we have risen from dead last, 17 out of 17, to 
number 6 in terms of best places to work.
    Mr. Meuser. I see that, that is terrific.
    Secretary Wilkie. If the Veterans of Foreign Wars (VFW)--
one other thing, sir, I apologize--the VFW just did its 
national survey of its many millions members, 90 percent 
satisfaction, and also those 90 percent are recommending that 
those veterans who do not use VA come into the system.
    Mr. Meuser. Okay. Again, terrific. Near record low veteran 
unemployment, we do hear that. Any comment on that?
    Secretary Wilkie. Yes. It is one of the best news stories 
in the country that is underappreciated. I have been able to go 
to the largest companies in the country, as well as mom-and-pop 
shops, and preach that veterans are the best value for the 
buck, particularly our young veterans. They can come in and 
look you in the eye and talk to you. They have also probably 
made--those who have stayed in the service to the age of 25 or 
26--they have probably made more life-altering decisions in 
their short lives than most Americans make in a lifetime, and 
that is an incredible benefit to employers at whatever end of 
the industrial spectrum they are.
    Mr. Meuser. Again, outstanding. Expanded access to care in 
VA medical facilities and the community, as well as gave 
veterans more choice and greater control over their health 
care. Certainly, that was the mission of the MISSION Act. Is 
that proving to be as effective as you would have liked?
    Secretary Wilkie. It is, but I have got to talk--I want to 
talk about a balance. It has been effective, we have put 
veterans at the center of their health care. If we can not 
provide what they need, they have the option of going to the 
private sector. Where we have seen the increase in traffic 
outside of VA is for specialty care, unique specialty care, but 
on the other side we have also seen record numbers of 
appointments within the VA. People are voting with their feet, 
they want to come someplace where people understand the culture 
and speak the language. It has created I think a wonderful 
balance in terms of our ability to serve veterans.
    Mr. Meuser. Great. Do you see a hybrid being the model, if 
you will, moving forward?
    Dr. Stone. Absolutely. There are just with the remoteness 
of our population, with the geographic dispersion, there will 
always be VA at the centerpiece of care integration, but the 
utilization when appropriate of commercial health care systems 
to support. You know, today, we will see 315,000 veterans, we 
will buy about 80,000 visits in addition to that, but 60,000 of 
those visits that will occur today are same-day visits inside 
our system.
    In addition, there are 440 veterans that are seeing their 
primary care doctor that will have a warm handshake and handoff 
to mental health on same-day visits. One hundred and ten 
thousand visits last year were done as mental health same-day 
visits.
    Mr. Meuser. I have limited time, so I want to jump to this 
question. Access and transportation has been a concern of mine 
and I think would have great benefits from our suicide problem. 
Access to health care, certainly the hybrid model, gaining 
benefits and services within the community has helped. What are 
we doing as far as assuring that our veterans can get to the VA 
facility?
    Dr. Stone. No. 1, we appreciate the VSOs that are helping 
us with that with volunteer drivers and donated vehicles. We 
are also working with the Walmart Corporation and the VSOs to 
get into communities both with direct face-to-face and remote 
visits. We have been working with Uber and Lyft to help fund in 
addition to our beneficiary travel programs. We are looking for 
any sort of innovative way to help the compromised veteran that 
can not drive on their own to get to us.
    Mr. Meuser. Okay, I will follow up with you.
    Mr. Chairman, I am over my time, I apologize. I yield back.
    The Chairman. Thank you, Mr. Meuser.
    Mr. Cisneros, you are recognized for 5 minutes.
    Mr. Cisneros. Thank you, Mr. Chairman. Thank you, Mr. 
Secretary, and thank you all for being here today.
    Dr. Stone, I just want to follow up on something that my 
colleague Mr. Pappas asked about the community care staff at 
the medical centers. You know, you said they are staffed and 
they are fully staffed, but I just visited Long Beach Medical 
Center, talking to them about this issue, and I know other 
individuals have kind of had some of the same experiences when 
they visit the medical centers, that the community care staff 
is overworked, they have too much work going on. What criteria 
are you using to determine that the community care staff is 
fully staffed?
    Dr. Stone. It is really the staffing model that the 
Assistant Under Secretary has brought to us that we created the 
budget from, but let me say this: I think you can find areas in 
this country that are overworked, I think you can find other 
areas in the country that we are doing pretty well, but we have 
seen substantial growth in specialty care in the community. 
What we are not seeing is that kind of same growth in primary 
care or mental health, as the Secretary has referenced. I would 
be happy to take a look at that market and see if we are off-
kilter and, if we are, we will staff it up. We have adequate 
resources to staff to where we need to be.
    Secretary Wilkie. I would add, and I think Dr. Roe would 
appreciate the comment, your area of the country, the 
chairman's area of the country, is exploding in terms of 
veterans population. Part of the need that you have identified, 
I believe, will be addressed in the AIR reports and the market 
assessments.
    Mr. Cisneros. All right. I want to ask about a couple other 
staffing questions, this one particularly regarding the 
vocational rehabilitation and employment program. I am pleased 
to hear that, you know, you are reaching your goal or you will 
soon reach your goal of one counselor to every 125 veterans 
that are enrolled in this program, but is that ratio based on a 
national number or is it more local? You know, is every 
center--are there are going to be some centers, especially in 
more metropolitan areas, where, you know, they are not going to 
have the 1-to-125 ratio?
    Mr. Lawrence. Sure. You are right, last year at this time 
when you and I bantered we were in the process of hiring 
sufficient counselors to reach that goal and we have. We have 
done both, we made sure at a national level and at a local 
level, we have shifted some things around. Like Dr. Stone 
pointed out, we are always monitoring that, that is required by 
law. We would like to do some more study, because as you and I 
talked in your office, this is one of the most popular programs 
and it yields some of the best benefits for our veterans.
    Mr. Cisneros. Right. The one thing I will--the concern I 
still keep hearing about, though, is the constant turnover of 
the counselors, they are being shuffled around. You know, a 
veteran is there, they work a relationship, they build a 
relationship with the counselor and then, boom, that counselor 
is moved and they do not even know, and then they are having to 
start all over again, you know, giving them their new 
information. I mean, why are we still kind of seeing this kind 
of turnover where people are constantly changing around and 
moving?
    Mr. Lawrence. Sure. Since you and I talked about this, we 
have done several things. I think your feedback was one around 
the consistencies of the outcomes and all of the counselors. 
There is sort of several things happened, one is sort of the 
kind of things you are hinting at, which is it should not have 
happened that way, the other is, of course, a very hot job 
market, as the Secretary--people leave us, we have to balance. 
Then we also do, in connection with your first question, we re-
balance the load to get people more attention. We try not to do 
as much of that as perhaps you are seeing.
    Mr. Cisneros. Okay. In the budget, Secretary Wilkie, it 
indicates that the Veterans Benefit Administration is going to 
relocate 166 full-time employees to the Vocational 
Rehabilitation and Employment (VR&E) program. All these full-
time employees focus on--well, are the employees focused on 
administrative help or are some of these going to be 
counselors?
    Mr. Lawrence. A little bit of both. We are trying to 
centralize some of the administrative tasks, so that we can 
actually free up more counselor time and, in addition, hire 
some more counselors.
    Mr. Cisneros. One other request I have, and if we can work 
this out, you know, I have several colleges in my district, a 
lot of them veterans are going, attending these schools. One, 
Mount San Antonio College, has an Memorandum of Understanding 
(MOU) for the VetSuccess on Campus (VSOC) program. It would be 
great if we could build in these memorandums of understanding 
for these other colleges as well. It is a great service at 
Mount San Antonio College, but the other ones, you know, being 
based in Orange County, have to go to the L.A. VA in order to 
get that support and they can not get it on the local level.
    On what grounds or what are we doing to kind of try and 
change this to make more local MOUs, so the veterans can get 
local service?
    Mr. Lawrence. The VSOC is one of our most popular programs, 
every school is asking for it. We are looking internally, we 
started this a little while ago, at a project to figure out 
where to find the resources to get counselors on as many 
campuses as we can. I am happy to come talk to you about that.
    Mr. Cisneros. All right, I appreciate that. Thank you very 
much and I yield back.
    The Chairman. Thank you, Mr. Cisneros.
    Mr. Steube, you are recognized for 5 minutes.
    Mr. Steube. Thank you, Mr. Chairman. I want to thank each 
and every one of you for your service to our Nation and what 
you do for our veterans.
    Just as a quick bit of background. I served 4 and a half 
years active duty, Operation Iraqi Freedom, 25th ID, I did a 
tour over there. I am a disabled veteran, I am 70 percent 
disabled, it took me 11 years to go through the appeals process 
to get that designation. I have obviously been on this 
committee for over a year now and have reached out many times, 
Mr. Secretary, to your office, still have not been able to get 
on your calendar, so my--well, let me say something first and 
then I will ask a direct question.
    I have town halls in my district and I have a very large 
population, I represent Southwest Florida, of veterans in my 
district. We live--most of my district is in a very rural area, 
so the nearest hospital is like a 4-hour drive, 3-and-a-half-
hour drive. Every town hall I have, both telephonic town halls 
and in-person town halls, by far, unequivocally, veterans' 
issues are the biggest challenge in my district. I just had a 
town hall in-person in Sebring, I would say 65 percent of the 
issues brought up were challenges that these individuals were 
facing with the VA, not good challenges that they were facing, 
not positive things. We had a tele-town hall not too long ago 
and one of the individuals in the tele-town hall said that it 
took him over a year through the Charlotte clinic to get 
hearing aids. This is somebody service-connected disabled.
    There are a lot of issues that are affecting my district. 
My constituents voted me up here to represent them on these 
issues and I would like to know who I need to contact to get on 
your calendar to talk about all these issues----
    Secretary Wilkie. Well, I----
    Mr. Steube.--because, quite frankly, 3 and a half minutes 
is nowhere near what I need to go through the litany of things, 
from the claims process that I have gone through personally, 
the appeals process that I have gone through personally, the 
health care issues that are directly faced in my district. We 
were supposed to have Sitterly come down, he canceled. We were 
supposed to meet with you in September, that got canceled. He 
was supposed to come to the district, that got canceled. It has 
been over a year. I am trying to serve my district and there 
are real, real challenges in the VA. We are blessed to have 
districts like the district in Ranking Member Roe's district 
where he has got a great hospital, great facility, and the 
treat for VA is great. I am on the opposite end of that 
spectrum where we do not even have a hospital in my district 
and we have a few scattered clinics, and those clinics can not 
handle anything.
    They bring in some things, the implementation of the 
MISSION Act in some areas of the country has been tremendous, 
in my district it has not, and there have been a huge amount of 
challenges.
    I just want to know who I can contact in your office to sit 
down with you and go over these issues.
    Secretary Wilkie. I am happy to do it. I wish I could 
answer as to why the schedules did not meet up, but as 
evidenced by some of your colleagues, I have been in a lot of 
their districts, I am happy to go. My family is in Tampa, so I 
am close by. But, no, just have your scheduler call my office 
and we will get together.
    Mr. Steube. Okay. Well, we have done that several times, so 
that is why I am asking now again.
    I will ask one very basic question that has come up and it 
is related to third party insurers. You know, all of us are 
interested in prompt payment by the VA of bills submitted by 
outside providers for community care, do you believe that the 
VA also should be interested in collecting every possible 
dollar that is due to the taxpayers for services that are 
provided in VA facilities and covered by third party insurers?
    Secretary Wilkie. Oh, absolutely. Yes, sir.
    Mr. Steube. Do you believe that the VA should be utilizing 
the same collection procedures that private sector providers 
use today?
    Secretary Wilkie. I do not know what the regulations would 
be, but the first--your first question is right on target, we 
should be. I do not know what the procedure would be----
    Mr. Steube. Well, the numbers that I have seen, I mean, the 
graph is kind of skewed. Like the numbers of things that we 
should be collecting and that are not getting collected by 
third party insurers I think would really help solve some of 
our budgetary issues----
    Secretary Wilkie. I agree.
    Mr. Steube.--that we face. I just want to make sure and if 
there is legislation that we need to do on this side of the 
chamber to make sure that that happens, I am happy to work on 
that.
    Mr. Rychalski. I can speak to a little of that. I think one 
of the big challenges they have is people self-disclosing that 
they have other health insurance. I think some people feel 
like, if I disclose it, my premiums are going to go up or 
something like that, the same thing we have experienced in the 
military health system. I, as the Secretary and I have some 
experience with this, agree that we should absolutely pursue 
that, it is just a matter of how aggressively we go after it. 
And I do not know that we should--we play all the commercial 
tactics. I mean, I think that we are dealing with the veteran 
population as well, so I think we have to look through that 
lens as well.
    Mr. Steube. Okay. Thank you guys for being here today. I 
will follow up with your office.
    I would yield any remaining time to the ranking member, if 
he has any questions; if not, I yield back to the chair.
    The Chairman. Thank you, Mr. Steube.
    Mr. Sablan, you are recognized for 5 minutes.
    Mr. Sablan. Thank you very much, Mr. Chairman.
    Mr. Secretary, welcome.
    Secretary Wilkie. Good to see you, sir.
    Mr. Sablan. I apologize that I was not exactly friendly 
when you first walked in and I have my reasons for that, Mr. 
Secretary.
    One of the goals of the community health care listed in the 
documents was to award and implement the new community care 
network contract in Region 5 and implement a new direction in 
Region 6. Region 6, of course, covers the Northern Marianas, 
American Samoa, and Guam, one of the highest enlistment per 
capita in the Nation.
    The Department's decision to run the community provider 
program for the Pacific Territories is described as a new 
direction. Mr. Secretary, when we met over lunch, you promised 
me that you were going to do everything you can to help me. 
This decision has in fact, Mr. Secretary, is a return to the 
old system, the ones which slipped through the chains and the 
need for Choice Program. How does the Department intend to 
ensure the problems from the old system do not come up again in 
this new direction for Region 6 veterans, for my veterans, for 
those in American Samoa, for those on Guam?
    Dr. Stone. Sir, what we found was that in Region 6 there 
was such a low number of providers trying to get a third party 
administrator to really administer that was ineffective and we 
felt that we could serve the veteran population better by 
directly contracting with the providers that are so 
geographically dispersed across your area.
    Mr. Sablan. Thank you. You are saying that we are going 
to--but I am correct, we are going back to the old system where 
veterans deal directly with VA?
    Dr. Stone. I am saying that----
    Mr. Sablan. In my district, sir----
    Dr. Stone.--the providers will deal directly with us----
    Mr. Sablan. Sir----
    Dr. Stone.--in our delivery system.
    Mr. Sablan. Okay. In my district, sir, we hired--or VA 
hired a social worker, it took VA longer to get that social 
worker to report to work on its first day than it took for that 
social worker to retire from his position, you know what I am 
saying? It took your department longer to get that guy to come 
to work on his first day than when that guy had left because he 
is retiring.
    Now, that is the kind of service, sir, we are going to--you 
know, we take these young men and women, put them in uniform, 
send them off to war, and give them a promise that we will 
forever take care of them for their service. I talked to a 
veteran just last Thursday who is now home, there is nothing 
else that they can do for him, I talked to him, he has cancer, 
and he goes in and out of the hospital, he goes in and out to 
get his painkiller medication that are so powerful that they 
can not give it to him at home because it could be dangerous.
    I have many questions. So not--the reason given is not 
enough interest to proceed, what exactly is meant by not enough 
interest to proceed?
    Dr. Stone. The size of this market is so small as far as 
the number of veterans that are in it that the third party 
administrators, we felt we could administer better directly. 
Now, I am respectful of the fact that you know this market 
better than we do and, if you think that is a bad decision, we 
would be happy to sit with you and talk through it. But our 
goal is the same and that is to serve the veterans in this 
area. Both the Secretary and I are veterans, both of us have 
had deployments, we understand the pain of this, but we felt 
that we could deliver care more effectively by directly 
contracting with your providers than going through a third 
party.
    Secretary Wilkie. I made a commitment to you, and I 
expressed this to the chairman, that my focus on the continent 
was Native populations, Native veterans, and then the Pacific. 
I visited Marianas, as you know, you were a gracious host. I 
promised you and I promised the chairman, I have to be more 
creative. I have to be more creative in getting our partners in 
the Department of Defense out to the Marianas and expand also, 
and I spoke to the Governor of Guam about this a week and a 
half ago, expand our VA presence in Guam as the naval hospital 
expands.
    We are being--trying to be very creative.
    Mr. Sablan. Yes. I am so envious, you know. The gentleman 
here is complaining that he does not have a hospital, but he 
has got several Community Based Outpatient Clinics (CBOCs). I 
do not have a CBOC. I do not have a vet center. You guys were 
talking about programs, care givers--those are not available in 
my district because VA will not put staff in my district to 
take care of veterans who are getting old, who need hospice 
care or who need people to come visit them at their homes. I 
have got nothing except for a fee based doctor who is available 
twice a week to see 400 veterans or almost 500. We have to 
figure something out better than what we are giving these 
veterans.
    Sir, when they put on a uniform, they are as much American 
as you are. Yet, when they get wounded and they go to the 
islands, they are only half an American. It is enough that they 
do not vote for their commander-in-chief, sir, give them some 
decency.
    Secretary Wilkie. Well, I have been very clear that the 
veterans of the Northern Marianas, Guam, and American Samoa 
serve in numbers in the Armed Forces greater than any other 
communities in the country, with the exception of native 
communities in the continental United States. I have made a 
commitment to do as much as I can.
    Last thing about my last visit to the Northern Marianas, I 
looked at and talked with the hospital provider in your 
district on your island to enhance our partnership there. I 
have had long discussions with United States Indo-Pacific 
Command (INDOPACOM), the command out of Hawaii, to bring folks 
in, their people, their ships to help with caring for veterans 
on your island, and also as I said, expanding the closest large 
veterans facility to you on Guam to service veterans on both 
islands.
    It is something I have worked on. I showed my commitment by 
coming to see you, also going to Samoa and also going to Guam. 
I hope to be out there again, but it is something that we are 
working hard on. I wish I could make it go faster.
    The Chairman. Mr. Sablan, we are----
    Mr. Sablan. My time is up, Mr. Chairman. Thank you very 
much, Mr. Secretary.
    The Chairman. Mr. Secretary, I hope that--I do grant your 
sincerity and I know you have traveled there, and so has the 
committee, and I share Mr. Sablan's frustrations, and I know 
you are frustrated. I encourage you to engage with us on a 
solution.
    Secretary Wilkie. I agree with you, sir. Yes.
    The Chairman. Thank you. Mr. Barr, you are recognized for 5 
minutes.
    Mr. Barr. Thank you, Mr. Chairman. Thank you, Secretary 
Wilkie, Dr. Stone, and our other witnesses for your service to 
our veterans. Obviously with Mr. Sablan's line of questions and 
Mr. Steube's line of questions, there is work to do. There are 
problems. I do want to just note for the record, my 
appreciation and my colleagues' appreciation for the 
president's budget request, $243 billion, a 10.2 percent 
increase above the 2020 enacted levels. I will note that the 
testimony that you provided again that the VA's budget has 
increased more than $60 billion or 33 percent since 2017 under 
this administration's leadership. The fact that the 2021 
request would support 404,835 full-time equivalent employees at 
the VA, an increase of nearly 15,000 above 2020, and then more 
than 33 percent of those employees are veterans, I think that 
is an indication of the commitment that the Trump 
administration has to the VA, and I think it also dispels the 
myth that this administration is interested in privatization.
    I think that those basic facts run totally contrary to this 
narrative that somehow this administration is moving toward 
privatization. Clearly not when you have that much of a 
significant increase in funding and employment at the 
Department. I appreciate this administration's promises made 
and promises kept approach to our veterans.
    As my colleagues have noted, there are challenges that 
remain. As we all know, the opioid epidemic is an issue that 
has touched every community in the United States, and 
especially in my home State of Kentucky. According to the CDC, 
Kentucky is among the top ten states with the highest opioid 
prescribing rates.
    I was encouraged to read your testimony. The efforts that 
the VA has taken to reduce the reliance on opioid medication 
for pain management, you note that alternative therapies like 
whole health, that are important to components of the VA's pain 
management strategy. As you know, I have been a strong advocate 
of these alternative therapies, like acupuncture, equine-
assisted therapy, adaptive sports. In the 2021 budget request, 
I will note that unfortunately funding for the VA's whole 
health initiative did not increase, and neither did funding for 
the adaptive sports program.
    My question is why is the funding stagnant if this is, in 
fact, an effective method of getting veterans off of opioids?
    Dr. Stone. Sir, you have recognized accurately that we have 
led the Nation in reduction of opioid use. Our actual opioid 
use disorder patients have actually from 1918 to 1919 actually 
went down. We just had a session in which we took a look at the 
use of whole health in the reduction of opioids in other pain 
medicines and found that if we added whole health techniques, 
tai chi, various cognitive efforts, yoga. What we found was an 
additional 38 percent reduction in pain medicines.
    Now, what you are seeing in the budget is we really believe 
it is time, instead of having us sitting off to the side, that 
we integrate into our packed team models, our care team models 
the capability to do this work. That is where, although you see 
it is stable in the budget, it is actually a reflection of an 
evolution in how we are approaching whole health techniques.
    Mr. Barr. Well, thanks for your efforts on opioid avoidance 
and I will just note for the record, my interest in the whole 
health, and the adaptive sports, and all of those alternatives. 
The appeals backlog, obviously we appreciate the $24 million 
increase for the Board of Veterans Appeals above the 2020 
enacted budget. We know that you have good intentions to 
address the pending Legacy appeals. I will tell you from my 
case work that despite the Appeals Modernization Act, and it 
has helped. We know that Appeals Modernization has helped. We 
still, though, have a problem with the Legacy appeals in our 
case work. We are seeing 3 year delays.
    Can you tell us what is the biggest factor causing that 
delay and what are we learning, and when are we going to get to 
those Legacy appeals? Because that is impacting my veterans.
    Dr. Lawrence. Sure. The Appeals Modernization Act, as you 
point out, is a great success. Let me sort of talk a little bit 
in the details. Over at the Veterans Benefits Administration, 
we process Legacy appeals, and those are generally resolved, 
but some can go to the Board of Veterans Appeals. The increase 
you describe is for more judges and more support to actually 
process their way through that.
    We are experiencing the last sort of part of the new 
beginning, if you will. You are right. This is a big focus. I 
know the board is thinking about not just in person hearings, 
but tele-hearings, and every kind of way to work that off. I 
believe they said this will be done by 2022, but I will be 
happy to arrange for them to come and talk to you about it. 
They know this is a very important effort.
    Mr. Barr. Thank you. I am over my time and I appreciate 
your service and your work. I yield back.
    The Chairman. Thank you, Mr. Barr. Ms. Underwood, you are 
recognized for 5 minutes.
    Ms. Underwood. Thank you, Mr. Chairman, and thank you, Mr. 
Wilkie, and everybody for joining us today.
    In the last 20 years, the number of women veterans coming 
to the VA for health care has tripled. This includes mental 
health care. In the next 20 years, that number is projected to 
double again. Too many American women are struggling to get 
quality, affordable health care. Gaps in our health care system 
and in our health care workforce are a big contributor to that.
    Finding and retaining staff is a challenge across the 
system at large, and it includes the VA. Secretary Wilkie, VA 
staff shortages for gender specific care are concerned, and one 
that you all outlined in your budget request, will this budget 
get us to a place by the end of the year where the gap between 
supply and demand is closing, not continuing to grow?
    Secretary Wilkie. I do believe it will begin to close. We, 
in this last fiscal year, just trained 7,000 more health care 
providers for women-specific care. We are seeing--we now have 
two health care professionals in each of our centers who deal 
specifically with women's health. That is part of the change.
    I do expect that the percentage of women veterans who are 
coming to VA to grow, we are now thankfully up to 41 percent 
enrolled, 84 percent satisfaction rate of the women veterans 
who use VA. It is a massive cultural shift. Be real quick, when 
I was born, my father was in an army that less than one-half of 
1 percent were women. As the undersecretary of defense under 
General Mattis, I was responsible for a force that was 17 
percent women for VA.
    Ms. Underwood. Right.
    Secretary Wilkie. That means 10 percent of our population.
    Ms. Underwood. Sir, you said 7,000. You were training 7,000 
clinicians, I am assuming----
    Secretary Wilkie. Providers and nurses, yes.
    Ms. Underwood. Okay. They are general practitioners, not to 
be offering gender-specific care; is that correct?
    Dr. Stone. They are providing gender-specific care in many 
residencies. Let me give you an example of that. As part of 
this budget, we will train 450 mental health providers in 
gender-specific care for women veterans.
    Ms. Underwood. Right. I guess what I am trying to delineate 
between is the general practitioner who might take care of 
women versus someone who is there to take care of women for 
their whole Full Time Equivalent (FTE).
    Dr. Stone. As we grow, we will--that is why we are doing 
the mini residencies of repurposing the workforce. There is not 
a gender-specific workforce out there that we can effectively 
hire, and therefore, we are training ourselves to get there, 
and we will rededicate that workforce as we get there.
    Let me give you an example of that. We make the diagnosis 
of breast cancer about 500 times a year in the VA. We have 
about 2,900 active breast cancer patients.
    Ms. Underwood. Right.
    Dr. Stone. Those are disbursed across the system so much 
that I can not have a dedicated full-time breast cancer 
surgeon, and a lot of that work goes out.
    Ms. Underwood. Okay. The VA is required to ensure that all 
women veterans that you have and you serve are assigned to 
women's health primary care provider, but right now only 78 
percent have one. Will the budget close that gap by next year?
    Dr. Stone. Yes.
    Ms. Underwood. Okay. The president has recently submitted a 
supplemental appropriations request to respond to the 
Coronarius. This package does not include any specific funding 
to assist VHA facilities in the event that they need to respond 
to Covid-19 cases. Given the diverse population of patients 
that the VA facilities interact with on a regular basis, it is 
obviously something that we need to ensure that we are planning 
for. Secretary Wilkie, what steps is VHA taking to ensure that 
veterans have the information that they need to keep themselves 
and their families safe?
    Secretary Wilkie. Well, thank you. VA is the foundational 
response force for national emergencies. Every year, we prepare 
and deploy for hurricanes, for earthquakes. We regularly train 
for outbreaks of viruses, medical emergencies. We have been--we 
do not need any extra money now.
    Ms. Underwood. Sir, I am not asking about the money. I am 
asking about what are you doing to share the information with 
the veterans and their families.
    Dr. Stone. We have had--we are subordinate to HHS in 
communication with the American people, and we have not gotten 
in front of that. We have had a series of missives that we have 
sent to our workforce, as well as we have been rehearsing all 
of our response systems. We have not directly communicated to 
the American veterans separate from HHS.
    Ms. Underwood. Okay. Even if it is not going out under a VA 
letterhead, have you sent anything to the veterans in your care 
about Coronarius?
    Dr. Stone. No.
    Ms. Underwood. No. Okay. Is that something that you all are 
planning to do in the weeks to come?
    Dr. Stone. As we watch this and respond to this, yes.
    Ms. Underwood. Is that something that has been part of your 
plans for pandemic response, that would include direct response 
from the VA, as their provider, to that veteran that they 
serve?
    Dr. Stone. Yes. This is part of a response that goes back 
to ebola----
    Ms. Underwood. Right.
    Dr. Stone.--in the early 1990's. Each of our hospitals has 
a response system that includes communication with veterans.
    Now, let me correct my answer just slightly. We just had a 
discussion with a number of the VSOs yesterday or day before 
regarding this and what we were doing, and what we needed from 
them when we begin directly communicating.
    Secretary Wilkie. To add to that, because we have been 
through these things before, we are looking at our supply 
chain. We are looking at our processes to prepare in the event 
that we are called on.
    Ms. Underwood. Okay. I know my time has expired, Mr. 
Chairman. I would just like to urge you to recognize that we 
are on the precipice of a significant public health crisis in 
our country, meaning the arrival of Coronarius at pandemic 
levels in the United States.
    You all know, as well as I do, that the VA is the primary 
care provider for a lot of individuals. Your providers are the 
trusted health care source that these individuals are 
interacting with. I would urge us to take a proactive public 
health response to manage that risk communication. They are not 
going to get it from anywhere else, and so let us not hide the 
ball here, sir. Thank you. I yield back.
    The Chairman. Thank you, Ms. Underwood. Mr. Steube, you are 
recognized for 5 minutes--Mr. Watkins, I am sorry.
    Mr. Watkins. Yes, Mr. Chair. That is all right. Well, that 
is Okay. Thanks to you all for being here. Like Mr. Steube, I 
am also a disabled veteran and I receive my health care through 
the VA. I have got a bone to pick with you all. I say that 
lovingly.
    I got a surprise bill and I was referred to community care 
outside the VA system in my home of Topeka, Kansas to a 
hospital called Stormont Vail. I know Stormont Vail well 
because my dad has been a doctor at it for 40 years. He has 
also been on the board of directors at Stormont Vail.
    The VA, I know all of those people quite well. I have lived 
in Topeka almost my entire life. I do not know how to solve 
this thing, man. I have called, and sat on hold for 25 minutes 
at a time, and been bounced around to other recordings and 
things like that. I can not seem to solve this surprise bill.
    Imagine that, because I know the VA system well. I know my 
doctors in the VA system well. This is my community. I have 
been a member of the greater Topeka medical community for my 
whole life, since I was six. I was referred to Stormont Vail, 
where my dad is on the board of directors. My dad is an 
endocrinologist, the very type of doctor whom I saw. There is 
this surprise bill. I can not solve it. I am in the U.S. 
Congress. Moreover, I am in the VA Committee, and the 
subcommittee that deals with electronic medical health records.
    I do not say that to make you feel uncomfortable. I said it 
because we are users of these systems. We are not in a bubble. 
Just like Greg said, we are dealing with this personally 
ourselves and it is one fight, and I thank you for continuing 
that fight. We have got a long way to go.
    Mr. Secretary, good to see you again, sir. The president's 
budget request of $90 million more to expedite the 
implementation of the Cerner Scheduling System, I think it is 
great. The medical centers in my district were slated to get 
the new system in 2025.
    We had a hearing about scheduling implementation last year, 
and it is clearly a great system, a much better improvement 
over Vista. With this acceleration, when can Eastern Kansas 
expect to see this modernized scheduling system?
    Secretary Wilkie. The goal is to have scheduling components 
by 2024, all in place.
    Mr. Watkins. All right. The VA has invested a significant 
amount of taxpayer funding to develop a modernized claims 
processing system for the Board of Veterans Appeals, called 
Case Flow. What is VA's timeline to sunset the board's Legacy 
system?
    Dr. Lawrence. We do not have anybody from the Board of 
Veterans Appeals here with us today. We can arrange for a 
follow up to make sure you get the information.
    Mr. Watkins. All right. That is all I got. I yield the 
remainder of my time. Thanks for your efforts.
    The Chairman. Thank you, Mr. Watkins. Well, we are coming 
to the conclusion of panel one testimony.
    Mr. Secretary, I want to thank you for appearing before 
this committee to testify on the budget. Before we leave, I do 
want to reiterate Ms. Underwood's plea that the VA carefully, 
how we prepare for an impending public health crisis, that VA 
does have a fourth mission, which is not just about our 
veterans. It is also about, as you said, being there for 
national emergencies. This, I think, is emerging into a 
national emergency.
    We ought to think--Dr. Stone, you talked about standing up 
testing capacity, and I think we will discuss this more. Before 
you leave, I do want to address another important issue, and 
that is the issue of sexual assault and harassment at our 
various VA facilities.
    We do need to make some cultural changes to improve the 
care of our women veterans to make them feel welcome. In making 
the cultural changes necessary to make the VA an inviting place 
for our increasing number of women veterans will require 
leadership from the top. One in four women in the military 
experience military sexual trauma during their service. At 
least one in four women veterans experience sexual or gender-
based harassment at VA facilities.
    Just because a medical center has a low complaint rate from 
women veterans, it does not mean that sexual harassment is not 
occurring at those facilities. It may mean that women just do 
not feel safe and comfortable coming forward.
    It is counter-intuitive that we may actually in the 
interim, in the short term, actually want to see more 
complaints being lodged at our medical centers. These are some 
of the issues that I hope that we will discuss at a future 
planned hearing--a hearing that I plan to schedule on this 
topic.
    What I want to know from you, Mr. Secretary, is will you 
commit to working with my staff to ensure that you personally 
appear at this hearing?
    Secretary Wilkie. Yes, sir.
    The Chairman. Thank you, sir. I appreciate that. With that, 
first panel is excused and ready to bring forward the second 
panel. Thank you.
    We will take a brief bathroom break, 5 minutes. A recess 
and people may do what they want to do on this recess for 5 
minutes.
    [Recess.]
    The Chairman. If we could take our seats and I would like 
to get panel two started. If panel two could take their seats.
    I would like to call the committee back to order and is 
Melissa here? She stepped out. Okay. Adrian is here. All right.
    I now invite our second panel to the witness table. We have 
seated at the witness table Mr. Adrian Atizado, Deputy National 
Legislative Director of Disabled American Veterans on behalf of 
the Independent Budget, accompanied by Mr. Carlos Fuentes, 
director of the National Legislative Service of the Veterans of 
Foreign Wars, on behalf of the Independent Budget; Mr. Morgan 
Brown, National Legislative Director of the Paralyzed Veterans 
of America, on behalf of the Independent Budget; and I know 
that Melissa stepped out, Melissa Bryant, the National Director 
of the American Legion on behalf the Independent Budget. I 
expect Melissa to take her seat shortly.
    Let us get this going. Mr. Atizado, you are recognized for 
5 minutes.

                  STATEMENT OF ADRIAN ATIZADO

    Mr. Atizado. Chairman Takano, Ranking Member Roe, and 
members of the committee, the co-authors of the Independent 
Budget, that would be Disabled American Veterans (DAV), 
Paralyzed Veterans of America (PVA), and VFW, we are certainly 
pleased to present our Fiscal Year 2021 funding recommendations 
for the Department of Veterans Affairs, including advanced 
appropriations for Fiscal Year 2022.
    I heard a little bit of discussion earlier with the first 
panel about the increasing resources that is going toward the 
Department of Veterans Affairs. I understand to the untrained 
eye, the overall veteran population is decreasing in light of 
the increasing amount of revenue, or I am sorry, resources 
going to VA, but as we all understand, the public may wonder 
why VA's budget, in fact, continues to increase.
    Simply, it is just that less than half of all veterans come 
to VA for their own benefits. For those that do, their numbers 
increase year over year, and the investments made in VA 
represents a continued commitment to care for those veterans, 
as they have honorably served and sacrificed in defense of our 
freedom.
    Our own Fiscal Year 2021 budget estimates affirm that these 
needs continue to grow. The Independent Budget (IB) recognizes 
the work done by Congress to secure stable and predictable 
funding for VA by appropriating in advance $1 billion in 
discretionary dollars. We would like to recognize the 
administration's request for VA, which provides 12, 13 percent 
increase, which is fantastic. Unfortunately, when we review 
this request, we believe it does fall short in meeting true 
needs of America's veterans in light of pending requirements 
that Congress has put on VA and other requirements VA is 
putting on itself to serve our Nation's veterans better.
    For Fiscal Year 2021, the IB recommends $114.8 billion in 
total discretionary budget authority for the VA. This 
recommendation is $4.4 billion more than the administration 
requested, and it is about $17.3 billion more than the current 
Fiscal Year that we are in, 2020.
    Most of this increased funding recommendation goes toward 
veterans' medical care, about $13.6 billion of that. Of this 
increase, about 85 percent, or $11.8 billion would go toward 
in-house VA care. This large increase is driven by our current 
services estimate reflecting the impact of projected 
uncontrollable inflation on the cost to provide services to 
veterans that are currently using the system. The estimate also 
assumes the baseline 3.1 pay raise, which Congress enacted back 
in December 2019, and a projected increase of about 65 new 
enrollee and unique patients.
    We also recommend an additional projected medical funding 
needs for VA of nearly $2.1 billion for a handful of programs, 
including VA's prosthetics and sensory aid services, the women 
veterans' health care, VA's comprehensive care giver support 
program, and to close the gap on VA's reported vacancies for 
outpatient mental health and primary care.
    VA's construction accounts is another major VA account the 
IB recommends additional funding. We recommend a total of $3.9 
billion, which is a $2.1 billion increase over current funding 
levels to address serious construction needs.
    Finally, the IB is recommending an increase of $1.2 billion 
to continue developing and deploying VA's electronic health--
medical record, and separately deploy VA's--a new VA scheduling 
system in advance of the 5-year that has been portrayed. We 
would like to see that scheduling system come out faster than 
is being requested, simply because not only does it provide 
operational efficiencies, it provides a lot of satisfaction and 
less turnover rate for the facilities than the VA staff that 
use that system.
    Chairman Takano, Ranking Member Roe, we recognize the 
administration's budget request contains numerous legislative 
proposals, and the IB would like the opportunity to work with 
you and your staff as the committee considers eat of these 
proposals to ensure veterans' interests are at the forefront.
    For example, the IB opposes four benefits related proposals 
that would reduce benefits or limit veterans' access or their 
survivor's access to their own benefits. Other proposal, 
though, we support, such as the one regarding VA's medical 
foster home program.
    This concludes our oral statement, and on behalf of the 
millions of veterans the IB VSOs represent, we want to thank 
you for this opportunity to testify. My esteemed colleagues 
from PVA and VFW are happy to answer any questions you may 
have.

    [The Prepared Statement Of Adrian Atizado Appears In The 
Appendix]

    The Chairman. Thank you, Mr. Atizado. I now call upon 
Melissa Bryant for 5 minutes.

                  STATEMENT OF MELISSA BRYANT

    Ms. Bryant. Thank you, Chairman Takano, Ranking Member Roe. 
Behalf of our national commander, James W. Bill Oxford, and the 
nearly two million members of the American Legion, we thank you 
for the opportunity to testify on the Department of Veterans 
Affairs Fiscal Year 2021 budget.
    As VA moves forward to serve the veterans of this Nation, 
it is imperative that the secretary have the tools and 
resources necessary to ensure that veterans receive the 
services they are entitled to in a timely, professional, and 
courteous manner, because we have earned it.
    The American Legion calls on this Congress to ensure that 
funding is maintained and is increased as necessary to ensure 
the VA has preserved and enhanced to serve the veterans of the 
21st century and beyond.
    I am going to go off script a little bit to reiterate for 
one comment that has been repeatedly brought up throughout the 
first panel, and that was the Agent Orange presumptives and 
reiterate that the American Legion supports for these Agent 
Orange presumptives to be given to these veterans who are 
waiting, because one of them is my father. That is something 
that I continue to use--or rather, I should say I share with 
the secretary in having a Vietnam veteran era parent, and 
knowing that his exposure to Agent Orange through his injury by 
punji spikes through his legs, is something that we know is 
traced to these ailments. My father being one of those veterans 
impacted by those Agent Orange presumptives, we urge for OMB 
and for others to ensure that those are tended to.
    Beyond that, within our written testimony for the American 
Legion, we also speak to the 17 points that have also been 
talked about throughout today's hearing, to include mental 
health provisions for suicide prevention, for Post Traumatic 
Stress Disorder (PTSD), for Traumatic Brain Injury (TBI), and 
of course, going all the way through to women veterans like 
myself, and ensuring that we have the gender specific care that 
we require, provided to us by the VA through our earned 
benefits.
    I will not belabor into those point in the interest of 
time, but I want to say that the American Legion appreciates 
the leadership of this committee and remains committed to 
ensuring that the VA has the necessary funds, the resources, 
and the staff to carry out its mission of caring for our 
Nation's veterans. We are committed to working with the 
Department of the VA and the committee to ensuring that we are 
provided with the highest level of support of care.
    With that, in the interest of time, I am going to conclude 
my oral statement so we can move into questions and answers. 
Thank you, gentlemen, for your time.

    [The prepared statement of Melissa Bryant appears in the 
Appendix]

    The Chairman. Thank you, Ms. Bryant. I will recognize 
myself for 5 minutes, and I want to quickly get into questions.
    I am sure all of you have seen the $53 million requested by 
the administration for the Prevents Task Force in Fiscal Year 
2021. Just very quickly, yes or no, were VSOs appropriately 
engaged by VA in the Prevents process? Mr. Atizado, I will 
begin with you.
    Mr. Atizado. Mr. Chairman, I can tell you that the last few 
meetings at the White House on the Prevents Task Force, we have 
not been invited, although we have been engaged with Dr. Van 
Dalen (phonetic) on her efforts.
    The Chairman. Okay. Yes. Mr. Fuentes?
    Mr. Fuentes. The VFW executive director, V.J. Wallace, is 
on the Prevents Task Force and we have been involved with the 
Task Force. No direct feedback on the exact monetary amount 
that they are requesting, though.
    The Chairman. Yes.
    Mr. Brown. PVA has been invited and participated in the 
meeting. We have had some opportunity to make some input.
    The Chairman. Ms. Bryant?
    Ms. Bryant. Likewise, the American Legion has been invited 
to the Prevents Task Force meetings. We have provided advice 
and counsel. Nothing further.
    The Chairman. Very quickly. What is your understanding of 
how these funds, these $53 million, will be used and do you 
know if your recommendations will be reflected in the final 
Prevents Task Force report released in March?
    Mr. Atizado. Well, Mr. Chairman, I could not say until we 
actually see what the roadmap is and how that translates down 
to the different--across the agencies and secretary's 
priorities, we could not make any kind of commitment at this 
point, I think.
    The Chairman. Go ahead.
    Mr. Fuentes. Same for the VFW. We will have to evaluate, 
but it looks promising.
    Mr. Brown. Same for PVA.
    Ms. Bryant. Likewise.
    The Chairman. Great. Thank you. The Independent Budget 
notes that institutional cultural change from the top is 
necessary to create a welcoming environment and ensure high 
quality care for women veterans. In your opinion, what actions 
should VA take that it is not currently taking to facilitate 
this cultural change? Why do not we begin with Ms. Bryant.
    Ms. Bryant. To your comments earlier, Mr. Chairman, we 
believe that the VA needs to seriously consider its end 
harassment campaign, and starting with setting that cultural 
competency for women as we enter the facilities in knowing that 
we are welcomed, and knowing that our services is recognized. 
That is something that VA one, needs to continue to enhance, 
appreciate the secretary's comments earlier in that they are 
looking at their bystander policy and how they would continue 
to help those who are perhaps feeling uncomfortable within the 
main spaces of the VA.
    We appreciate that the care that is provided in the women's 
clinics is outstanding, depending on the facilities that you 
attend, such as the DC VA where I attend. However, we also know 
that all facilities are not created the same. Ensuring that we 
are not harassed in other parts of medical facilities, doubling 
down on the end harassment campaign, doubling down on gender 
specific care, not so much general practitioners who provide 
pelvic exams or anything else that would be for a woman, but 
more gynecologists and those who focus on gender-specific care. 
Those are steps that the VA needs to continue to push upon.
    The Chairman. Would anyone else like to respond?
    Mr. Fuentes. I would like to add as well, this committee 
and this body has passed the Debra Sampson Act, which will 
significantly improve care for women veterans. The Senate needs 
to do that. We are hopeful to work with you to secure Senate 
passage.
    I also want to add that women veterans choose the gender of 
their provider. Not all women veterans want to get care from a 
women's clinic, but not all women who want care from a women's 
clinic are able to get that care. Privacy and gender 
competencies of all service lines is also an issue that needs 
to be addressed.
    The Chairman. Great. Thank you. Thank you. I want to move 
on to a question about infrastructure. The Independent Budget 
requests a much higher budget request for infrastructure. 
Quickly, how would you prioritize VA's needs on infrastructure?
    Mr. Fuentes. If I may, VFW believes that--IB believes that 
VA has a pretty large, over $60 billion IT issue, I am sorry, 
infrastructure issue, and they are just chipping away and not 
chipping away as much as they can. There is a $7 billion 
backlog on--corrections, which is related to safety, making 
sure that these facilities are safe for veterans who are using 
them.
    That would be the priority, looking at the safety, but also 
the access caps. VA can hire all 50,000 vacancies or fill them 
today, but they would not have places to put them. That is 
going to be a real big issue.
    The Chairman. All right. My time is up. Dr. Roe, go ahead. 
You are recognized for 5 minutes.
    Mr. Roe. Thank you. Let it be known that I sent in my 
American Legion dues late, but I doubled the amount. How is 
that? I sent in twice as much I was supposed to.
    Ms. Bryant. We appreciate that. You are paid up for second 
life then, sir.
    Mr. Roe. Matter of fact, a little more than double. 
Interestingly, when the discussion a minute ago was on the 
gender issue, it took me back to my time in the military, and I 
served in the second infantry division at Camp Casey, Camp 
Bradley, and then down in 121 Evac in Seoul. Until I was at the 
121 Evac hospital, there was not a single--I do not remember a 
single female in the second infantry division, and I think I 
would have remembered that, which is how the VA has changed.
    It literally was all a male organization. I mean, it was 
set up for men. I never thought about it when I got here 
because my office, as an OBGYN doctor, was all set up for 
women. I just made the assumption that it was all set up. It is 
not. You are absolutely right. I have traveled to I can not 
tell you how many VAs now, and some of them really have 
excellent facilities, gender-specific facilities. They really 
are good.
    The problem of staffing up is a problem, because of our 
shortage of medical providers around the country. I think VA is 
going in the right direction. Certainly when I heard Dr. Stone 
last--a couple of weeks ago we had breakfast with him, that now 
41 percent of eligible female veterans are going to a VA, that 
is a good number, and 48 percent of eligible men are going. 
That is almost a parody now. That is a good thing. I give them 
a shout out for that.
    I hear you loud and clear. I think the VA understands that 
and wants to get moving. Here is--I know we went through hours 
of discussion when we talked about the MISSION Act. All of you 
all sat around a table. We talked and debated back and forth 
about the construction needs. I think one of the things we are 
going to need your help on is that, because the VA is going to 
have to transform the way it is doing business. As you 
mentioned, the $60 billion, if we begin to make those capital 
improvements, it has got to be done right. Whether it is 
through leasing, building, I do not know what it is going to 
be, but when those market assessments come in, and let me tell 
you, this is going to be hard work that nobody gets--you know, 
if I go in and say to the local Kiwanis Club at home, ``I am 
going to talk about the air infrastructure,'' they are going to 
run for the exits.
    We are going to have to do the hard work, and it is going 
to be up to you guys to help us do that hard work, and that is 
going to be, I think, the hardest part of the MISSION Act to 
undo to get the VA right sized. It is not going to be that 
every Congressman says, ``Well, I have got to keep this 
hospital of four people in it open.'' We have got to have 
enough courage, we do, enough courage to say, ``No, that is not 
the way it is set up.''
    I really do, I wish in a way I was going to be here another 
term or two to work through that, because it is not going to be 
easy and fun, but it is incredibly important about how our 
veterans, long after nobody knows who was on this dais serves, 
50 years, 30 years from now. I mean, think about 2050. That is 
only 30 years away. The VA can not look in 2050 like it does 
today, because I can promise you, health care is not going to 
be delivered that way.
    I am asking you right now, and I know you are--all of you 
all at the table were a tremendous help in writing this. The 
question is can we execute it, and do we, up here, the elected 
officials, have enough courage to do what we need to do. I will 
let any of you answer that. It is more of a statement, not a 
question.
    Mr. Atizado. Ranking Member Roe, thank you so much for your 
commentary. We could not agree more. One of the critical 
aspects of the MISSION Act was, in fact, infrastructure review. 
The timing, though, I think is most important. The idea to do 
an infrastructure review after market assessment was done is 
critical, but the idea of a market assessment was to ensure 
that the underlying health care system is stabilized.
    Now, what is happening here is we have a contract vehicle 
that does not quite align with statutory or regulatory 
requirements. You have got a third party administrator that is 
just stepping in, trying to lean real far forward to try and 
meet not only the needs but the gap in policy. We are still 
waiting for the network and the subsequent referral patterns 
for patients for veterans in and out of those networks, as well 
as a change in--responsibility under this new veteran community 
care program.
    We are trying to wait for all of that to stabilize to a 
point where we can get a really better idea as far as what the 
workload, and the demand, and the need is going to be into the 
future. We will want those market assessments is to capture 
that. We do not want to leap too far forward and start 
tinkering with infrastructure, which this committee knows is 
very hard to deal with, decades. Right.
    Mr. Fuentes. If I could--if I may, Dr. Roe, and thank you 
very much for your leadership on that specific part of the 
bill, that Member of Congress will insist that that facility 
stays is because his or her constituents, the veterans who are 
served by that, are not happy with the replacement plan. That 
is really going to be the lynchpin here as to whether this 
works or not. Unfortunately, we are concerned that the veterans 
we have asked have not been asked by VA what they would like to 
see, what type of improvements they would like to see, because 
ultimately, that has to be the center of it. When they went to 
Fayetteville and they said they did a market assessment, we 
asked our folks at Fayetteville, ``Did VA ask you?'' You know, 
``What is going on? They want to reform the infrastructure plan 
here. Did they ask you anything?'' They said, ``No.''
    That is going to be an issue that needs to be addressed and 
we are hopeful that--I know you share that concern, so 
hopefully we can.
    Mr. Roe. Okay. Thank you. I yield back, Mr. Chair.
    The Chairman. Thank you, Dr. Roe. We are now at the close 
of our second panel's testimony and questioning period. Again, 
I would like to thank the witnesses for their appearances and 
their testimony. We have heard your concerns on behalf of 
veterans and look forward to working closely with each of you.
    All members will have 5 legislative days to revise and 
extend their remarks, and to include extraneous material. 
Again, thank you for appearing before us today, and this 
hearing is now adjourned.
    [Whereupon, at 12:54 p.m., the committee was adjourned.]

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                         A  P  P  E  N  D  I  X

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                    Prepared Statements of Witnesses

                              ----------                              


                  Prepared Statement of Robert Wilkie

    Good afternoon, Chairman Takano, 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) 2021 Budget for 
the Department of Veterans Affairs (VA), including the Fiscal Year 2022 
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, Veterans 
Benefits Administration (VBA); and Jon Rychalski, Assistant Secretary 
for Office of Management and Chief Financial Officer.
    I begin by thanking Congress and this Subcommittee for your 
continued strong support and shared commitment to our Nation's 
Veterans. With the funding provided by Congress, VHA provides high 
quality health care services to 9.3 million enrolled Veterans; VBA 
provides educational benefits for over 900,000 beneficiaries and 
guaranteed over 624,000 home loans; and our National Cemetery 
Administration (NCA) will inter an estimated 137,600 Veterans and care 
for over 4 million gravesites in our 156 sacred National Cemeteries. We 
are on the other end of the national security continuum, as we take 
care of those who have already borne the battle, and I continue to 
believe this is one of the noblest missions in government.

                                Progress

    Solid progress on some of the most transformational initiatives in 
VA's history has taken place in the last 18 months, with the result 
being a string of wins that puts Veterans front and center where they 
belong.
    One of our most notable accomplishments is the near-flawless 
implementation of the VA Maintaining Internal Systems and Strengthening 
Integrated Outside Networks (MISSION) Act of 2018 signed into law by 
President Trump in 2018, giving Veterans real choice over their health 
care decisions. Emboldened by predictions of an imminent VA system 
collapse, we effectively rolled out this landmark legislation with no 
disruption to Veteran care. Less than 5 months after the rollout of the 
VA MISSION Act's community care provisions, VA had made more than 2.2 
million referrals to community care. In addition, we implemented a new 
urgent care benefit and more than 90,000 urgent care visits had been 
completed in the same timeframe, and it is only becoming more popular 
with Veterans. In October 2019, eligible Veterans conducted more than 
5,000 urgent care visits each week, thanks to the 6,400 local urgent 
care providers that have contracted to provide this benefit for VA.
    Success with the VA MISSION Act had tremendously positive second 
and third order effects. Because Veterans like what they see, VA is 
delivering more care overall than ever before. In Fiscal Year 2019, VA 
completed more than 59.9 million internal episodes of care - a record 
high and about 1.7 million more than the year before. Even better, 
Veterans' overall trust in VA now sits at 72 percent, as compared to 60 
percent in 2016. Statistics show:

      Eighty-seven percent of Veterans now trust the VA health 
care they receive;

      In a recent Veterans of Foreign Wars survey, nearly three 
quarters of respondents reported improvements at their local VA; and

      More than 90 percent said they would recommend VA care to 
other Veterans.

    We expanded other venues of care for Veterans as well. VA is a 
leader in using telehealth technology to diagnose and treat Veterans 
remotely, by connecting Veterans with health care providers 
electronically, sometimes in their own homes. In Fiscal Year 2019, VA 
exceeded 2.6 million telehealth episodes of care to more than 900,000 
Veterans. To increase access to telehealth services, VA has established 
multiple innovative agreements for `Anywhere to Anywhere' connected 
care programs with Walmart, Philips, T-Mobile, Sprint, and Verizon. 
These partnerships give Veterans who may need help with Internet 
service more options to connect with VA health care providers through 
video telehealth.
    We have also tackled some of our most pressing social issues: 
opioid use disorder (OUD), homelessness, and a regrettable scourge on 
our society: suicide.
    President Trump's 2018 Initiative to Stop Opioids Abuse and Reduce 
Drug Supply and Demand directly contributed to a 19 percent reduction 
in the number of patients receiving opioids nationwide. Overall, since 
the President took office, there has been a 35 percent decline in 
Veterans being dispensed an opioid from a VA pharmacy.
    VA has achieved impressive results in fighting Veteran homelessness 
by working with local governments, companies, and other stakeholders. 
In Fiscal Year 2018, the total number of Veterans experiencing 
homelessness decreased 5.4 percent, and in 2019, that number dropped 
another 2.1 percent. In the last two fiscal years, VA has helped 
124,900 Veterans and their families by housing them or preventing them 
from becoming homeless. Thanks to these partnerships, we've seen 78 
communities and 3 states effectively end Veteran homelessness.
    The success of these partnerships suggests it's a good way to 
reduce Veteran suicide, and so VA adopted a public-health approach to 
suicide prevention, which focuses on equipping communities to help 
Veterans connect with local support and resources. The public-health 
approach is central to VA's first ever National Strategy for Preventing 
Veteran Suicide, which was published in 2018, as well as the 
President's Roadmap to Empower Veterans and End a National Tragedy of 
Suicide (PREVENTS) Executive Order (EO) 13861. PREVENTS aims to bring 
together stakeholders across all levels of government and the private 
sector to address the national suicide epidemic and provide our 
Veterans with the specific mental health and suicide prevention 
services they deserve.
    Our recent successes reveal the magnitude of change occurring at 
VA. But it is only part of the story because we have even more 
fundamental changes to how VA operates on the cusp of deployment. VA is 
on the verge of delivering its new electronic health record (EHR) 
solution at Mann-Grandstaff VA Medical Center (VAMC) in Spokane, WA, 
followed by VA Puget Sound Health Care System (HCS) in Seattle and 
American Lake, WA. Congress has made it clear, and I have always 
maintained, that we not rush to implement a new EHR at the sacrifice of 
the quality patient care we promised and are committed to delivering to 
our Veterans and other beneficiaries. VA identified that the new EHR 
solution requires additional systems configuration to execute planned 
user training at the Mann-Grandstaff VAMC in Spokane, Washington. As 
such, VA is not proceeding with the previously planned March go-live at 
this location. VA is taking every precaution to deliver an effective 
system for our clinicians and users, and we are committed to getting 
this absolutely right for our Veterans. Analysis has begun in earnest 
on the schedule impact of the user training shift, and we hope to have 
a revised and fully vetted schedule to present to key stakeholders in 
the coming weeks; with periodic updates provided as needed. After 
implementation at our initial sites, the new EHR will be delivered to 
over 1,200 VA hospitals and clinics through a phased deployment 
strategy. Concurrent with the deployment of our new EHR modernization 
is the installation of a new medical logistics system, the Department 
of Defense's (DoD) Defense Medical Logistics Standard Support (DMLSS) 
system. We are also deploying our new accounting and acquisition 
system, the integrated Financial and Acquisition Management System, to 
NCA with full implementation across VA following in the coming months 
and years.
    The magnitude of change has been so great, and the pace so quick, 
that VA must carefully assess our resource needs to ensure we can 
adequately sustain what we have accomplished while continuing to make 
investments in key areas that promise the greatest return for our 
dollars. It is against that backdrop that our Fiscal Year 2021 Budget 
was developed, with emphasis on sustaining the ground we have gained.

                    Fiscal Year 2021 Budget Request

    The President's Fiscal Year 2021 Budget requests $243.3 billion for 
VA--$109.5 billion in discretionary funding (including medical care 
collections). The discretionary request is an increase of $12.9 
billion, or 14.1 percent, over the enacted Fiscal Year 2020 
appropriation. It would sustain the progress we have made; provide 
additional resources to improve patient access and timeliness of 
medical care services for the approximately 9 million Veterans enrolled 
for VA health care; and improve benefits delivery for our Veterans and 
their beneficiaries. The President's Fiscal Year 2021 Budget also 
requests $133.8 billion in mandatory funding, $9.1 billion or 7.2 
percent above 2020.
    For the Fiscal Year 2022 AA, the budget requests $98.9 billion in 
discretionary funding including medical care collections for Medical 
Care and $145.3 billion in mandatory advance appropriations for VBA's 
benefits programs: Compensation and Pensions; Readjustment Benefits; 
and Veterans Insurance and Indemnities.
    For Medical Care, VA is requesting $94.5 billion (including $4.5 
billion in medical care collections) in Fiscal Year 2021, a 13 percent 
increase over the 2020 level (including the $615 million transfer from 
the Veterans Choice Fund), and a $2.3 billion increase over the 2021 
AA. The request fully supports sustainment of the provisions included 
in VA MISSION Act, including the streamlining and enhancement of 
community care services, an urgent care benefit, expansion of our 
caregiver support program, and other authorities and programs that will 
improve VA's ability to provide high-quality, timely, Veteran-centric 
care in line with Veterans' preferences and clinical needs.
    This is the largest budget request in VA history, allowing VA to 
sustain our remarkable progress, continue the upward trajectory of 
modernizing our systems, and be a center of innovation, providing 
options to Veterans when it comes to their own care. I urge Congress to 
support and fully fund our Fiscal Year 2021 and Fiscal Year 2022 AA 
budget requests.
    Next, I will highlight progress we have made, as well as planned 
activities, in health care, benefits, business transformation, 
infrastructure, and cemetery operations among others and how the 
resources we are requesting will contribute to our continued success.

                              Health Care

VA Medical Centers

    In January 2019, VHA began an initiative to optimize clinic 
practice management and improve access to care through the Improving 
Capacity, Efficiency, and Productivity initiative. The goal of the 
initiative was to leverage existing resources and increase internal 
capacity to maximize the care we provide inside VA with the enhanced 
eligibility for community care under the VA MISSION Act. The project 
consisted of a 3-phased approach: Phase 1 focused on improving data 
accuracy (of labor mapping, bookable time, Primary Care Management 
Model, stop codes, and person class) through one-on-one support via 
virtual site visits; Phase 2 centered on implementation of tailored 
strong practice solutions (based on process measure data) to help 
medical centers maximize capacity using existing resources; and Phase 3 
encouraged VAMCs to leverage innovative methods of care, such as 
clinical resource hubs, clinical contact centers, e-consults, and 
telehealth services.
    Through this effort, the number of VAMCs that met the VA MISSION 
Act average wait time standard of less than or equal to 20 days jumped 
from 47 percent to 65 percent. To replicate this success, we are 
adopting these same practices at an additional 30 VAMCs.
    Over the last several years, we have also increased provider 
staffing levels significantly. In the last year alone, we increased 
physician staffing levels by 2 percent; Nurse Practitioners by 7 
percent; and Physician Assistants by 3 percent. We also increased 
clinic support staff for providers and delivered an additional 2.8 
million total clinical episodes of care in Fiscal Year 2019. In Fiscal 
Year 2019, physician workload increased by 2 percent with over 72 
million physician encounters. Clinical workload of physicians, measured 
in a common relative value unit scale that considers the time and 
intensity of the service, increased by 4 percent. Provider productivity 
remained relatively constant.

Community Care Network

    We continue our successful deployment of the Community Care Network 
contracts, which use third party administrators (Optum Public Sector 
Solutions in Regions 1, 2, and 3; TriWest Healthcare Alliance in Region 
4; contracts for Regions 5 and 6 are still in progress) to provide a 
credentialed network of providers for community care. Region 1 is fully 
deployed; Regions 2 and 3 are in progress; and Region 4 deployment will 
begin later this year. Our robust network of over 880,000 providers 
across the United States gives us exceptional flexibility in meeting 
Veterans' health care needs no matter where they reside. Realizing that 
we needed to do a better job of paying claims from community providers, 
our contracts require administrators to process and pay claims from the 
community providers based on the more stringent timelines included in 
the VA MISSION Act. The Fiscal Year 2021 Budget requests $18.5 billion 
for Community Care, an increase of 21 percent over the Fiscal Year 2020 
funding level. These resources will allow us to provide real choice to 
our Veterans, and we estimate we will have 33 million visits to 
community care providers in Fiscal Year 2021, an increase of 3.9 
percent over Fiscal Year 2020.

Caregiver Support Program

    As we implement the VA MISSION Act, we are expanding our caregiver 
program to 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 (IT) 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. The 2021 Budget request for 
the Caregivers Support Program (CSP) is $1.2 billion, $650 million of 
which is specifically to implement the program's expansion. In October 
2019, VA successfully launched a replacement IT solution, known as the 
Caregiver Record Management Application (CARMA), to support the 
program. Our efforts in Fiscal Year 2020 are focused on automating 
stipend payments and improving existing functionality. Over the course 
of the next year, we will implement interprofessional Centralized 
Eligibility and Appeals Teams. This is intended to improve consistency 
in Program of Comprehensive Assistance for Family Caregivers (PCAFC) 
eligibility determinations across the enterprise. Led by physicians, 
these teams will assist with evaluating PCAFC eligibility, tier 
changes, revocations, and appeals. To ensure smooth operations 
following PCAFC expansion, VA is working aggressively to recruit, hire 
and train new team members. These interprofessional teams will be 
phased in over the course of the next several months and VA anticipates 
them being fully mission capable in summer 2020.
    Some additional key initiatives include the hiring of a program 
Lead Coordinator at every Veterans Integrated Service Network (VISN) to 
standardize care and services. We also implemented the Annie Text 
system to alleviate caregiver stress and burden through supportive text 
and developed a toolkit for caregivers that educates and provides 
resources for caregivers on how to recognize and respond to suicide 
warning signs. CSP continues to develop, implement, and refine services 
including peer support, caregiver self-care, and dementia care as well 
as modernizing processes, programming, and staffing to better serve our 
Nation's Veterans and their caregivers. As of February 2020, over 350 
new staff have been added to the program with the goal of hiring 
approximately 680 more staff in Fiscal Year 2020. To continue to 
support the expansion for this program under the VA MISSION Act, 
ongoing workload modeling will be assessed, and additional staff may be 
required.

Suicide Prevention and Treatment

    On March 5, 2019, President Trump signed the National Roadmap to 
Empower Veterans and End Suicide (EO 13861), also known as PREVENTS. 
This created 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. The road map is on track to be delivered to the 
White House in the coming weeks. The PREVENTS Office will then work 
with government agencies on the Task Force, private-sector entities, 
and State and local communities to implement the recommendations. The 
Fiscal Year 2019 Suicide Prevention and Treatment budget was fully 
executed as planned, supporting the Veterans Crisis Line as well as 
other critical clinical and community suicide prevention efforts. The 
Fiscal Year 2021 Budget requests $10.2 billion for mental health 
services, a $683 million increase over Fiscal Year 2020. The Budget 
specifically would invest $313 million for suicide prevention 
programming, a $76 million increase over the Fiscal Year 2020 enacted 
level. The request would fund over 19.7 million mental health 
outpatient visits in a mental health setting, an increase of nearly 
272,000 visits over the Fiscal Year 2020 estimate. This builds on VA's 
current efforts. Since June 2017, VHA has hired 6,047 mental health 
providers, which is a net increase of 1,754 providers serving our 
Veterans. Suicide is a national public health issue that affects all 
Americans. Suicide prevention is my top clinical priority and we are 
actively implementing a comprehensive public health approach to reach 
all Veterans--including those who do not receive VA benefits or health 
services.

Opioid Safety & Reduction Efforts and Treatment of Opioid Use Disorder

    The Fiscal Year 2021 Budget includes $504 million, a $79.1 million 
increase over Fiscal Year 2020, to address treatment of OUD and opioid 
safety and reduction efforts, including specific funding related to 
programs supported through the Comprehensive Addiction and Recovery Act 
(CARA) of 2016, Public Law 114-198. Funding for CARA programs is 
included in the Fiscal Year 2021 Budget at the level of $121 million, a 
$64.6 million requested increase over advanced appropriation previously 
approved for Fiscal Year 2021 to specifically address over-reliance on 
opioid analgesics for pain management, improve access to treatment for 
OUD, and to provide safe and effective use of opioid therapy when 
clinically indicated. This CARA budget would provide support for 
deployment of evidence-based practices, toolkits, and research to 
enhance and expand patient-centered, safe, and effective pain care. 
This will be accomplished through several efforts including: developing 
and implementing a national program for Opioid Stewardship that will 
enhance the continued expansion and implementation of the Opioid Safety 
Initiative; providing funding for fully staffing and supporting CARA-
required Pain Management Teams with hiring, toolkits, training and 
expert guidance; and providing increased access to interdisciplinary 
pain management through multiple modalities including but not limited 
to: increased field staffing for pain management teams at facilities; 
greatly expanded access to telehealth for pain management; and 
treatment of OUD so that we can reach all Veterans under our care. 
Another particularly important risk mitigation strategy for opioids, 
and for all controlled substance, is access to State Prescription Drug 
Monitoring Programs (PDMP), which allow for safer prescribing. VA is 
working toward an automated process of PDMP queries that can be 
accessed within EHR by prescribers and their delegates and therefore 
integrates into the clinical workflow. We expect this to be implemented 
in FY 2020. VA is in the process of integrating PDMPs into both the 
legacy health records system and the new EHR. PDMP's solution for the 
legacy system will provide integrated access for clinicians and 
delegates across the available State data bases and the Military Health 
System. VA's new EHR will initially provide integrated access to 
prescribers directly to the Washington State PDMP.
    Multiple initiatives are underway to increase access to life-saving 
medication for OUD. In the past 4 years, the number of Veterans with 
OUD receiving buprenorphine, injectable naltrexone, or opioid treatment 
program administered methadone increased by more than 20 percent. Most 
of these medications are provided in substance use disorder treatment 
clinics, but only about half of Veterans clinically diagnosed with OUD 
receive treatment in these clinics. In order to reach Veterans where 
they are, VA launched the Stepped Care for Opioid Use Disorder Train-
the-Trainer initiative to increase access to OUD medication treatment 
in Primary Care, General Mental Health, and Pain Management Clinics. In 
the first 14 months, 18 pilot teams increased the number of patients 
receiving buprenorphine in these clinics by 141 percent. During FY 
2020, VA plans to provide additional training and support to expand 
access to stepped care for OUD treatment in settings outside of 
substance use disorder specialty care with future plans focused on 
ensuring timely access to life saving medication for the treatment of 
OUD regardless of where the Veteran presents for care.
    VA's Opioid Safety Initiative has greatly reduced reliance on 
opioid medication for pain management, in part by reducing opioid 
prescribing by more than 55 percent over the past 5 years. Seventy-five 
percent of VA's reduction can be attributed to not starting Veterans 
with chronic, non-cancer pain on long-term opioid therapy and instead 
utilizing multimodal strategies that manage Veteran pain more 
effectively long-term. As VA continues its efforts to address opioid 
over-use, options such as non-opioid medications; behavioral therapy; 
restorative therapies (such as physical therapy and occupational 
therapy); interventional pain care; and the Whole Health (WH) system of 
care transformation that includes complementary and integrative health 
(CIH) treatments (such as massage therapy, yoga, meditation, 
acupuncture, Tai Chi, etc.) are important components to VA's Pain 
Management Strategy. Initial results from the analysis of the 18 WH 
Flagship sites as required by CARA have just become available and 
demonstrate a threefold reduction in opioid use among Veterans with 
chronic pain who used WH services (including CIH) compared to those who 
did not in the first 2 years. Monitoring will continue of these 
original 18 sites as well as the 36 additional facilities that were 
added in 2018. As required by CARA, all VHA facilities have established 
or are in the process of implementing interdisciplinary pain management 
teams or pain clinics that support Veterans and our Primary Care Teams 
in delivering the best pain care possible. While these efforts are well 
underway, we must continue to provide access to these safe and 
effective pain care approaches systemwide, wherever the Veteran is 
located.

Women Veterans

    The number of women Veterans enrolling in VA health care is 
increasing, placing new demands on VA's health care system. Women make 
up 16.9 percent of today's Active Duty military forces and 19 percent 
of National Guard and Reserves. More women are choosing VA for their 
health care than ever before, with women accounting for over 30 percent 
of the increase in Veterans served over the past 5 years. The number of 
women Veterans using VHA services has tripled since 2001, growing from 
159,810 to over 500,000 today. To address the growing number of women 
Veterans who are eligible for health care, VA is strategically 
enhancing services and access for women Veterans by investing $50 
million in a hiring initiative in 2021. The Fiscal Year 2021 Budget 
projects $626 million for gender-specific women Veterans' health care, 
a $53 million increase over Fiscal Year 2020. This Budget would also 
continue to support a full-time Women Veterans Program Manager at every 
VA health care system. VHA has also made a commitment to train mental 
health providers to address women Veterans' complex and unique needs, 
including gender-related suicide risks. One of our key initiatives is 
the Women's Mental Health Mini-Residency and national Reproductive 
Mental Health/Psychiatry consultation initiatives. To date, more than 
450 VA providers have attended the mini-residency. Participants 
indicate that the training increased their competency to provide 
gender-sensitive care to women Veterans and positively impacted women's 
mental health services at their local facility. The mini-residency is 
required training for all Women's Mental Health Champions, who serve as 
a local contact for women Veterans' mental health.
    Additionally, VA launched a National Women's Reproductive Mental 
Health Consultation Program in Fiscal Year 2020. With this new 
resource, expert consultation is now available to all VA clinicians on 
topics such as treating premenstrual, perinatal, and perimenopausal 
mood disorders, and treating women's mental health conditions that can 
be affected by gynecologic conditions. Without this program, key mental 
health care needs of women might not be detected or treated. User 
feedback has been overwhelmingly positive. Consultations have focused 
on highly complex patient presentations and prescribing considerations 
and reaffirm the critical need for this national resource.
    This Budget would continue to support Women's Mental Health 
training and consultation programs. It would also support 0.10 Full-
Time Equivalent (FTE) protected time for a Women's Mental Health 
Champion at every VHA health care system to facilitate consultations 
and develop resources that increase the visibility and accessibility of 
gender-sensitive women's mental health care and contribute to a 
welcoming care environment.

Treatment of Military Sexual Trauma

    When asked by their VA health care provider, about 1 in 3 women and 
1 in 100 men report that they experienced sexual assault or sexual 
harassment during their military service. These experiences, which VA 
refers to as military sexual trauma (MST), can have a significant 
impact on Veterans' mental health, physical health, general well-being, 
and are also associated with an increased risk for suicide. VA's 
services for MST can be critical resources to help Veterans in their 
recovery journey. Since VHA began systematic MST-related monitoring in 
Fiscal Year 2007, there has been a 344 percent increase in the number 
of female Veterans receiving MST-related outpatient care and a 256 
percent increase in the number of male Veterans receiving MST-related 
outpatient care. In Fiscal Year 2019, more than 2,014,671 MST-related 
outpatient visits were provided--an 11 percent increase from Fiscal 
Year 2018. The cost of providing MST-related care is incorporated into 
broader health care costs for each VA health care system (HCS) and, as 
such, VHA's requested increases for health care services funding more 
broadly will directly benefit MST survivors. These funds are needed to 
maintain the full continuum of outpatient, inpatient, and residential 
mental health services as well as medical care services that are 
crucial to assisting MST survivors in their recovery. Funding also 
supports VHA's universal screening program in which every Veteran seen 
for health care is asked about experiences of MST, so that he or she 
can be connected with MST-related services as appropriate. 
Additionally, funding supports the MST Coordinator program, in which 
every VA health care system has a designated MST Coordinator who can 
help Veterans access MST-related services and programs.

Precision Oncology

    The Fiscal Year 2021 Budget includes $75 million to support VHA's 
precision oncology initiative, which aims to improve the lives of 
Veterans with cancer by ensuring that no matter where they live, they 
have access to cutting-edge cancer therapy using Precision Medicine, 
telehealth, and a learning HCS that integrates research with clinical 
care. Precision oncology is an evolution from one-size-fits-all cancer 
care. We are learning that we can increase treatment success and 
decrease side-effects by picking the treatment based upon 
characteristics of the patient and of the cancer. It primarily focuses 
on mutations in the patient's and cancer's DNA, respectively. The 
requested Fiscal Year 2021 funding for this initiative would support:

      Investment in new national lung cancer network and 
expanded prostate cancer coverage;

      Enhanced ability to track - and conduct performance 
improvement - across a broader range of precision oncology quality 
measures at the national level;

      Scaling access to genetic counseling with the growth of 
genetic testing;

      Expanding access to national tele-oncology;

      Additional clinical trials for prostate and lung cancer; 
and

      Exploration of new opportunities for breast cancer 
research.

Telehealth

    The Fiscal Year 2021 Budget request includes $1.3 billion for care 
provided through telehealth. 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 1.3 million video telehealth visits in Fiscal 
Year 2019, a 26 percent increase in video telehealth visits over the 
prior year. Representing the fastest growing segment of VA telehealth, 
more than 10 percent of the 900,000 Veterans using VA telehealth 
received care through video telehealth in the comfort of their home or 
another non-VA location using VA Video Connect. In Fiscal Year 2021, 
our goal is to have all VA providers offering VA Video Connect services 
to Veterans when clinically appropriate and requested by the Veteran.

Strengthening VA's Internal System of Care

    The Fiscal Year 2021 Budget supports VHA's Plan for Modernization 
including continued progress toward becoming a high reliability 
organization (HRO) and the realignment of VHA Central Office (VHACO) to 
better support our care providers in the field. The HRO model is the 
managerial framework for transformational change. HROs focus on 
continuous improvement and enhancing the customer experience. VHA has 
identified its own path to high reliability to meet Veterans' unique 
needs. Starting in 2019, VHA began instilling HRO principles, tools, 
and techniques at every level of the organization to address root 
causes; advance VA and VHA priorities; and ultimately achieve our 
vision of providing exceptional, coordinated, and connected care for 
Veteran health and well-being. In Fiscal Year 2021, VHA will continue 
to promote HRO principles and move closer to its aim of becoming a 
``zero harm'' organization that is constantly learning and applying 
those lessons toward improving Veteran care. On January 8, 2020, VA 
announced the redesign of VHACO as part of its modernization efforts to 
reflect leading health care industry practices and address clinical 
integration. The new structure now supports joint leadership roles of a 
chief medical officer and expanded chief nursing officer. The new 
structure clarifies office roles and streamlines responsibilities to 
eliminate fragmentation, overlap, and duplication. It also allows VHA 
to be more agile and to respond to changes and make decisions more 
quickly. This positions VHA to better support Veterans Integrated 
Service Networks (VISN) and facilities directly serving Veterans. VHACO 
staff includes the approximately 20,000 staff located throughout the 
country that provide operational support to VAMCs. The proposed change 
in structure will not result in a reduction or termination of staff.

Animal Research

    VA conducts an array of research in areas significant to Veterans' 
health care. VA only conducts research with animals when absolutely 
necessary. There are some research questions that cannot be addressed 
other than by research with animals, and VA refuses to ignore Veterans 
whose health care needs that research. For example, animal research in 
Cleveland involving researchers from VA recently led to the development 
of a device that allows Veterans with spinal cord injuries to cough on 
their own and communicate with a stronger voice, leading to increased 
independence and a significant reduction in respiratory infections and 
deaths. This important advancement would not have been possible using 
computer simulations, test tube techniques, `organ on a chip' 
technology, or smaller animal species. VA has very few animal studies 
active at any one time, but some health care problems like this one can 
only be addressed with animal research, underscoring the importance of 
this kind of research in helping Veterans who have been severely 
injured on the battlefield.

                                Benefits

Blue Water Navy

    One of the most significant changes for our Veterans in 2019, was 
the signing of the Blue Water Navy Vietnam Veterans Act of 2019 in 
June, with an effective date of January 1, 2020. As of February 20, 
2020, VA has received over 36,000 potential Blue Water Navy (BWN) 
claims and has already issued $105 million in retroactive benefit 
payments to more than 3,000 BWN Veterans and survivors. In Fiscal Year 
2021, VA expects to receive 70,000 BWN claims and appeals. VA's Fiscal 
Year 2021 funding request includes $137 million for VBA General 
Operating Expenses (GOE) to support BWN implementation. This Budget 
request includes sustaining 691 FTE for claims processing; call center 
agents; quality reviews; and contracting for the continued scanning of 
deck logs, service records, and paper claims from the National Archives 
and Records Administration. The Budget also supports standard business 
operations, which include support to enable Private Medical Records 
requests, audit reviews of deck log transcription services, and 
strategic communications/outreach to Veterans and key stakeholders.

Forever GI Bill

    The Fiscal Year 2021 Budget for VBA includes an increase of $20.5 
million as a result of provisions in The Harry W. Colmery Veterans 
Educational Assistance Act (the Colmery Act) of 2017. The Department 
remains steadfast in its commitment to ensuring every Post-9/11 GI Bill 
beneficiary is made whole based on the rates established under the 
Colmery Act. We have taken significant steps to ensure there is broad 
awareness and understanding of our actions to date. VA executed a 
comprehensive communications and training campaign to schools, Veteran 
Service Organizations, State approving agencies, students, 
beneficiaries, and other stakeholders to regularly provide updates and 
seek input on VA activities and progress.

Appeals Modernization

    One year after the successful implementation of the Veterans 
Appeals Improvement and Modernization Act (AMA), VA is encouraged by an 
active business transformation that is improving Veterans' appeals 
experience. AMA is transforming VA's complex and lengthy appeals 
process into one that is simple, timely, and fair to Veterans and that 
ultimately gives Veterans choice, control, and clarity in the claims 
and appeals processes. The Fiscal Year 2021 request of $198.0 million 
for the Board of Veterans' Appeals (the Board) is $24 million above the 
Fiscal Year 2020 enacted budget and will sustain approximately 1,161 
FTE. This Budget would prioritize the resolution of legacy appeals at 
the Board while simultaneously adjudicating appeals under AMA. In 
addition to adjudicating appeals and claims under AMA, addressing 
pending legacy appeals will continue to be a priority for VA in Fiscal 
Year 2020 and Fiscal Year 2021. In October, VA finalized an enterprise 
plan to resolve non-remand legacy appeals by the end of calendar year 
2022. I am proud of the work being done at VA to make sure those 
Veterans waiting the longest for a decision get their results.

                        Business Transformation

    Business transformation continues to be central to my focus and is 
essential for the Department 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.

Electronic Health Record Modernization

    In 2018, VA awarded Cerner Government Services, Inc. a 10-year 
contract to acquire the same EHR solution being deployed by DoD, which 
will enable seamless sharing of health information, improve care 
delivery and coordination, and provide clinicians with data and tools 
that support patient safety. With the support of Congress, VA's Office 
of Electronic Health Record Modernization has made significant strides 
toward Go-Live at our initial operating capability sites in the Pacific 
Northwest.
    The 2021 Budget includes $2.6 billion to continue VA's efforts to 
implement a longitudinal health record and to ensure interoperability 
with DoD. This request provides necessary resources for full deployment 
of VA's new EHR solution at the remaining sites in VISN 20 and VISN 22. 
Additionally, it partially funds the concurrent deployment of waves 
comprised of sites in VISNs 7 and 21. VA's new EHR solution will be 
deployed at VAMCs, as well as associated clinics, Vet Centers, mobile 
units, and ancillary facilities.

Information Technology Modernization

    The 2021 Budget of $4.9 billion continues to invest in the Office 
of Information and Technology (OIT) modernization effort, enabling us 
to streamline VA efforts to operate more effectively and decrease our 
spending while increasing the services we provide. 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 $496 million in technology development funding will 
be dedicated to specific modernization efforts to support major 
initiatives such as the VA MISSION Act, the Colmery Act, BWN, LogiCole 
(formerly DMLSS), and the Financial Management Business Transformation 
(FMBT). The Budget also invests $341 million for information security 
to protect Veterans' and employees' information.
    The 2021 OIT Budget includes $250 million for the Infrastructure 
Readiness Program (IRP) to guide the ongoing refresh and replacement of 
the IT Infrastructure resources that sustain all VA IT operations. IRP 
identifies the current State of the IT Infrastructure and provides 
analysis for the strategy to refresh and modernize IT Infrastructure 
assets based on equipment age, expiration of warranty, support 
limitations, lifecycle estimates, business requirements, technology 
roadmap, financial planning and policy changes. The term ``Technical 
Debt'' is normally associated with software development and is 
generally understood to relate to making short term decisions and 
tradeoffs that can cause significant rework to address in the long 
term. For IRP purposes, ``technical debt'' refers to the cost needed to 
bring legacy infrastructure components to a State of full efficacy. 
Technical debt multiplies year over year and reduces available 
resources for allocation to VA business priorities.
    Reducing technical debt will enable VA to more rapidly deliver IT 
solutions for joint VA business priorities that enable the exceptional 
customer experience, care, benefits, and services Veterans have earned. 
A robust, healthy IT infrastructure is necessary to ensure delivery of 
reliable, available, and responsive IT services to all VA staff offices 
and administration customers as well as Veterans.

Financial Management Business Transformation

    VA's financial management system for essential accounting and 
financial activities is more than 30 years old and is growing more 
obsolete by the day. VA established the FMBT program to achieve VA's 
goal of modernizing its financial and acquisition management systems. 
In support of the FMBT program, the 2021 Budget requests a total of 
$221 million for FMBT, including $111.1 million in IT funds and General 
Administration funding of $13.9 million. FMBT will leverage the 
Franchise Fund to bill costs to the Administrations and Staff Offices 
when the Franchise Fund sells non-IT services to these customers. 
Additionally, FMBT is leveraging the Supply Fund for costs associated 
with implementing the acquisition community. FMBT will achieve its 
first scheduled deployment in July 2020 with the implementation of the 
National Cemetery Administration (NCA). This will be followed by the 
implementation of Veterans Benefits Administration (VBA) General 
Operating Expense (GOE) in February 2021.

Supply Chain Modernization and LogiCole

    VA's request includes $111.5 million for transitioning VA's Supply 
Chain Management. VA is embarking 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.
    VA is 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 VA 
to remain fully committed to providing quality health care and applying 
resources where they are most needed.
    Based on the collaboration with DoD, VA will transition to 
LogiCole, formerly DMLSS, on an enterprise-wide basis 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 
decisionmaking and integration required across functions, such as 
acquisition, logistics, and construction. The LogiCole 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.
    VA is piloting LogiCole at James A. Lovell Federal Health Care 
Center and VA initial EHR sites in Spokane and Seattle to analyze VA 
enterprise-wide application. In LogiCole, VA is leveraging a proven 
system that DoD has developed, tested, and implemented.

Infrastructure Improvements and Streamlining

    In Fiscal Year 2021, VA will continue improving its infrastructure 
and provide for expansion of health care, burial, and benefits services 
where needed most. The request includes $1.4 billion in Major 
Construction funding, as well as $400 million in Minor Construction to 
fund VA's highest priority infrastructure projects. These funding 
levels are consistent with our requests in recent years and represent a 
combined 8.5 percent increase for Major Construction and Minor 
Construction funding over the FY 2020 appropriation.

Major and Minor Construction

    This funding supports major medical facility projects including 
providing the final funding required to complete projects in Tacoma, WA 
- American Lake Construction of New Specialty Care Building 201, and 
Long Beach, CA - Mental Health and Community Living Center. The request 
also includes continued funding for ongoing major medical projects at 
Canandaigua, NY - Construction and Renovation; Alameda, CA - Community 
Based Outpatient Clinic & National Cemetery; San Diego, CA - Spinal 
Cord Injury and Seismic Corrections; Livermore, CA - Realignment and 
Closure of the Livermore Campus; and Dallas, TX - Spinal Cord Injury 
Center. The request also includes funding to construct an inpatient 
facility in Tulsa, OK, which will be VA's second project under the 
authorities provided in the Communities Helping Invest through Property 
and Improvements Needed for Veterans Act of 2016, also referred to as 
CHIP IN. The potential project will include both VA's contribution and 
resources from a partner who will construct a health care facility for 
Veterans to be donated to VA upon completion.
    The Fiscal Year 2021 request includes funding for national cemetery 
expansion and improvement projects in San Antonio, TX, and San Diego, 
CA. The Fiscal Year 2021 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 $400 million in minor construction funds 
that will be used to expand health care, burial, and benefits services 
for Veterans. The minor construction request includes funding for 37 
newly identified projects as well as existing partially funded 
projects.

Leasing

    VA is also requesting authorization of 13 major medical leases in 
2021 to ensure access to health care is available in those areas. The 
2021 request includes major medical facility leases that VA previously 
submitted for congressional authorization in Fiscal Year 2019 and 
Fiscal Year 2020. These leases include new leases totaling $88 million 
and 371,051 net usable square feet (NUSF) in Columbia, MO; Hampton, VA; 
Lawrence, IN; and Salt Lake City, UT; and replacement leases totaling 
$187 million and 849,428 NUSF in Atlanta, GA; Baltimore, MD; Baton 
Rouge, LA; Beaufort, SC; Beaumont, TX; Jacksonville, NC; Nashville, TN; 
Plano, TX, and Prince George's County, MD. VA is requesting funding of 
$1.054 billion to support ongoing leases and delivery of additional 
leased facilities during the year. These new and ongoing leases 
represent over 1.2 million square feet of leased space providing state-
of-the-art care for our Nation's Veterans.

Repurposing or Disposing Vacant Facilities

    To maximize resources for Veterans, VA repurposed or disposed of 
189 of the 430 vacant or mostly vacant buildings since June 2017 
resulting in an estimated $4.5 million in annual operations and 
maintenance cost avoidance. Due diligence efforts (environmental/
historic) for the remaining buildings are substantially complete, 
allowing them to proceed through the final disposal or reuse process. 
VA continues to identify additional vacant buildings for disposal or 
reuse in order to continue to maximize resources and save taxpayer 
dollars.

                            Customer Service

    As I have described in past testimony, my prime directive is 
customer service. In order to sustain VA's commitment to customer 
experience I will be requesting in Fiscal Year 2021 a shift from a 
reimbursable authority (RA) funding model to a hybrid RA and budget 
authority (BA) model for our Veterans Experience Office (VEO). The 
Fiscal Year 2021 request is for $11.5 million in direct BA funding. 
This strategic shift in VEO's budget model will highlight your 
commitment and VA's commitment to customer service and the 
institutionalization of customer experience capabilities within the 
Department now and in the future. Veterans, their families, caregivers, 
and survivors deserve nothing less than to know that VA is prioritizing 
their experiences as a core part of the business. The results and 
impact of VEO are showing. Veteran trust in VA has increased by 12 
percent since 2016. In the last year, Veteran satisfaction with the 
redesigned VA.gov Website has increased by 9 percent using Veteran 
feedback to improve the site - proof positive that when the Department 
employs VEO capabilities and practices, it produces better results for 
Veterans, their families, caregivers, and survivors. VEO is also 
driving the personalization aspect of customer experience by leveraging 
business processes and integrated technology solutions for Veterans and 
their families to make their online and telephonic interactions with VA 
easier and on par with industry. From their first interaction with VA, 
customers are ``known'' because of an integrated VA Profile, a data 
management initiative that synchronizes Veteran data across the VA's 
systems, thereby creating a comprehensive Veteran customer profile. An 
accurate customer profile synchronized across multiple systems is 
significant, as more than a half million Veterans update their contact 
information with VA each month; now, they do not have to provide the 
same information each time they contact VA and VA employees can better 
focus their time on serving Veterans' needs. VA Profile has already 
made more than 5.7 million contact information updates.

                    National Cemetery Administration

    The President's Fiscal Year 2021 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 2021 Budget includes $360 million for 
NCA's operations and maintenance account, an increase of $32 million 
(9.8 percent) over the Fiscal Year 2020 level. This request will fund 
the 2,085 FTE employees needed to meet NCA's increasing workload and 
expansion of services, while maintaining our reputation as a world-
class service provider. In 2019, NCA achieved an American Customer 
Satisfaction Index score of 97, the highest result ever achieved for 
any organization in either the public or private sector. This ranking 
is the seventh consecutive time NCA received the top rating among 
participating organizations. The 2021 Budget will allow us to build 
upon this unprecedented record of success.
    In Fiscal Year 2021, NCA will inter an estimated 137,600 Veterans 
and eligible family members and care for over 4 million gravesites at 
156 National Cemeteries, which includes 11 cemeteries being transferred 
from the Department of the Army, and 33 soldiers' lots and monument 
sites. NCA will continue to memorialize Veterans by providing an 
estimated 360,000 headstones/markers and distributing 630,600 
Presidential Memorial Certificates. NCA will also continue efforts to 
modernize Veterans' memorialization through the Veterans Legacy Program 
and Veterans Legacy Memorial (VLM). In 2021, NCA will again partner 
with universities and communities to tell the stories of Veterans 
buried in VA national cemeteries. In addition to these partnerships, 
NCA will continue the roll out of VLM, a public memorial platform that 
shares Veteran-related content with the general public.
    VA is committed to investing in NCA's infrastructure, particularly 
to keep existing National Cemeteries open and to construct new 
cemeteries consistent with existing burial policies. NCA is amid the 
largest expansion of the cemetery system since the Civil War. NCA will 
establish 18 new national cemeteries across the country, including 
rural and urban locations. The 2021 Budget includes operations and 
maintenance funding to continue activation of new cemeteries that are 
open for burials. The Fiscal Year 2021 request also includes $94 
million in major construction funds for two gravesite expansion 
projects (Fort Sam Houston in San Antonio, TX and Miramar, CA) and $86 
million in minor construction funds for gravesite expansion and 
columbaria projects to keep existing national cemeteries open, address 
infrastructure deficiencies and other requirements necessary to support 
national cemetery operations.
    The Budget request 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 total request for the Office of Accountability and 
Whistleblower Protection (OAWP) in Fiscal Year 2021 is $26.5 million, 
which includes funding for 125 FTE employees. This is an additional 
$4.3 million, or 18 percent over the Fiscal Year 2020 appropriation and 
includes funding for an additional 11 FTEs. This funding level will 
enable OAWP to implement the oversight and compliance requirements of 
the VA Accountability and Whistleblower Protection Act of 2017 and 
continue to conduct thorough and timely investigations into 
whistleblower disclosures, allegations of senior leader misconduct and 
poor performance, and whistleblower retaliation. In Fiscal Year 2019, 
OAWP received 2,951 submissions, directly conducted approximately 167 
investigations, and monitored approximately 551 investigations that 
were referred out for investigation to VA Administrations and staff 
offices, as required by law. 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 Fiscal Year 2021 Budget also requests $228 million for the 
Office of the Inspector General (OIG), an $18 million increase over the 
2020 enacted level, for 1,048 FTEs in 2021 to support essential 
oversight of VA's programs and operations through independent audits, 
inspections, reviews, and investigations; and for the timely detection 
and deterrence of fraud, waste, and abuse. Additional resources will be 
used to enhance oversight in program areas that are vital to Veterans 
and taxpayers, particularly implementation of the VA MISSION Act and 
the ongoing EHR modernization effort. To that end, OIG will 
significantly expand oversight of community care, including ongoing 
efforts to detect and deter health care fraud, financial stewardship, 
and procurement.

                               Conclusion

    Thank you for the opportunity to appear before you today to address 
our Fiscal Year 2021 Budget and Fiscal Year 2022 AA Budget request. The 
resources requested in this budget will ensure VA remains on track to 
meet congressional intent to implement the VA 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, adaptive, and delivers on 
our promises to America's Veterans.
                                 ______
                                 

                  Prepared Statement of Adrian Atizado

    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 
Fiscal Year (FY) 2021 funding request for the Department of Veterans 
Affairs (VA), including advance appropriations for Fiscal Year 2022.
    Prior to the Administration's budget request, the IB released its 
comprehensive VA budget recommendations for all discretionary programs 
for Fiscal Year 2021, as well as advance appropriations recommendations 
for medical care accounts for Fiscal Year 2022.\1\ The recommendations 
also include funding to implement the VA MISSION Act of 2018, Public 
Law (P.L.) 115-182, and other reform efforts. The IB urges Congress to 
continue vigorous oversight of VA to ensure an accurate assessment of 
its true needs. Our own Fiscal Year 2021 estimates affirm that these 
needs continue to grow.
---------------------------------------------------------------------------
    \1\ The full IB budget report addressing all aspects of 
discretionary funding for VA can be downloaded at 
www.independentbudget.org.
---------------------------------------------------------------------------
    For Fiscal Year 2021, the IB recommends $114.8 billion in total 
discretionary budget authority for the VA. This recommendation is $4.4 
billion more than the Administration's request and an 18 percent 
increase over Fiscal Year 2020. After reviewing the Administration's 
budget request for VA, which provides a 13 percent increase, we believe 
the request falls short of meeting the needs of America's veterans in 
light of the requirements of the VA MISSON Act, increasing need for 
medical care, claims and appeals processing, information technology 
(IT) modernization and construction needs.
    The Administration's Fiscal Year 2021 request for all VA medical 
care of approximately $95.6 billion is $2.8 billion less than the IB 
estimates is necessary to fully meet the demand by veterans for health 
care during the fiscal year. For Fiscal Year 2021, the IB recommends 
approximately $98.4 billion in total medical care funding and 
approximately $100.6 billion for Fiscal Year 2022. This recommendation 
reflects the necessary adjustments to the baseline for all Medical Care 
program funding of the preceding fiscal year, increases based on new 
and existing workload, and the 3.1 percent Federal pay adjustment, 
among other things. Our recommendation did not assume any funds 
remaining in the Veterans Choice Fund established by section 802 of 
P.L. 113-146, the Veterans Access, Choice, and Accountability Act of 
2014 (VACAA) based on P.L. 116-94, the Further Consolidated 
Appropriations Act, 2020, and subsequent appropriations for the section 
802 account.

    Medical Services.--For Fiscal Year 2021, the IB recommends $64.4 
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 3.1 
percent increase for pay and benefits across the board for all VA 
employees in Fiscal Year 2021.

      Our estimate of growth in patient workload is based on a 
projected increase of approximately 65,000 new unique patients. These 
patients include priority group 1-8 veterans and covered non-veterans, 
which we estimate the cost to be approximately $991 million.

      The IB believes that there are additional projected 
medical program funding needs for VA totaling over $2.1 billion. 
Specifically, an additional $328 million to provide additional 
centralized prosthetics funding (based on actual expenditures and 
projections from the VA's Prosthetics and Sensory Aids Service); $200 
million to expand and improve services for women veterans; $20 million 
to support VA's authority for reproductive services including in vitro 
fertilization (IVF); $779 million to implement eligibility expansion of 
the VA comprehensive caregiver support program; $776 million to close 
the reported vacancies for both outpatient mental health and Patient 
Aligned Care Team (PACT) by 10 percent.

    The Administration's Fiscal Year 2021 budget request for VA Medical 
Services, including collections, of $60.4 billion is approximately $4.0 
billion below the IB recommendation. Although the Administration's 
request reflects an apparent increase of 10 percent over Fiscal Year 
2020 funding levels, 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 the requested increase is not enough. Of great concern to our 
members is the timeline Congress set out in the VA MISSION Act for 
expanding its comprehensive caregiver support program has clearly not 
been met. The delay in certifying the IT solution to support expansion 
of the caregiver program and VA's failure to timely publish a Notice of 
Purpose Rulemaking raises troubling concerns about VA's ability to 
fully implement the caregiver expansion. Severely injured World War II, 
Korean War, and Vietnam War veterans and their family caregivers have 
waited nearly a decade for equal treatment and it is simply 
unacceptable to ask them to wait longer.
    In terms of funding, the Administration's Fiscal Year 2021 request 
included approximately $1.2 billion for VA's comprehensive caregiver 
support program. Because this request represents an overall increase of 
$485 million over Fiscal Year 2020, it is noteworthy that $650 million 
is to implement the eligibility expansion required under the VA MISSION 
Act; thus, we are concerned this request assumes a reduction in the 
number of existing program participants--approximately 20,000 approved 
family caregivers. The IB recommends appropriating $779 million for 
Fiscal Year 2021 for the phase-one expansion scheduled toward the end 
of Fiscal Year 2020, with only a small portion of the expansion cost 
absorbed in Fiscal Year 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. To continue the expansion, the IB recommends 
$1.4 billion for Fiscal Year 2022.

    Medical Community Care.--The IB recommends $18.2 billion for this 
account for Fiscal Year 2021, which includes the growth in current 
services. We note the volatility in obligations within this account 
particularly for contractual services, for which the vast majority of 
obligated funds are spent. In addition, our recommendation does not 
assume any funds remaining in the Veterans Choice Fund established by 
section 802 of the VACAA based on P.L. 116-94. For Fiscal Year 2022, 
the IB recommends $18.7 billion for Medical Community Care.
    The Administration's Fiscal Year 2021 budget authority request for 
Medical Community Care of $20.4 billion is comprised of $3.2 billion 
increase over Fiscal Year 2020 funding, an estimated increase of $247 
million in medical community care collections from $537 million to $784 
million, and $1.1 billion remaining in the Veterans Choice Fund 
account. We have serious doubts whether projected to actual spending 
will converge given the volatility in obligations within this account, 
the transfer of administrative responsibilities for certain regional 
networks and provider coverage, and new responsibilities VA is assuming 
under the new Veterans Community Care Program. Most concerning to the 
IB is VA's proposal to increase non-VA care by nearly 25 percent next 
Fiscal Year compared to just over a 10 percent funding increase for 
care provided at VA medical facilities because the we believe that 
veterans prefer to get care from VA providers than through the Veterans 
Community Care Program.

    Medical and Prosthetic Research.--The Administration's request of 
$787 million is nearly $82 million below the IB recommendation of $860 
million. The request represents a 2 percent cut, at a time when medical 
research inflation is increasing in excess of 2 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.

    Vocational Rehabilitation and Employment (VR&E).--This program was 
authorized to hire an additional 174 FTEs in Fiscal Year 2019 and 
implemented workforce increases and tech modernization. In order to 
ensure the 1 to 125 ratio is maintained nationally and even within each 
VA regional office or region, for Fiscal Year 2021, the IB recommends 
$17.2 million for 156 FTE for VR&E, 87 percent of which are Vocational 
Rehabilitation Counselors (VRCs). As recently reported, VRCs can spend 
60 percent of their time with administrative functions, thus 
necessitating the addition of administrative staff.
    However, in the recent Administration's budget request, it was 
indicated that with guidance in the Fiscal Year 2020 Appropriations 
Act, 2020, VBA will also reallocate 166 FTE to VR&E, a result of 
decreased resources required to process legacy appeals, to support 
anticipated program growth and maintain the 1:125 counselor-to-veteran 
ratio at the station level. To be clear, the 1:125 ratio is based on 
VRCs and not administrative staff. The Administration's proposal would 
not increase the number of VRCs, only administrative staff. While we 
agree that an increase in administrative staff is warranted, the number 
of FTE for VRCs needs to addressed as well.

    Board of Veterans' Appeals (BVA).--For Fiscal Year 2021, the IB 
recommends approximately $218 million for the BVA, an increase of 
approximately $36 million over the estimated Fiscal Year 2020 
appropriations level, which reflects funding for current services with 
increases for inflation and Federal pay raises and an additional 100 
FTE.
    In February 2019, the Veterans Appeals Improvement and 
Modernization Act (AMA), P.L. 115-55, took full effect, making 
significant changes in how veterans appeal VBA claims decisions, both 
within VBA and at the Board of Veterans' Appeals (BVA). There are 
currently 17,000 pending AMA hearings with the Board and 59,000 pending 
legacy hearings, for a total of 66,000 pending hearings. In Fiscal Year 
2019, BVA conducted a record number of 22,743 hearings, a 38 percent 
increase over the prior year. Even at that rate, it will take three 
years to hold all hearings for legacy appeals and yet not address the 
current 17,000 pending AMA appeals with requested hearings, not to 
mention the additional AMA appeals received during those three years.
    The Administration's budget request would not increase staffing at 
the Board. It indicates VA expects to lose 29 FTE, based on attrition, 
in Fiscal Year 2021. However, as the number of backlog hearings has not 
drastically been reduced and many of the legacy hearings have been 
pending for years, we are recommending an increase of 100 FTE for the 
Board to address the 66,000 pending hearings.

    Information Technology (IT).--VA relies extensively on information 
technology to meet day-to-day operational needs. At Congress' 
direction, over a decade ago, VA centralized all IT budget authority, 
management, and development under a chief information officer (CIO). It 
is now one of the few agencies of its size with a CIO that has complete 
IT authority affecting the entire organization. Centralization mandated 
fiscal discipline, security, standardization, and interoperability. Yet 
little oversight, if any, has been conducted of this organization since 
centralization and its performance in supporting VA's statutory 
missions, including benefits and health care delivery, research, and 
education and training of health professions. For Fiscal Year 2021, the 
IBVSOs recommend approximately $4.3 billion for the administration of 
the VA's IT program to meet the need to sustain VistA for an estimated 
7-10 years after initial operating capabilities are attained at initial 
sites for replacing VistA.
    For several years, the VA has indicated the development of IT 
applications remains under VA's three separate administrations--VBA, 
VHA, and the National Cemetery Administration (NCA); however, the 
development funding has been in decline over the last 5 years. In 
nominal dollars since 2014, total development funding has been reduced 
by over 40 percent while the overall funding has increased by 6 
percent. We are pleased VA is requesting an increase of $68 million in 
development activities. The IB similarly recommends $150 million, of 
which $65 million would be provided to VA's Education Services and the 
remaining $85 million to OIT, to develop an IT system capable of 
handling today's difficult tasks, and tomorrow's upcoming changes. In 
addition, we recommend IT development funding of $15 million for Fiscal 
Year 2021 for the BVA's Case Flow, which currently does not have all 
the functionalities needed to replace the legacy Veterans Appeals 
Control and Locator System (VACOLS).
    To support the electronic health record modernization efforts in 
Fiscal Year 2021, the IB recommends $2.48 billion, which includes $180 
million to support accelerated deployment of Cerner Millennium 
Scheduling System. These amounts are also based on VA's deployment 
schedule estimating Fiscal Year 2021 resource needs to complete initial 
operating capability sites and deployment throughout the remainder of 
VISN 20 and 22, and initiating deployment in VISN 21.

    Construction Programs.--The Administration's Fiscal Year 2021 
request for VA's construction programs of $1.9 billion dollars is a 
deeply disappointing retreat in funding to maintain VA's aging 
infrastructure. At the Senate Committee on Veterans' Affairs hearing on 
March 26, 2019, in response to Senator Manchin's question about VA's 
``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 Fiscal Year 2021 budget submission, which states that VA's, 
``Long-Range SCIP plan includes 3,595 capital projects that would be 
necessary to close all currently identified gaps with an estimated 
magnitude cost of between $49-$59 billion not including activation 
costs.'' However, VA's Fiscal Year 2021 budget request for major and 
minor construction combined is just over $1.9 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.
    Some major construction 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 recommends 
$2.7 billion for VA's Fiscal Year 2021 major construction, over $1.4 
billion more than VA's request.
    To ensure VA funding keeps pace with all current and future minor 
construction needs, the IB recommends Congress appropriate an 
additional $760 million in Fiscal Year 2021 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. VA's Fiscal 
Year 2021 request of $400 million is significantly less it has 
requested in previous years, and will only allow the critical 
infrastructure backlog to continue to grow.
    Non-Recurring Maintenance (NRM) had seemed to slip through the 
cracks within the construction space in previous years. VA's Fiscal 
Year 2021 request of $1.8 billion in budget authority for NRM, however, 
is a significant increase from previous years. NRM projects are often 
necessary maintenance that is preventative in nature and saves 
equipment and facilities from reaching failure points. Heavy investment 
in NRM is a wise expenditure because spending money to maintain 
equipment and buildings ensure longevity and costs a fraction of having 
to replace buildings with new construction. The IB is pleased VA has 
requested to invest in this critical concern.
    A congressionally mandated research infrastructure report shows a 
total cost of $99.5 million in Priority 1 deficiencies having an 
immediate need for correction within 1 year, such as correcting life-
safety hazards, returning components to normal service or operation, 
stopping accelerated deterioration, and replacing items that are at or 
beyond their life cycle. The total cost to correct Priority 1-5 
deficiencies is estimated at $207.1 million. Accordingly, the IB 
recommends a minimum of $99.5 million for Fiscal Year 2021 to correct 
all Priority 1 deficiencies.
    Grants for State extended care facilities, commonly known as State 
home construction grants, are a critical element of Federal support for 
State veterans' homes. For Fiscal Year 2021, the IB recommends $250 
million for grants for State extended care facilities to fund 
approximately half of the Federal share of projects on the Fiscal Year 
2020 VA State Home Construction Grants Priority List for Group 1, those 
that have already secured their required State matching funds.

    National Cemetery Administration.--The IB commends the 
Administration for requesting a $31-million-dollar increase in 
appropriations for NCA to account for its obligation to manage 156 
national cemeteries and to meet a continued increase in demand for 
burial space which is not expected to peak until 2022. NCA continues to 
expand and improve the national cemetery system, to include a plan to 
open additional burial sites in 2021. NCA has also inherited 11 Army 
post cemeteries which it must perpetually maintain. VA's request of 
$360 million for NCA operations and maintenance is $24 million more 
than the IB recommendation of $336 million.
    Additionally, NCA has undertaken the task of creating a digital 
memorial page for each veteran interred in a VA national cemetery as 
part of the Veterans Legacy Memorial. This much needed expansion of the 
national cemetery system will help to facilitate the projected increase 
in annual veteran interments and will simultaneously increase the 
overall number of graves being maintained by NCA to more than 4 million 
by 2021. The IB strongly believe that VA national cemeteries must honor 
the service of veterans and fully support NCA's National Shrine 
initiative, which ensures our Nation's veterans have a final resting 
place deserving of their sacrifice to our Nation. The IB also support 
NCA's Veterans Legacy Program (VLP), which helps educate America's 
youth about the history of national cemeteries and the veterans they 
honor. Recently enacted P.L. 116-107, which authorizes NCA to provide 
grants as part of VLP, may enable VA to significantly expand VLP and 
ensure more veterans can have their stories preserved in perpetuity.

    Administration Legislative Proposals.--The IBVSOs strongly oppose 
four benefits related legislative proposals included in the budget that 
would reduce benefits to disabled veterans that were earned through 
their service:

        1. Effective Date Simplification for Claims for Increased 
        Evaluation:

    VA seeks to amend title 38, United States Code, Sec.  5110(b)(3) to 
make the date of receipt of a claim the effective date for an increased 
rating. While VA states this is a simplification of claims for 
increase, this proposed amendment would take away billions of dollars 
from veterans by disallowing entitlement to an increased evaluation 
prior to the date of claim.
    Title 38. United States Code, Sec.  5110(b)(3) states, ``the 
effective date of an award for increased compensation shall be the 
earliest date as of which it is ascertainable that an increase in 
disability has occurred, if application is received within one year 
from such date.''
    For example, if medical evidence establishes entitlement to an 
increase rating eight months prior to the date the claim for VA 
benefits was submitted, the effective date for benefits granted will be 
that date eight months prior. By eliminating this statutory provision, 
VA would virtually discredit any medical evidence prior to the date of 
claim on claims for increase and negatively impact effective dates for 
individual unemployability. Not only would this bear directly on 
retroactive compensation, this proposal would also confound certain 
protections and other ancillary benefits based on effective dates.
    The Administration's proposal would reduce anticipated disability 
compensation to veterans by $678 million in 2021, $3.5 billion over 5 
years, and $7.5 billion over 10 years. We strongly oppose this attempt 
to ``simplify'' effective dates for claims for increase particularly 
when the result will be billions of dollars in lost disability 
compensation for those who were injured or made ill in service.

        2. Limit Disability Evaluations to Criteria within the VA 
        Schedule for Disabilities (VASRD):

    VA seeks to amend title 38, United States Code, Sec.  1155 so that 
disability evaluations can only be established based on criteria within 
the VASRD and effectively eliminate extra-schedular consideration.
    Extra-schedular cases are not defined by statute but in 38, Code of 
Federal Regulations, Sec.  3.321(b)(1). It notes that to accord justice 
to the exceptional case where the schedular evaluation is inadequate to 
rate a single service-connected disability, an extra-schedular 
evaluation commensurate with the average impairment of earning capacity 
due exclusively to the disability is to be considered. The governing 
norm in these exceptional cases is a finding that application of the 
regular schedular standards is impractical because the disability is so 
exceptional or unusual due to such related factors as marked 
interference with employment or frequent periods of hospitalization.
    The United States Court of Appeals for Veterans Claims (Court) has 
set out a three-part test, based on 38, Code of Federal Regulations, 
3.321(b)(1) for determining whether a claimant is entitled to an extra-
schedular rating: (1) the established schedular criteria must be 
inadequate to describe the severity and symptoms of the claimant's 
disability; (2) the case must present other indicia of an exceptional 
or unusual disability picture, such as marked interference with 
employment or frequent periods of hospitalization; and (3) the award of 
an extra-schedular disability rating must be in the interest of 
justice. Thun v. Peake, 22 Vet. App. 111 (2008), affd, Thun v. 
Shinseki, 572 F.3d 1366 (Fed. Cir. 2009).
    The VASRD does not contemplate every disease or disability, nor 
does it provide an evaluation for every set of symptoms and 
complications caused by each disability. This proposal would eliminate 
any veteran attempting to be afforded justice for the severity and 
symptoms of an unusual disability picture that provides marked 
interference with employment or frequent hospitalizations. This is an 
attempt to avoid the precedence as established by the Court.
    The Administration's proposal would reduce anticipated disability 
compensation to veterans by $74.7 million in 2021, $1.1 billion over 5 
years, and $4.2 billion over 10 years. We strongly oppose this attempt 
to ``simplify'' effective dates for claims for increase particularly 
when the result will be billions of dollars in lost disability 
compensation for those who were injured or made ill in service.
    We oppose any proposal that would eliminate extra-schedular 
consideration as it will not consider veterans' with unusual disability 
pictures based on marked interference with employment or frequent 
hospitalizations and effectively tip the scales of justice against 
them.

        3. 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 24 years of round-down resulted in 
veterans and their beneficiaries losing billions of dollars.
    In the Administration's proposed budget for Fiscal Year 2020, the 
Administration sought legislation to round-down the computation of COLA 
for 5 years. This would have cost beneficiaries $34 million in 2020, 
$637 million for 5 years, and $2 billion over 10 years.
    The Administration's proposed budget for Fiscal Year 2021 is 
seeking to round-down COLA computations from 2021 to 2026. 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 told, the 
government estimates that it would cost beneficiaries $39 million in 
2020 and $677 million for 5 years and $2.2 billion over 10 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.

        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 title 38, United States Code, Sec.  1116 to 
eliminate payment of benefits to survivors and estates of deceased 
Nehmer class members. If a Nehmer class member, per 38 Code of Federal 
Regulations, 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 IB supports one of VA's legislative proposals regarding VA 
approved 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 increase VA's funding for Fiscal Year 2021 and 2022, 
veterans will be forced to wait longer for benefits and services 
leaving unfulfilled the promises made to those who have served and 
sacrificed defending our country.
                                 ______
                                 

                  Prepared Statement of Melissa Bryant

    Chairman Takano, Ranking Member Roe, and distinguished members of 
the Committee on Veterans' Affairs, on behalf of National Commander, 
James W. ``Bill'' Oxford, and the nearly two million members of The 
American Legion, we thank you for the opportunity to testify on the 
Department of Veterans Affairs (VA) Budget Request For Fiscal Year 
2021.
    As VA moves forward to serve the veterans of this Nation, it is 
important that the Secretary have the tools and resources necessary to 
ensure that veterans receive the services they are entitled to in a 
timely, professional, and courteous manner - because they have earned 
it. The American Legion calls on this Congress to ensure that funding 
is maintained and increased as necessary to ensure the VA is preserved 
and enhanced to serve the veterans of the 21st Century, and beyond.

               Provides Funding for Overall Mental Health

    Post-traumatic stress disorder (PTSD) and traumatic brain injury 
(TBI) 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 7.1 percent increase in funding will provide much-needed 
funding dedicated to this area. While veterans who served in Iraq and 
Afghanistan are not the largest group 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.\1\ The need for specialized mental health services 
will only grow.
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    \1\ https://www.census.gov/library/stories/2018/04/post-9-11-
veterans.html
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    In 2019, VA successfully hired more than 1,000 additional mental 
health providers with the Mental Health Hiring Initiative.\2\ VA also 
increased same-day warm handoffs from the Primary Care Providers and 
Primary Care-Mental Health Integration providers by 19 percent, from 
2016 through 2019, which resulted in 110,000 same-day primary care 
encounters in 2019.\3\ These actions have greatly increased the access 
and timeliness of quality mental health care for the Nation's veterans.
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    \2\ https://www.va.gov/budget/docs/summary/
fy2021VAbudgetInBrief.pdf
    \3\ https://www.va.gov/budget/docs/summary/
fy2021VAbudgetInBrief.pdf
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    While The American Legion acknowledges advances in this area, there 
remains significant room for improvement. From the 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. The American Legion's 
report, The Road Home, also indicates VA must continue to search for 
the most effective treatment programs for veterans with comorbidities 
of PTSD, and TBI with substance use disorder and chronic pain.\4\ 
Providers in VA must take care to prevent at-risk veterans from 
becoming dependent on alcohol or drugs used to ``self-medicate.''
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    \4\ www.legion.org/sites/legion.org/files/legion/publications/
60VAR0818percent20 Thepercent20Roadpercent20Homepercent20-percent20TBI-
PTSD.pdf
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    The American Legion believes VA must focus on mental health without 
sacrificing awareness and concern for other conditions afflicting 
servicemembers and veterans. As an immediate priority, 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 president's proposed budget requests 
$10.2 billion for veterans' mental health services, an increase of $683 
million (7.1 percent) above 2020. The American Legion supports this 
action as a positive step forward.

               Prioritizes Funding for Suicide Prevention

    The Budget also provides $313 million, a 32-percent increase over 
the 2020 enacted level, to support the Administration's veteran suicide 
prevention initiatives, including the National Roadmap to Empower 
Veterans and End Suicide, a population-based, public health model 
encouraging partnerships at the national, regional, and local levels.

        -A Budget for America's Future, Administration's Proposed 
        Fiscal Year 2021 Budget

    Suicide prevention and mental health is a top priority of The 
American Legion, VA, and the Department of Defense (DoD). The American 
Legion is deeply concerned by the high suicide rate among 
servicemembers and veterans. Veterans ages 18-34 are particularly 
troubling as their suicide rates have risen 76 percent from 2005 to 
2017 with 44.5 veterans per every 100,000 dying by suicide each 
year.\5\ Women have become an increasing percentage of the veteran 
population which has grown 6.5 percent from 2005 to 2017. 
Unfortunately, the 2017 rate of suicide among women veterans was 2.2 
times the rate among non-veteran women.\6\ In 2017, veterans accounted 
for 13.5 percent of all deaths by suicide among U.S. adults while only 
constituting 7.9 percent of the U.S. adult population.\7\ These 
statistics are disheartening as suicide among veterans has increased by 
6.1 percent from 2005 to 2017 despite the national attention veterans 
suicide has received.
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    \5\ https://www.mentalhealth.va.gov/docs/data-sheets/2019/
2019_National_Veteran_Suicide_ Prevention_Annual_Report_508.pdf
    \6\ Ibid
    \7\ Ibid
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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 over 
650,000 phone calls every year, as well as thousands of electronic 
chats and text messages. The VCL has improved its ability to answer 
incoming calls from 70 percent in 2017 to 99.96 percent in 2019 with an 
average response time of an average of eight seconds or less.\8\ VA 
also hired more than 400 Suicide Prevention Coordinators (SPCs), mental 
health professionals that specialize in suicide prevention.\9\
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    \8\ Ibid
    \9\ Ibid
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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 DoD and VA 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.\10\ 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.
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    \10\ archive. legion.org /bitstream /handle/ 20.500.12203/ 9286/
2018S020.pdf ?sequence =1&is Allowed =y
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    President Donald Trump's executive order, titled the ``President's 
Roadmap to Empower Veterans and End a National Tragedy of Suicide'' 
(PREVENTS), will require top officials from multiple government 
agencies to coordinate a strategy to tackle the issue of veterans 
suicide. The American Legion believes this initiative is a step in the 
right direction, but it must be properly coordinated with the 
activities of Congress and should not take any resources from VA to 
support itself.
    Congress must ensure sufficient resources are available for 
effective VA suicide prevention efforts. Funding for the aforementioned 
programs must be provided as well as money for new programs. President 
Trump has called for a 32 percent increase in VA spending in Fiscal 
Year 2021, up to a total of $313 million for suicide prevention. The 
American Legion appreciates the serious attention paid to this issue by 
the White House and urges Congress to appropriate these funds.

                     Combats Military Sexual Trauma

    Military Sexual Trauma (MST) refers to experiences of sexual 
assault or repeated, threatening sexual harassment that a veteran 
experienced during his or her military service. These actions are a 
gross betrayal of the trust between the men and women who serve in our 
armed forces and are more common than should ever be acceptable. 
National data exposes that about 1 in 4 women and 1 in 100 men stated 
that they experienced MST when asked by their VA provider.\11\ Although 
rates of MST are higher among women, because there are so many more men 
than women in the military, there are actually significant numbers of 
women and men seen in VA who have experienced MST. However, these 
numbers do not even account for those who choose not to report MST or 
those who do not seek treatment from VA.
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    \11\ https://www.mentalhealth.va.gov/docs/mst_general_factsheet.pdf
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    VA has taken significant steps to tackle the issue of MST. Every VA 
health care system now has a designated MST Coordinator who serves as a 
contact person for MST-related issues. This person can help veterans 
find and access VA services and programs. VA also provides treatment 
for physical and mental health conditions related to experiences of MST 
free of charge regardless of service connection.\12\ The Veterans 
Benefits Administration (VBA), in response to a 2018 VA Office of 
Inspector General (OIG) report, updated their ``PTSD Due to MST'' 
training course and mandated training to be completed by March 2019 to 
ensure claims processors were trained adequately to adjudicate MST 
claims.\13\
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    \12\ Ibid
    \13\ https://www.va.gov/oig/pubs/VAOIG-17-05248-241.pdf
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    The American Legion acknowledges that VA has made significant 
strides in handling the problem of MST, but work remains to be done. 
The American Legion uniquely understands the challenges VA faces to 
support survivors of MST due to our routine site visits through our 
System Worth Saving (SWS) program. This innovative partnership was 
launched in 2003 to promote best practices at VA Medical Centers (VAMC) 
and VA Regional Offices (VARO). During these visits, some critical 
issues we have witnessed include insufficient training of VA staff, 
lack of adequate time to process MST claims, high rate of attrition and 
compassion fatigue among VA staff who work on MST related issues, 
implications of bias and subjective ratings, and a continued culture of 
sexual harassment within VA facilities.\14\
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    \14\ https://www.legion.org/systemworthsaving/reports
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    The American Legion believes that our Nation's veterans should 
never suffer at the hands of institutions whose existence and mission 
is to care for them. We believe in the quality of care at VA facilities 
and remain committed to a strong VA. The administration's proposed 
budget requests $10.2 billion for veterans' mental health services, an 
increase of $683 million (7.1 percent) above 2020, which includes MST 
related treatment. The American Legion appreciates the serious 
attention that MST has received and urges Congress to appropriate these 
funds.

                    Provides Critical Funding for IT

    In 2021, OIT (Office of Information and Technology) is requesting 
$4.912 billion, an increase of $540.4 million (12.4 percent) over the 
2020 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 2021

    VA's Information Technology (IT) infrastructure has been an 
evolving technological necessity over the past 40 plus years, sometimes 
leading the industry, and sometimes trailing. 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 Project Advancing Telehealth through Local Access Stations, or 
ATLAS. Project ATLAS will enable remote examinations in selected 
American Legion posts, among other locations.
    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. 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 
its systems. The president's budget provides $4.9 billion for essential 
investments in IT to improve the online interface between veterans and 
VA. This includes major investments of over $300 million to support the 
implementation of the MISSION Act, over $250 million for Infrastructure 
Readiness Program, and over $50 million for the VA Enterprise Cloud 
solution.\15\
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    \15\ https://www.va.gov/budget/docs/summary/
fy2021VAbudgetInBrief.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 architecture capable of processing disability and 
education 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 a seamless 
transition between the Department of Defense and VA.

             Electronic Health Record Modernization (EHRM)

    The request includes $2.6 billion (an increase of $1.2 billion or 
82 percent from 2020) to continue VA's EHRM effort to create and 
implement a single longitudinal electronic health record from active 
duty to Veteran status, and to ensure interoperability with the 
Department of Defense (DoD).

        -Department of Veterans Affairs - Budget in Brief 2021

    The American Legion, through Resolution No. 83 Virtual Lifetime 
Electronic Record, has long endorsed and supported the VA in creating a 
Lifetime Electronic Health Records (EHR) system. Additionally, The 
American Legion has encouraged both DoD and VA to either use the same 
EHR system or, at the very least, utilize interoperable systems.
    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 $2.6 billion as part of a multiyear effort 
to continue the implementation of a new EHR system.\16\ The EHR is a 
high-priority initiative that ensures a seamlessly integrated 
healthcare record between DoD and VA, by bringing all patient data into 
one common system. As such, we call on Congress to fund it accordingly.
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    \16\ https://www.va.gov/budget/docs/summary/
fy2021VAbudgetInBrief.pdf
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                       Enhances Veteran Outreach

    Outreach to veterans has been an ongoing issue for VA as it seeks 
to bring veterans into the VA system. For example, a recent VA health 
care utilization report found that only approximately 62 percent of all 
separated Operation Enduring Freedom (OEF), Operation Iraqi Freedom 
(OIF), or Operation New Dawn (OND) veterans have used VA health care 
since October 1, 2001.\17\ This has been documented for a variety of 
reasons such as not understanding what benefits and services they are 
entitled to, bad past experiences with VA services and facilities, or a 
general distrust of VA.
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    \17\  https://www.publichealth.va.gov/epidemiology/reports/
oefoifond/health-care-utilization/
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    VA must do a better job reaching out to veterans to ensure they 
know what benefits and services they can receive. This is especially 
critical with the passage of new legislation, such as H.R. 299, the 
Blue Water Navy Vietnam Veterans Act of 2019, to ensure veterans have a 
clear understanding. VA must also take a proactive step with outreach 
to create an environment of trust with veterans that VA will take care 
of them with quality service. This is especially important when VA is 
trying to help underserved communities such as racial and ethnic 
minorities, women, and LGBT veterans. The administration's budget 
requests $413.0 million for General Administration, $57.1 million (16 
percent) above 2020 which covers public relations and outreach. 
Specifically, the budget requests $3.2 million in additional funds for 
the Office of Public and Intergovernmental Affairs.\18\ We call upon 
Congress to adequately fund these efforts to conduct outreach to 
veterans, including those of underserved communities, and for VA to 
utilize the funds fully and effectively.
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    \18\ https://www.va.gov/budget/docs/summary/
fy2021VAbudgetInBrief.pdf
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                 Further Implements the VA MISSION Act

    The 2021 request fully supports continued implementation of the 
MISSION Act. The MISSION Act is fundamentally transforming VA 
healthcare by giving Veterans greater access to health care in VA 
facilities and the community, expanding benefits for caregivers, and 
improving VA's ability to recruit and retain the best medical 
providers.

        -Department of Veterans Affairs - Budget in Brief 2021

    In response to veterans preference to receive medical services 
closer to their homes, Congress enacted the VA MISSION Act in 2018, a 
historic law that contains a number of policy priorities of The 
American Legion and other veteran stakeholders.\19\ 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, and to 
develop strategic plans with completed market assessments to provide 
care to veterans under the new VCCP.
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    \19\ VA Mission Act Pub. L. No: 115-182
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    The budget includes $18.5 billion in 2021, a 21 percent increase 
from 2020, for the Medical Community Care program. The American Legion 
supports the president in adequately funding the success of the 
consolidated community care program. We offer this support recognizing 
that VA must continue to properly allocate sufficient funding to 
maintain VA's existing healthcare infrastructure. Additionally, our 
support relies on the understanding that VA must expand capacity in 
locations where demand for care justifies additional VA infrastructure.

                       Ensures Proper VA Staffing

    The 2021 request supports a total of 404,835 FTE, or 14,866 FTE 
above the 2020 estimated level to expand access to health care and 
improve benefits delivery. This includes clinical and hospital staff in 
the Veterans Health Administration (VHA), including physicians, nurses, 
and scheduling clerks. These dedicated employees come to work for 
America's Veterans and have a close connection with Veterans - over 33 
percent are Veterans themselves. The 2021 request assumes a 1 percent 
pay raise.

        -Department of Veterans Affairs - Budget in Brief 2021

    The American Legion has long expressed concern about staffing 
shortages at VA. Unfortunately, no easy solutions exist for VA to 
effectively and efficiently recruit and retain staff at VA healthcare 
facilities. 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.
    It is important to understand that simply providing additional 
funding will not resolve the issue of staff shortages. 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.
    The president's budget recognizes the need for additional staff and 
has proposed adding an additional 14,866 full-time employees above 2020 
levels. The American Legion supports adding additional employees to 
ensure the timely delivery of services but urges the VA to 
simultaneously employ creative solutions to solve VA staffing issues as 
well.

                     Better Care for Women Veterans

    The needs of a growing number of women Veterans mean that VA must 
provide more gender-specific primary care services, expand access to 
gynecology, and continue to identify and serve the health care needs 
for a unique Veteran population.

        -Department of Veterans Affairs - Budget in Brief 2021

    Women are a vital component of the U.S. Armed Forces and have 
increasingly served in higher numbers than ever before. As a result, VA 
needs to be prepared for the sustained increase of younger female 
veterans as they complete their active service. The 2015 Department of 
Veterans Affairs Women Veterans Report noted 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.\20\ While VA has made 
significant advancements in meeting the demands of an increasingly 
diverse veteran population, continued diligence is required to ensure 
that all veterans receive the high quality care they deserve.
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    \20\  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
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    VA must ensure that women veterans have access to quality gender-
specific healthcare across the entirety of the network. 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. 
The continued funding of a full-time Women Veterans Program Manager at 
every VHA health care system is essential to ensuring women veterans 
needs are met.
    The American Legion continues to advocate for improved delivery of 
timely and quality healthcare for women using VA. Ensuring women 
veterans receive the quality care they deserve is a top priority of The 
American Legion. The president's budget recognizes the need for 
additional funding in this critical area, and has proposed an increase 
of $53 million which is 9 percent over last year's authorization 
levels.

                Military and Veteran Caregiver Services

    Funding requirements for the CSP are driven by an increase in the 
eligible Veteran population. Currently, only Veterans injured on or 
after September 11, 2001 are eligible for this program. The 2021 
request supports the expansion of this program under the MISSION Act to 
include eligible pre-9/11 era Veterans seriously injured in the line of 
duty.

        -Department of Veterans Affairs - Budget in Brief 2021

    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 was integral in ensuring America's veterans are 
properly care for.
    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 in the line of duty on or after Sept. 11, 2001.
    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. All veterans should receive the 
same level of benefits for equal service. Thus, The American Legion 
supported the expansion of benefits to include all veterans who 
otherwise meet the eligibility requirements contained in the supports 
the expansion of this program under the MISSION Act. 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. Moreover, 
we urge VA to swiftly implement the expansion of caregiver benefits 
with the funds that have been allocated by Congress. Failure to 
properly implement this expansion in the most expedited manner possible 
will only serve to perpetuate this obvious injustice.
    The president's Fiscal Year 2021 budget requests $1.2 billion for 
the Caregiver Support Program, a $485 million (68 percent) increase 
over the 2020 levels. The American Legion supports this initiative and 
urges Congress to appropriate funds to ensure the expansion of benefits 
to veterans of all periods of service.

            Additional Funding for State Approving Agencies

    State Approving Agencies (SAAs) are responsible for approving and 
supervising programs of education for the training of veterans, 
eligible dependents, and eligible members of the National Guard and the 
Reserves. SAAs grew out of the original GI Bill of Rights that became 
law in 1944. Though SAAs have their foundation in Federal law, SAAs 
operate as part of State governments. SAAs approve programs leading to 
vocational, educational or professional objectives. These include 
vocational certificates, high school diplomas, GEDs, degrees, 
apprenticeships, on-the-job training, flight training, correspondence 
training and programs leading to required certification to practice in 
a profession.
    SAAs currently employ 250 professionals across 56 states and 
territories and are responsible for over 9,000 facilities and more than 
150,000 programs. SAAs serve our veterans by protecting the quality and 
integrity of the GI Bill programs. These unique State agencies, funded 
by Federal contract through the VA, approve programs according to 
Federal and State requirements. They provide oversight to make sure 
schools remain compliant with those requirements through school visits 
and routine renewal of approval.
    After being flat funded for over a decade at $19 million dollars, 
Congress increased the funding of SAAs to $23 million dollars ($3 
million in discretionary funding has never been paid by VA and is not 
counted in the increase) in 2017. This amount of funding is far short 
of the needed increase to reflect the increasing complexity of 
administering the benefit given legislative changes and the rapid 
growth of beneficiaries driven by the Post 911 and Colmery GI Bills. 
This along with the increased cost of hiring and retaining personnel, 
to include rising health care and benefit costs (well over $20,000 
average per professional over the past decade) means that SAAs continue 
to struggle to provide the needed service to and protection for 
veterans and their families. As such, we urge Congress to increase the 
SAA allocation from $23 to $30 million to allow these critical agencies 
to continue to provide approval and oversight of quality educational 
and training programs for our veterans.

                Ensuring Quality Care to Rural Veterans

    The budget requests $270 million for rural health projects. VA is 
committed to improving the care and access for Veterans in 
geographically rural areas.

        -Department of Veterans Affairs - Budget in Brief 2021

    It is imperative that VA ensures veterans have access to high 
quality care no matter where they live. Veterans who live in rural or 
highly rural communities often face difficulties when attempting to 
receive treatment. Although the implementation of the MISSION Act has 
allowed veterans to receive care in their communities, rural veterans 
still encounter challenges when seeking medical services.
    VA's use of telehealth technology is integral in ensuring veterans 
who live in rural communities have access to VA services. 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 veterans who 
received care via telehealth lived in rural areas, yet many more 
veterans have limited access to this technology due to a lack of 
reliable connectivity. To ensure that more veterans have access to this 
technology, The American Legion has partnered with VA and Philips to 
bring telehealth technologies to local American Legion posts.
    This program, known as Project ATLAS, will expand the availability 
of telehealth and allow veterans to be examined by a doctor in a 
familiar setting. 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.
    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. 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 concerned about accessing 
care in rural areas as VA realigns services closer to population 
centers. 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 community services can meet or 
exceed the services VA currently provides.
    The president's proposed budget requests $1.3 billion for the total 
Telehealth program, an increase of $271 million above the 2020 level. 
In 2022, VA is requesting $1.7 billion, an increase of $48 million 
above the 2021 level. The American Legion ardently supports this 
initiative and urges Congress to appropriate funds to bring affordable 
VA healthcare to veterans in rural areas through this program.

                      The Veteran Appeals Process

    VA requests $198 million in budget authority and 1,161 FTE for the 
Board of Veterans' Appeals (Board) to support its operations.

        -Department of Veterans Affairs - Budget in Brief 2021

    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.\21\
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    \21\  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 
9 years to resolve the over 200,000 case backlog.\22\
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    \22\  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 in February 
2019. The AMA sets forth specific elements that VA must address in its 
implementation, including reporting requirements. For example, AMA 
requires VA to provide reports to Congress every 6 months. VA's last 
report to Congress was in August 2019, so the best information 
available is six months old.\23\ According to that report, the Veterans 
Benefits Administration has a clear path to a sustainable steady State 
workload by 2022.
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    \23\  http:// www.veterans law library.com/ files/ VA_ Appeals_ 
Modernization_ Update_ August_ 2019.pdf
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    However, the Board of Veterans' Appeals (BVA) did not report 
information on the AMA workload in that report and it is unclear if the 
BVA is on a path to sustainable performance or how long it will take to 
get there or whether it has adequate resources. We need a lot more data 
about inflows, outflows and inventory for every docket in the BVA, 
including the legacy docket and all three AMA dockets. 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.

                    Medical and Prosthetic Research

    The 2021 request for the Medical and Prosthetic Research 
appropriation is $787 million, an increase of $37 million, or 5 
percent, from 2020...

    VA has among the richest health datasets in the world, including 
those associated with the Million Veteran Program (MVP). These datasets 
hold information that will benefit both Veterans and the Nation. To 
accelerate the rate of these discoveries, VA is taking the steps 
necessary to ensure that research with a translational trajectory will 
be conducted at larger scale.

        -Department of Veterans Affairs - Budget in Brief 2021

    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 two decades, 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.
    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.
    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.
    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.
    Finally, The American Legion is supportive of VA's landmark Million 
Veteran Program (MVP) research effort. MVP is a national research 
program to learn how genes, lifestyle and military exposures affect 
health and illness. MVP-based studies focus on topics including PTSD, 
suicide prevention, heart disease and diabetes. Findings from several 
studies have appeared in high-impact medical and scientific journals. 
More than 800,000 veterans are already enrolled in MVP, and the recent 
launch of online enrollment has made it easier for more veterans to 
take part.\24\
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    \24\  https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5387
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                      Assisting Homeless Veterans

    The VA requests approximately $1.9 billion for homeless programs, 
$82 million above 2020. The 2021 request includes an increase of $30 
million for case management for the Department of Housing and Urban 
Development-VA Supportive Housing (HUD-VASH) program.

        -Department of Veterans Affairs - Budget in Brief 2021

    The American Legion strongly believes that homeless veteran 
programs should be granted increased funding to provide supportive 
services such as, but not limited to: outreach, health care, 
rehabilitation, case management, personal finance planning, 
transportation, vocational counseling, employment, and education. 
Additionally, we urge VA to leverage all monies appropriated to them by 
Congress to ensure continued progress in the fight against veteran 
homelessness.
    The American Legion continues to place special priority on the 
issue of veteran homelessness. With veterans making up about 11 percent 
of our Nation's total adult homeless population, there is reason to 
give this issue special attention. Along with various community 
partners, we remain committed to seeing VA's objective of ending 
veteran homelessness achieved. 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.

                 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. States are pivoting toward 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.

                 National Cemetery Administration (NCA)

    No aspect of the VA is as critically acclaimed as the National 
Cemetery Administration (NCA). In the 2010 American Customer 
Satisfaction Index, the NCA achieved the highest ranking of any public 
or private organization. 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.
    While NCA met their goal of having 90 percent of veterans served 
within 75 miles of their home, their aggressive strategy to improve 
upon this in the coming five years will necessitate funding increases 
for new construction. 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 the expansion of existing cemetery facilities 
as the need arises. Additionally, it is imperative that Congress 
continue to appropriately fund the Veterans Legacy Program, which 
honors our nations veterans by educating America's youth on the service 
and sacrifices of those veterans interred at national cemeteries. The 
American Legion urges Congress to adequately fund all programs to meet 
the burial needs of our Nation's veterans.

              Advance Appropriations for Fiscal Year 2022

    The 2022 Medical Care Advance Appropriations request includes a 
discretionary funding request of $98.9 billion (with medical care 
collections). The 2022 mandatory funding request is $145.3 billion for 
veterans benefits programs (Compensation and Pensions, Readjustment 
Benefits, and Veterans Insurance and Indemnities).

        -Department of Veterans Affairs - Budget in Brief 2021

    The VHA manages the largest integrated health-care system in the 
United States, with 170 medical centers, nearly 1,400 community-based 
outpatient clinics, community living centers, Vet Centers and 
domiciliary serving over 9.2 million enrolled veterans. The American 
Legion believes those veterans should receive the best care possible.
    If veterans are going to receive the best possible care, 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.

                               Conclusion

    In closing, The American Legion appreciates the leadership of this 
committee and remains committed to ensuring VA has the necessary funds, 
resources, and staff to carry out its mission of caring for our nations 
veterans. Further, The American Legion is committed to working with the 
Department of Veterans Affairs and this committee to ensure that 
America's veterans are provided with the highest level of support and 
healthcare.
    Chairman Takano, Ranking Member Roe, and distinguished members of 
this committee, The American Legion thanks this committee for holding 
this important hearing and for the opportunity to explain the views of 
the nearly 2 million members of this organization. For additional 
information regarding this testimony, please contact Ms. Melissa 
Bryant, Legislative Director, at [email protected] or (808) 263-2981.