[Senate Hearing 116-]
[From the U.S. Government Publishing Office]



 
     MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2020

                              ----------         
                              


                        TUESDAY, APRIL 30, 2019

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 2:46 p.m. in room SD-124, Dirksen 
Senate Office Building, Hon. John Boozman (chairman) presiding.
    Present: Senators Boozman, Murkowski, Hoeven, Collins, 
Capito, Daines, Schatz, Tester, Udall, and Baldwin.

                     DEPARTMENT OF VETERANS AFFAIRS

STATEMENT OF HON. ROBERT L. WILKIE, SECRETARY


               opening statement of senator john boozman


    Senator Boozman. Good afternoon and thank you for coming 
today to discuss the Department of Veterans Affairs fiscal year 
2020 and 2021 Budget Requests.
    I'd like to begin by recognizing today's panel. The 
Honorable Robert Wilkie, Secretary of Veterans Affairs. He's 
accompanied by his leadership team in the VA's Office of 
Electronic Health Record Modernization, including the Honorable 
Dr. Paul Lawrence, the Under Secretary for Benefits of the 
Veterans Benefits Administration, the Honorable Randy Reeves, 
the Under Secretary for Memorial Affairs, the Honorable Jon 
Rychalski, the Assistant Secretary for Management and Chief 
Financial Officer, Dr. Richard Stone, Executive in Charge of 
the Veterans Health Administration.
    We apologize for running late. You know, we schedule these 
things in advance and all of a sudden we have votes and that's 
the only thing that we've got to do around here is vote.
    So the budget requests $220 billion in fiscal year 2020 for 
the Department of Veterans Affairs, including medical care 
collections. This includes $93 billion in discretionary funds, 
6.5 billion or seven and a half percent increase over fiscal 
year 2019.
    The budget also requests a total of $221 billion in 
advanced appropriations for 2021.
    Although the large fiscal year 2020 increase highlights the 
importance of programs for veterans, it also reflects creation 
of the Veterans Community Care Program which consolidated 
multiple community care programs through the MISSION Act. The 
estimate of the 2020 cost of the MISSION Act-related programs 
is $8.9 billion, an amount that in past years would have been 
funded through mandatory appropriations but now we must 
consider it covered by discretionary funds.
    Members of this subcommittee remain committed to providing 
VA with the resources needed to care for our veterans. However, 
to do that, we must have accurate cost and execution estimates 
from the department. None of us wants to repeat the experience 
of past budget shortfalls.
    In addition, the budget requests $1.6 billion for 
electronic health records modernization. This includes funds 
for the third year of a 10-year contract with SERNA. As I have 
previously noted, many of us on this committee have long 
advanced for a single joint medical record that will follow 
service members throughout their career in military and into 
their time as veteran. We remain hopeful that the collaboration 
between VA and DoD and SERNA can deliver on this vision.
    Timely and effective implementation of the Veterans 
Community Care Program and the electronic health record 
modernization efforts pose significant challenges for the 
department in fiscal year 2020.
    This VA addresses interoperability of both legacy and 
community health systems and programs. It's essential that its 
community, including staff, providers, and veterans are 
educated on the changes in policy and processes.
    In addition to updates on those programs, we look forward 
to hearing details about the department's request for mental 
health services, including efforts to combat opioid use 
disorder and prevent veteran suicide, initiatives to prevent 
veteran homelessness, and efforts to improve care for our rural 
veterans, including through telehealth.
    We also appreciate VA's efforts to reduce the appeals 
backlog and address the implementation challenges of the 
Forever G.I. Bill.
    Just a lot going on, which a lot of good things, including 
ensuring veterans receive the benefits required under the law.
    Finally, we are aware that the Justice Department requested 
an extension on the deadline to appeal the Federal Circuit 
Court decision regarding benefits for Bluewater Navy veterans. 
We would like to hear more about the expected costs associated 
with this case and what, if any, additional resources VBA may 
need as a result.
    We look forward to discussing these and other issues this 
afternoon and with that, I yield to our Ranking Member, Senator 
Schatz, for his opening statement.


               opening statement of senator brian schatz


    Senator Schatz. Thank you, Mr. Chairman, for holding this 
hearing.
    Robust funding for VA comes at a critical time. The opioid 
crisis is bearing down on our veterans. We continue to see 
tragic reports of suicides in parking lots. So it's important 
that VA is making a strong request for more than $93 billion, 
$6.6 billion over what was provided last year, and I'm glad 
that suicide prevention remains VA's top clinical priority with 
investments in mental health and outreach to vulnerable 
veterans.
    The budget request also includes more funding for women's 
health, so that women who have served will have access to high-
quality primary care wherever and whenever they come for 
treatment.
    But I also have concerns. Let's start with EHR. Over the 
past 2 years, this committee has provided nearly $2 billion in 
funding for an overhaul of VA's electronic health records.
    Now we all know this is important. Otherwise, it's 
difficult for VA to share health data with DoD and community 
providers, but the VA needs to show how it's spending the money 
that we've been appropriated.
    I understand that you have big bills that are coming in the 
third and fourth quarters of the fiscal year, but so far, we've 
only seen $37.5 million obligated of the $1.3 billion that you 
plan to spend this year, and it seems likely that you'll carry 
over significantly more funding to next year than you've 
projected.
    So it's unclear whether there is a need at this point for 
another $1.6 billion for EHR. I am not saying that you should 
spend the money faster. I am saying that your budget request 
should reflect the reality of what you actually need and can 
spend, which brings us to the implementation of the MISSION 
Act.
    The VA's request includes just about nine billion for the 
MISSION Act which replaces the Choice Program on June 6th. The 
MISSION Act is supposed to help veterans access to care no 
matter where they live. So if the VA in their care doesn't 
offer the care or services that they need, they can go into the 
community. That's especially important for veterans who live in 
rural and remote areas, including my home state of Hawaii, but 
I am worried that this request isn't enough to actually pay for 
the MISSION Act.
    So either you won't be able to fully implement the 
legislation or you're going to hurt VA's internal health care 
system which provides services that many veterans can't get in 
their communities, access to audiologists, therapy for spinal 
cord injury, prosthetic fittings, or TBI or PTSD treatment.
    We have to make sure that the VA has the money it needs to 
give our veterans high-quality care wherever they seek it and 
I'm committed to working with you, Mr. Chairman, to make that a 
reality.
    Finally, I have some concerns that hit a little closer to 
home. On the top of the list is the status of the proposed one-
stop shop clinic in Hilo. It has been in the SKIF for years, 
but it can't seem to get done because the VA's Minor 
Construction Program is broken.
    I get that there are competing projects, but our veterans 
in Hilo had to move from one temporary building to another, 
first to move out of a tsunami flood zone and now because of 
issues with the medical park the clinic is currently located 
in. The band-aid doesn't work anymore. Local veterans are 
frustrated and confused and they're not the only ones that are 
getting jammed on services because of this program.
    We need to fix the way the VA does minor construction so 
that veterans, like those in Hilo, are not waiting a decade for 
VA to follow through on a promised project.
    I hope our witnesses can offer a path forward on this and 
the other issues before the subcommittee.
    Thank you, Mr. Chairman.
    Senator Boozman. Thank you, and again thank you for being 
here, Secretary Wilkie.


               summary statement of hon. robert l. wilkie


    Secretary Wilkie. Thank you, Mr. Chairman, and thank you to 
the distinguished members of this committee and thank you for 
having the VA leadership team here.
    When I first reported to Congress this year on the state of 
VA, I testified that VA was better and that was thanks to 
support from the Senate and the President through a series of 
comprehensive legislative actions in the last year.
    We now have an experienced and unified VA leadership and a 
workforce devoted to veterans. We have been the recipient of 
several pieces of good news that reinforce those trends.
    For the first time in my career in Washington, the 
Partnership for Public Service now ranks VA as one of the best 
places in the Federal Government to work. The Annals of 
Internal Medicine at Dartmouth said that VA health care is as 
good or better than any health care in any region of the 
country, and the Journal of the American Medical Association 
said that veterans access to VA care appears to have improved 
not only between 2014 and 2017 but now wait times have 
surpassed those that exist in three out of four specialties in 
the private sector.
    In talks last year, I said VA was on the cusp of 
transformation, but in February, I revised that. We are no 
longer on the cusp. We are in the middle of it. A major driver 
of our transformation is the MISSION Act, which authorizes me 
to set access standards to provide veterans the best and most 
timely care either in VA or through community care.
    As this committee knows, the MISSION Act simplifies and 
consolidates seven community care programs into a single 
streamlined simple-to-use program. It also extends the Choice 
Program and expands the Caregiver Program and provides a new 
urgent care benefit as well as other access improvements.
    We have changed access and availability times to put 
veterans on the same plane as those who use Tricare, Medicare, 
and other major health insurance programs. Eligible veterans 
will also have access to urgent care through VA community care 
providers that they select in advance.
    At the same time we are improving the MISSION Act, we are 
also moving forward on major reforms within the institution. 
Supply chain management, also HR improvement. As Senator Schatz 
pointed out, the electronic health record, which for the first 
time, will create a living interoperable health care record to 
be built the day that that American walks into the military 
entrance processing station.
    No longer will people like my father after 30 years of 
service be forced to carry around an 800-page paper record that 
is the only record of his medical service in the military.
    We have reduced opioid prescriptions more than 50 percent 
in the past 4 years and are helping veterans deal with pain in 
many other ways.
    Senator Schatz raised the number one clinical priority for 
this department and that is suicide prevention. We are already 
a national leader in suicide prevention. We have already hired 
3,900 mental health providers in the last year and we now 
provide same-day mental health services for veterans in need at 
every VA medical center.
    Last February, in Palm Beach, three VA employees risked 
their lives to save a veteran from suicide. Two of them were 
wounded, one seriously. Our veterans' crisis line has expanded 
to three call centers.
    Since 2007, crisis line counselors have dispatched life-
saving emergency services nearly 100,000 times, saving lives by 
picking up the phone to be there when veterans need help, and I 
want to be clear on one point. Despite what some in the media 
have said, there is no voice mail on our crisis hotline. The 
wait time for an answer on our crisis hotline is eight seconds. 
In the private sector, it is usually more than a minute.
    We are also implementing the President's new Executive 
Order creating a national task force on suicide charged with 
producing a national roadmap to prevent veteran suicide, a 
national research strategy focused where it is most needed, and 
a grant program to support the efforts of local communities in 
connecting veterans to the care available.
    I will add, Mr. Chairman, that VA can and will do more, but 
all the money and new and innovative programs that Congress and 
the whole of government approach can conjure up won't be enough 
to stem this national tide of suicides and bring the numbers 
down unless we as a nation, as a society, and as communities 
take a deep look at who we are and how we view and respond to 
our neighbors and fellow citizens who are dealing with mental 
health issues.
    Men and women who are isolated, deeply lonely, and have 
lost all hope in life, and even with the introspection and 
self-criticism and assessment, there will still be some people 
and some veterans who will take their lives when help and 
relief is available, and I will note that just today, National 
Public Radio had a major story on teen suicide and how it 
spiked after the debut of a major movie entitled 13 Reasons 
Why.
    The New York Times yesterday said the same thing. Two weeks 
ago, in the Washington Post on their front page, they 
highlighted the plight of a small town in Utah where six high 
school students in the last year had taken their lives. All of 
this points to the need for a national comprehensive response.
    I'm pleased to tell you that because of VA's experience, we 
will be taking the lead in bringing together NIH, DoD, HUD, and 
HHS to combat this scourge.
    So quickly, the President's 2020 budget is absolutely 
crucial to the success of this department and the success of 
transformation. The budget will give us the resources to get 
things right and ensure long-term success in that 
transformation.
    $97 billion in discretionary spending, a seven and a half 
percent increase, 132 billion in mandatory spending, an 11 
percent increase, and funding for 393,000 full-time employees, 
an increase of 13,000.
    As Senator Schatz said, the budget funds all of our top 
priorities, 8.9 billion for the MISSION Act, which is a 19 
percent increase in community care, and 81 percent of that is 
also devoted to VA delivered care, 1.6 billion to give VA and 
DoD the same electronic health record system and another $1.6 
billion for capital investment.
    As I said, Mr. Chairman, the state of VA is getting 
stronger. We are making steady progress and we are on the road 
to providing world-class 21st Century health care 
administration for all of those who have borne the battle.
    I thank you for your courtesy and look forward to your 
questions.
    [The statement follows:]
              Prepared Statement of Hon. Robert L. Wilkie
    Good afternoon, Chairman Boozman, Senator Schatz, and distinguished 
Members of the Subcommittee. Thank you for the opportunity to testify 
today in support of the President's fiscal year 2020 Budget for the 
Department of Veterans Affairs (VA), including the fiscal year 2021 
Advance Appropriation (AA) request. I am accompanied today by Dr. 
Richard Stone, Executive in Charge, Veterans Health Administration 
(VHA), Dr. Paul Lawrence, Under Secretary for Benefits, Randy Reeves, 
Under Secretary for Memorial Affairs, and Jon Rychalski, Assistant 
Secretary for 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 
VA. In my estimation, two Federal Government departments must rise 
above partisan politics--the Department of Defense (DoD) and VA. The 
bipartisan support this Subcommittee provides sustains that 
proposition. To continue VA's momentum, the fiscal year 2020 budget 
request fulfills the President's strong commitment to Veterans by 
providing the resources necessary to improve the care and support our 
Veterans have earned through sacrifice and service to our country.
                    fiscal year 2020 budget request
    The President's fiscal year 2020 Budget requests $220.2 billion for 
VA--$97.0 billion in discretionary funding (including medical care 
collections). The discretionary request is an increase of $6.8 billion, 
or 7.5 percent, over the enacted fiscal year 2019 budget. It will 
sustain the progress we have made and provide additional resources to 
improve patient access and timeliness of medical care services for the 
approximately 9 million enrolled Veterans eligible for VA healthcare, 
while improving benefits delivery for our Veterans and their 
beneficiaries. The President's fiscal year 2020 budget also requests 
$123.2 billion in mandatory funding, $12.3 billion or 11.1 percent 
above 2019.
    For the fiscal year 2021 AA, the budget requests $91.8 billion in 
discretionary funding including medical care collections for Medical 
Care and $129.5 billion in mandatory advance appropriations for 
Compensation and Pensions, Readjustment Benefits, and Veterans 
Insurance and Indemnities benefits programs in the Veterans Benefits 
Administration (VBA).
    For VA Medical Care, VA is requesting $84.1 billion (including 
collections) in fiscal year 2020, a 9.6 percent increase over the 2019 
level, and a $4.6 billion increase over the 2020 AA, primarily for 
community care and to transition the Choice Program workload to VA's 
discretionary Medical Community Care account. This Budget will provide 
funding for treating 7.1 million patients in 2020.
    This is a strong budget request that fulfills the President's 
commitment to Veterans by ensuring that they receive high-quality 
healthcare and timely access to benefits and services while 
concurrently improving productivity and fiscal responsibility. I urge 
Congress to support and fully fund our fiscal year 2020 and fiscal year 
2021 AA budget requests--these resources are critical to enabling the 
Department to meet the evolving needs of our Veterans and successfully 
execute my top priorities.
                            customer service
    It is the responsibility of all VA employees to provide an 
excellent customer service experience (CX) to Veterans, Servicemembers, 
their families, caregivers, and survivors when we deliver care, 
benefits, and memorial services. I am privileged to champion this 
effort.
    Our National Cemetery Administration has long been recognized as 
the organization with the highest customer satisfaction score in the 
Nation. That's according to the American Customer Satisfaction Index 
ACSI). And that's across all sectors of industry and government. We 
need to work to scope that kind of success across all benefits and 
services.
    That's why I incorporated CX into the fiscal year 2018-2024 VA 
Strategic Plan. Last year, I issued VA's first customer service policy. 
That policy outlines how VA will achieve excellent customer service 
along three key pillars: CX Capabilities, CX Governance, and CX 
Accountability. I am holding all VA executives, managers, supervisors, 
and employees accountable to foster a climate of customer service 
excellence. We will be guided by our core VA Values of Integrity, 
Commitment, Advocacy, Respect, and Excellence (I-CARE). These values 
define our culture of customer service and help shape our standards of 
behavior.
    Because of VA's leadership in customer experience, our Veterans 
Experience Office has been designated Lead Agency Partner for the 
President's Management Agenda (PMA) Cross-Agency Priority (CAP) Goal on 
Improving Customer Experience across government.
    Our goal is to lead the President's work of improving customer 
experience across Federal agencies and deliver customer service to 
Veterans we serve that is on par with top private sector companies.
    This is not business as usual at VA. We are changing our culture 
and putting our Veteran customers at the center of our process. To 
accomplish this goal, we are making investments in Customer Service, 
and we are making bold moves in training and implementing customer 
experience best practices.
    Veterans Experience Office.-- The Veterans Experience Office (VEO) 
is my lead organization for achieving our customer service priority and 
providing the Department a core customer experience capability. VEO 
offers four core customer experience capabilities, including real-time 
customer experience data, tangible customer experience tools, modern 
technology, and targeted engagement. For fiscal year 2020, VEO is 
shifting from a full reimbursable authority (RA) funding model to a 
hybrid of a RA and budget authority (BA) model. The fiscal year 2020 
request of $69.4 million for the VEO ($8.6 million in BA and $60.6 
million in RA) is $8.1 million above the fiscal year 2019 enacted 
budget. The budget increase and the transition to a BA highlights VA's 
commitment to customer service and the institutionalization of CX 
capabilities within the Department to improve care, benefits and 
service to Veterans, their families, caregivers and survivors.
                       mission act implementation
    The VA MISSION Act of 2018 (the MISSION Act) will fundamentally 
transform elements of VA's healthcare system, fulfilling the 
President's commitment to help Veterans live a healthy and fulfilling 
life. It is critical that we deliver a transformed 21st century VA 
healthcare system that puts Veterans at the center of everything we do. 
The fiscal year 2020 budget requests $8.9 billion in the VA Medical 
Care program for implementation of key provisions of the MISSION Act: 
$5.5 billion for continued care of the Choice Program population; $2.9 
billion for expanded access for care based on average drive time and 
wait time standards and expanded transplant care; $272 million for the 
Urgent Care benefit, and $150 million to expand the Program of 
Comprehensive Assistance for Family Caregivers.
    Access to Care.--Over the past few years, VA has invested heavily 
in our direct delivery system, leading to reduced wait times for care 
in VA facilities that currently meet or exceed the quality and 
timeliness of care provided by the private sector. And VA is improving 
access across its more than 1,200 facilities even as Veteran 
participation in VA healthcare continues to increase.
    From fiscal year 2014 through fiscal year 2018, VA saw an increase 
of 226,000 unique patients for outpatient appointments (a 4 percent 
increase). Since fiscal year 2014, the number of annual appointments 
for VA care is up by 3.4 million. There were over 58 million 
appointments in VA facilities in fiscal year 2018--620,000 more than 
the prior fiscal year. We have significantly reduced the time to 
complete an urgent referral to a specialist. In fiscal year 2014, it 
took an average of 19.3 days to complete an urgent referral and in 
fiscal year 2018 it took 2.1 days, an 89 percent decrease. As of 
December 2018, that time was down to about 1.6 days.
    Still, our patchwork of multiple separate community care programs 
is a bureaucratic maze that is difficult for Veterans, their families, 
and VA employees to navigate.
    The MISSION Act empowers VA to deliver the quality care and timely 
service Veterans deserve so we will remain at the center of Veterans' 
care. Further, the MISSION Act strengthens VA's internal network and 
infrastructure so VA can provide Veterans more healthcare access more 
efficiently.
    Transition to the New Community Care Program.-- We are building an 
integrated, holistic system of care that combines the best of VA, our 
Federal partners, academic affiliates, and the private sector.
    The Veterans Community Care Program consolidates VA's separate 
community care programs and will put care in the hands of Veterans and 
get them the right care at the right time from the right provider. On 
January 30, 2019, we announced proposed access standards that would 
determine if Veterans are eligible for community care under the access 
standard eligibility criterion in the MISSION Act to supplement care 
they are provided in the VA healthcare system. The proposed regulation 
for the program (RIN 2900-AQ46) was published in the Federal Register 
on February 22, 2019, and was open for comments through March 25, 2019.

New Veterans Community Care Program Eligibility Criteria

    1. VA does not offer the care or services the Veteran requires;

    2. VA does not operate a full-service medical facility in the State 
in which the Veteran resides;

    3. The Veteran was eligible to receive care under the Veterans 
Choice Program and is eligible to receive care under certain 
grandfathering provisions;

    4. VA is not able to furnish care or services to a Veteran in a 
manner that complies with VA's designated access standards;

    5. The Veteran and the Veteran's referring clinician determine it 
is in the best medical interest of the Veteran to receive care or 
services from an eligible entity or provider based on consideration of 
certain criteria that VA would establish; or

    6. The Veteran is seeking care or services from a VA medical 
service line that VA has determined is not providing care that complies 
with VA's standards for quality.

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

    1. For primary care, mental health, and non-institutional extended 
care services VA is proposing a 30-minute average drive time from the 
Veteran's residence.

    2. For specialty care, VA is proposing a 60-minute average drive 
time from the Veteran's residence.

    3. VA is proposing appointment wait-time standards of 20 days for 
primary care, mental healthcare, and non-institutional extended care 
services and 28 days for specialty care from the date of request, 
unless a later date has been agreed to by the Veteran in consultation 
with the VA healthcare provider.

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

    VA remains committed to providing care through VA facilities as the 
primary means for Veterans to receive healthcare, and it will remain 
the focus of VA's efforts. As a complement to VA's facilities eligible 
Veterans who cannot receive care within the requirements of these 
proposed access standards would be offered community care. When 
Veterans are eligible for community care, they may choose to receive 
care with an eligible community provider, or they may continue to 
choose to get the care at their VA medical facility.
    The proposed access standards are based on analysis of practices 
and our consultations with Federal agencies--including the DoD, the 
Department of Health and Human Services, and the Centers for Medicare & 
Medicaid Services--private sector organizations, and other non-
governmental commercial entities. Practices in both the private and 
public sector formulated our proposed access standards to include 
appointment wait-time standards and average drive time standards.
    VA also published a Notice in the Federal Register seeking public 
comments, and in July 2018, VA held a public meeting to provide an 
additional opportunity for public comment.
    With VA's proposed access standards, the future of VA's healthcare 
system will lie in the hands of Veterans--exactly where it should be.
    Urgent Care.--This budget will also invest $272 million in 
implementing the new urgent (walk-in care) benefit included in the VA 
MISSION Act. On January 31, 2019, VA published a proposed rule that 
would guide the provision of this benefit using the provider network 
available through national contracts. Under the new urgent care 
authority, we will be able to offer eligible Veterans convenient care 
for certain, limited, non-emergent healthcare needs.
    Caregivers.--The MISSION Act expands eligibility for VA's Program 
of Comprehensive Assistance for Family Caregivers (PCAFC) under the 
Caregiver Support Program, establishes new benefits for designated 
primary family caregivers of eligible Veterans, and makes other changes 
affecting program eligibility and VA's evaluation of PCAFC 
applications. Currently, the Program of Comprehensive Assistance for 
Family Caregivers is only available to eligible family caregivers of 
eligible Veterans who incurred or aggravated a serious injury in the 
line of duty on or after September 11, 2001. Implementation of the 
MISSION Act will expand eligibility to eligible family caregivers of 
eligible Veterans from all eras.
    Under the law, expansion will begin when VA certifies to Congress 
that VA has fully implemented a required information technology system. 
The expansion will occur in two phases beginning with eligible family 
caregivers of eligible Veterans who incurred or aggravated a serious 
injury in the line of duty on or before May 7, 1975, with further 
expansion beginning 2 years after that.
    Over the course of the next year, VA will be establishing systems 
and regulations necessary to expand this program. Caregivers and 
Veterans can learn about the full range of available support and 
programs through the Caregivers website, www.caregiver.va.gov, or by 
contacting the Caregiver Support Line toll-free at 1-855-260-3274.
    The fiscal year 2020 Budget for the Caregivers Support Program is 
$720 million, $150 million of which is specifically requested to 
implement the program's expansion because of the MISSION Act.
    Telehealth.--VA is a leader in providing telehealth services. VA 
leverages telehealth technologies to enhance the accessibility, 
capacity, and quality of VA healthcare for Veterans, their families, 
and their caregivers anywhere in the country. VA achieved more than one 
million video telehealth visits in fiscal year 2018, a 19 percent 
increase in video telehealth visits over the prior year. Telehealth is 
a critical tool to ensure Veterans, especially rural Veterans, can 
access healthcare when and where they need it. With the support of 
Congress, VA has an opportunity to continue shaping the future of 
healthcare with cutting-edge technology providing convenient, 
accessible, high-quality care to Veterans. The fiscal year 2020 Budget 
includes $1.1 billion for telehealth services, a $105 million or 10.5 
percent increase over the 2019 current estimate.
    Section 151 of the MISSION Act strengthens VA's ability to provide 
even more telehealth services because it statutorily authorizes VA 
providers to practice telehealth at any location in any State, 
regardless of where the provider is licensed. VA's telehealth program 
enhances customer service by increasing Veterans' access to VA care, 
while lessening travel burdens.
    In fiscal year 2018, more than 782,000 Veterans (or 13 percent of 
Veterans obtaining care at VA) had one or more telehealth episodes of 
care, totaling 2.29 million telehealth episodes of care. Of these 
782,000 Veterans using telehealth, 45 percent live in rural areas. VA's 
major expansion for telehealth and telemental health over the next five 
years, for both urban and rural Veterans, will focus on care in or near 
the Veteran's home. VA's target is to increase Veterans receiving some 
care through telehealth from 13 percent to 20 percent using telehealth 
innovations like the VA Video Connect (VVC) application, which enables 
private encrypted video telehealth services from almost any mobile 
device or computer. VVC will be integrated into VA clinicians' routine 
operations to provide Veterans another option for connecting with their 
care teams.
    Strengthening VA's Workforce.--Recruitment and retention are 
critical to ensuring that VA has the right doctors, nurses, clinicians, 
specialists and technicians to provide the care that Veterans need. The 
fiscal year 2020 Budget strengthens VHA's workforce by providing 
funding for 342,647 FTE, an increase of 13,066 over 2019. VA is also 
actively implementing MISSION Act authorities that increased VA's 
ability to recruit and retain the best medical providers by expanding 
existing loan repayment and clinical scholarship programs; it also 
established the authority to create several new programs focused on 
medical school students and recent graduates. VA is also implementing 
additional initiatives to enhance VA's workforce, such as the expanded 
utilization of peer specialists and medical scribes.
                        business transformation
    Business transformation is essential if we are to move beyond 
compartmentalization of the past and empower our employees serving 
Veterans in the field to provide world-class customer service. This 
means reforming the systems responsible for claims and appeals, GI Bill 
benefits, human resources, financial and acquisition management, supply 
chain management, and construction. The Office of Enterprise 
Integration (OEI) is charged with coordination for these efforts.
    Office of Enterprise Integration.--The scale and criticality of the 
initiatives underway at VA require management discipline and strong 
governance. As part of OEI's coordination role in VA's business 
transformation efforts, we have implemented a consistent governance 
process to review progress against anticipated milestones, timelines, 
and budget. This process supports continuous alignment with objectives 
and identifies risks and impediments prior to their realization.
    For example, our VA Modernization Board recently initiated a 
leadership integration forum to synchronize deployment schedules across 
three major enterprise initiatives: adoption of Defense Medical 
Logistics Standard Support (DMLSS), financial management business 
transformation, and our new electronic health record. This forum 
allowed us to assess the feasibility of a concurrent deployment and 
identify an alternate course of action. By implementing strong 
governance and oversight, we are increasing accountability and 
transparency of our most critical initiatives.
    Appeals Modernization.--The Veterans Appeals Improvement and 
Modernization Act of 2017 (AMA) was signed into law on August 23, 2017 
and took effect on February 19, 2019. The Appeals Modernization Act 
transforms VA's complex and lengthy appeals process into one that is 
simple, timely, and fair to Veterans and ultimately gives Veterans 
choice and control over how to handle their claims and appeals.
    The fiscal year 2020 request of $182 million for the Board of 
Veterans' Appeals (the Board) is $7.3 million above the fiscal year 
2019 enacted budget and will sustain the 1,125 FTE who will adjudicate 
and process legacy appeals while implementing the Appeals Improvement 
and Modernization Act. The Board continues to demonstrate its 
commitment to reducing legacy appeals and decided a historic number of 
appeals--85,288--in fiscal year 2018, the highest number for any fiscal 
year. The Board is on pace to decide over 90,000 appeals in 2019.
    To ensure smooth implementation, the Board launched an aggressive 
workforce plan to recruit, hire, and train new employees in fiscal year 
2018. The Board on-boarded approximately 242 new hires, including 217 
attorneys/law clerks and approximately 20 administrative personnel.

The new appeals process features three decision-review lanes:

    1. Higher-Level Review Lane: A senior-level claims processor at a 
VA regional office will conduct a new look at a previous decision based 
on the evidence of record. Reviewers can overturn previous decisions 
based on a difference of opinion or return a decision for correction. 
VBA has a 125-day average processing goal for decisions issued in this 
lane.

    2. Supplemental Claim Lane: Veterans can submit new and relevant 
evidence to support their claim, and a claims processor at a VA 
regional office will assist in developing evidence. VBA has a 125-day 
average processing goal for decisions issued in this lane.

    3. Appeal Lane: Veterans who choose to appeal a decision directly 
to the Board of Veterans' Appeals (Board) may request direct review of 
the evidence the regional office reviewed, submit additional evidence, 
or have a hearing. The Board has a 365-day average processing time goal 
for appeals in which the Veteran does not submit evidence or request a 
hearing.

    In addition to focusing on implementation of the Appeals 
Modernization Act, addressing pending legacy appeals will continue to 
be a priority for VBA and the Board in fiscal year 2019. VBA's efforts 
have resulted in appeals actions that have exceeded projections for 
fiscal year to date 2019. VBA plans to eliminate completely its legacy, 
non-remand appeals inventory in fiscal year 2020 and significantly 
reduce its legacy remand inventory in fiscal year 2020.
    Finally, VBA is also undertaking a similar, multi-pronged approach 
to modernize its appeals process through increased resources, 
technology, process improvements, and increased efficiencies. VBA's 
compensation and pension appeals program is supported by 2,100 FTEs. 
VBA added 605 FTEs in fiscal year 2019 to process legacy appeals and 
decision reviews in the modernized process. As of October 1, 2018, to 
best maximize its resources an enable efficiencies, VBA centralized 
these assets to conduct higher-level reviews at two Decision Review 
Operation Centers (DROC). VBA will convert the current Appeals Resource 
Center in Washington, DC, into a third DROC using existing assets.
    Forever GI Bill.--Since the passage of the Harry W. Colmery 
Veterans Educational Assistance Act of August 16, 2017, VA has 
implemented 28 of the law's 34 provisions. Twenty-two of the law's 34 
provisions require significant changes to VA information technology 
systems, and VA has 202 temporary employees in the field to support 
this additional workload.
    Sections 107 and 501 of the law change the way VA pays monthly 
housing stipends for GI Bill recipients, and VA is committed to 
providing a solution that is reliable, efficient and effective. Pending 
the deployment of a technology-based solution, Veterans and schools 
will continue to receive GI Bill benefit payments as normal. By asking 
schools to hold fall enrollments through the summer and not meeting the 
implementation date for the IT solutions of Sections 107 and 501, some 
beneficiaries experienced delayed and incorrect payments.
    In accordance with the Forever GI Bill Housing Payment Fulfillment 
Act of 2018, VA established a Tiger Team tasked to resolve issues with 
implementing sections 107 and 501 of the Forever GI Bill. This month we 
awarded a new contract that we believe will provide the right solution 
for implementing Sections 107 and 501. By December 2019, we will have 
Sections 107 and 501 fully implemented. By spring 2020, all enrollments 
will be processed according to the Colmery Act. We will recalculate 
benefits based on where Veterans take classes, and we will work with 
schools to make Sections 107 and 501 payments retroactive to the first 
day of August 2018, the effective date.
    The Department is committed to making sure every Post-9/11 GI Bill 
beneficiary is made whole based on the rates established under the 
Forever GI Bill, and we are actively working to make that happen. We 
got the word out to Veterans, beneficiaries, schools, VSOs, and other 
stakeholders that any Veteran who is in a financial hardship due to a 
late or delayed GI Bill payment should contact us immediately.
    In December 2018, we updated the housing rates like we normally 
would have in August. Those rates were effective for all payments after 
January 1, 2019. Additionally, we processed over 450,000 rate 
corrections, ensuring that any beneficiary who was underpaid from 
August through December received a check for the difference. We have 
completed the spring peak enrollment season without any significant 
challenges. We worked with schools to get enrollments submitted as 
quickly as possible.
    As VA moves forward with implementation, we will continue to 
regularly update our Veteran students and their institutions of 
learning on our progress and what to expect. Already, VA has modified 
its definition of ``campus'' to better align itself with statutory 
requirements, and in doing so has lessened the administrative burden on 
schools to report to VA housing data.
    Information Technology Modernization.--The fiscal year 2020 budget 
request of $4.343 billion continues VA's investment in the Office of 
Information Technology (OIT) modernization effort, enabling VA to 
streamline efforts to operate more effectively and decrease our 
spending while increasing the services we provide. The budget allows 
OIT to deliver available, adaptable, secure, and cost-effective 
technology services to VA--transforming the Department into an 
innovative, twenty first century organization--and to act as a steward 
for all VA's IT assets and resources. OIT delivers the necessary 
technology and expertise that supports Veterans and their families 
through effective communication and management of people, technology, 
business requirements, and financial processes.
    The requested $401 million funds for development will be dedicated 
to mission critical areas, continued divestiture of legacy systems such 
as the Benefits Delivery Network and the Burial Operations Support 
System, and initiatives that are directly Veteran-facing. Funds will 
continue to support Veteran focused initiatives such as Mental Health, 
MISSION Act and Community Care, and the continued transition from the 
legacy Financial Management System (FMS) to the new Integrated 
Financial and Acquisition Management System (iFAMS). The Budget also 
invests $379 million for information security to protect Veterans' 
information.
    Financial Management Business Transformation (FMBT).--As mentioned 
above, a critical system that will touch the delivery of all health and 
benefits is our new financial and acquisition management system, iFAMS. 
In support of the Financial Management Business Transformation (FMBT) 
program, the fiscal year 2020 budget requests $66 million in IT funds, 
$107 million in Franchise Fund Service Level Agreement (SLA) funding 
from the Administrations and other Staff Offices to be paid to the 
Financial Services Center (FSC), and General Administration funding of 
$11.9 million.
    Through the FMBT program, VA is working to implement an enterprise-
wide financial and acquisition management system in partnership with 
our service provider, CGI Federal Inc. VA will utilize a cloud hosted 
solution, configured for VA, leveraging CGI's Software as a Service 
(SaaS) model. VA will gain increased operational efficiency, 
productivity, reporting capability, and flexibility from a modern 
Enterprise Resource Planning (ERP) cloud solution. The new cloud 
solution will also provide additional security, storage, and 
scalability.
    Infrastructure Improvements and Streamlining.--I want to thank 
Congress for providing $2 billion in additional funding for VA 
infrastructure in 2019. This additional funding for minor construction, 
seismic corrections, and non-recurring maintenance will enhance our 
ability to address infrastructure needs. In fiscal year 2020, VA will 
continue improving its infrastructure while transforming our healthcare 
system to an integrated network to serve Veterans. This budget allows 
for the expansion of healthcare, burial and benefits services where 
needed most. The request includes $1.235 billion in Major Construction 
funding, as well as $399 million in Minor Construction to fund VA's 
highest priority infrastructure projects. These funding levels are 
consistent with our requests in recent years.
Major and Minor Construction
    This funding supports major medical facility projects including 
providing the final funding required to complete these projects: New 
York, NY--Manhattan VAMC Flood Recovery, Bay Pines, FL--Inpatient/
Outpatient Improvements, San Juan, PR--Seismic Corrections, Building 1; 
and Louisville, KY--New Medical Facility. The request also includes 
continued funding for ongoing major medical projects at San Diego, CA--
Spinal Cord Injury and Seismic Corrections, Reno, NV--Correct Seismic 
Deficiencies and Expand Clinical Services Building, West Los Angeles, 
CA--Site utilities for Build New Critical Care Center, and Alameda, 
CA--Outpatient Clinic & National Cemetery.
    The 2020 request includes additional funding for the completion of 
the new cemetery at Western New York Cemetery (Elmira, NY) and the 
replacement of the cemetery at Bayamon, PR (Morovis), and expansion 
project at Riverside, CA. The national cemetery expansion and 
improvement projects at Houston and Dallas, TX and Massachusetts 
(Bourne, MA) are also provided for. The fiscal year 2020 Budget 
provides funds for the continued support of major construction program 
including the seismic initiative that was implemented in 2019 to 
address VA's highest priority facilities in need of seismic repairs and 
upgrades.
    The request also includes $399 million in minor construction funds 
that will used to expand healthcare, burial and benefits services for 
Veterans. The minor construction request includes funding for 131 newly 
identified projects as well as existing partially funded projects.
Leasing
    VA is also requesting authorization of seven major medical leases 
in 2020 to ensure access to healthcare is available in those areas. 
These leases include new leases totaling $33 million in Colombia, MO 
and Salt Lake City, UT as well as replacement leases totaling $104 
million in Baltimore, MD; Atlanta, GA; Harlingen, TX; Jacksonville, NC; 
and Prince George's County, MD. VA is requesting funding of $919 
million to support ongoing leases and delivery of additional leased 
facilities during the year.
Repurposing or Disposing Vacant Facilities
    To maximize resources for Veterans, VA repurposed or disposed of 
175 of the 430 vacant or mostly vacant buildings since June 2017. Due 
diligence efforts (environmental/historic) for the remaining buildings 
are substantially complete, allowing them to proceed through the final 
disposal or reuse process.
                           suicide prevention
    Suicide is a national public health issue that affects all 
Americans, and the health and well-being of our nation's Veterans is 
VA's top priority. Twenty (20) Veterans, active-duty Servicemembers, 
and non-activated Guard or Reserve members die by suicide on average 
each day, and of those 20, 14 had not been in our care. That is why we 
are implementing broad, community-based prevention strategies, driven 
by data, to connect Veterans outside our system with care and support. 
The fiscal year 2020 Budget requests $9.4 billion for mental health 
services, a $426 million increase over 2019. The Budget specifically 
invests $222 million for suicide prevention programming, a $15.6 
million increase over the 2019 enacted level. The request funds over 
15.8 million mental health outpatient visits, an increase of nearly 
78,000 visits over the 2019 estimate. This builds on VA's current 
efforts. VA has hired more than 3,900 new mental health providers 
yielding a net increase in VA mental health staff of over 1,000 
providers since July 2017. Nationally, in the first quarter of 2019, 90 
percent of new patients completed an appointment in a mental health 
clinic within 30 days of scheduling an appointment, and 96.8 percent of 
established patients completed a mental health appointment within 30 
days of the day they requested.
    Preventing Veteran suicide requires closer collaboration between 
VA, DoD, and the Department of Homeland Security (DHS). On January 9, 
2018, President Trump signed an Executive Order (13822) titled, 
``Supporting Our Veterans During Their Transition from Uniformed 
Service to Civilian Life.'' This Executive Order directs DoD, VA, and 
DHS to develop a Joint Action Plan that describes concrete actions to 
provide access to mental health treatment and suicide prevention 
resources for transitioning uniformed Servicemembers in the year 
following their discharge, separation, or retirement. On March 5, 2019, 
President Trump signed the National Roadmap to Empower Veterans and End 
Suicide Executive Order (13861), which creates a Veteran Wellness, 
Empowerment, and Suicide Prevention Task Force that is tasked with 
developing, within 1 year, a road map to empower Veterans to pursue an 
improved quality of life, prevent suicide, prioritize related research 
activities, and strengthen collaboration across the public and private 
sectors. This is an all-hands-on-deck approach to empower Veteran well-
being with the goal of ending Veteran suicide.
    For Servicemembers and Veterans alike, our collaboration with DoD 
and DHS is already increasing access to mental health and suicide 
prevention resources, due in large part to improved integration within 
VA, especially between the VBA and VHA. VBA and VHA have worked in 
collaboration with DoD and DHS to engage Servicemembers earlier and 
more consistently than we have ever done in the past. This engagement 
includes support to members of the National Guard, Reserves, and Coast 
Guard.
    VA's suicide prevention efforts are guided by our National Strategy 
for Preventing Veteran Suicide, a long-term plan published in the 
summer of 2018 that provides a framework for identifying priorities, 
organizing efforts, and focusing national attention and community 
resources to prevent suicide among Veterans. It also focuses on 
adopting a broad public health approach to prevention, with an emphasis 
on comprehensive, community-based engagement.
    However, VA cannot do this alone, and suicide is not solely a 
mental health issue. As a national problem, Veteran suicide can only be 
reduced and mitigated through a nationwide community-level approach 
that begins to solve the problems Veterans face, such as loss of 
belonging, meaningful employment, and engagement with family, friends, 
and community.
    The National Strategy for Preventing Veteran Suicide provides a 
blueprint for how the nation can help to tackle the critical issue of 
Veteran suicide and outlines strategic directions and goals that 
involve implementation of programming across the public health 
spectrum, including, but not limited to:

  --Integrating and coordinating Veteran Suicide Prevention across 
        multiple sectors and settings;

  --Developing public-private partnerships and enhancing collaborations 
        across Federal agencies;

  --Implementing research informed communication efforts to prevent 
        Veteran suicide by changing attitudes knowledge and behaviors;

  --Promoting efforts to reduce access to lethal means;

  --Implementation of clinical and professional practices for assessing 
        and treating Veterans identified as being at risk for suicidal 
        behaviors; and

  --Improvement of the timeliness and usefulness of national 
        surveillance systems relevant to preventing Veteran suicide.

    Every day, more than 400 Suicide Prevention Coordinators (SPC) and 
their teams--located at every VA medical center--connect Veterans with 
care and educate the community about suicide prevention programs and 
resources. Through innovative screening and assessment programs such as 
REACH VET (Recovery Engagement and Coordination for Health--Veterans 
Enhanced Treatment), VA identifies Veterans who may be at risk for 
suicide and who may benefit from enhanced care, which can include 
follow-ups for missed appointments, safety planning, and care plans.
    VHA has also expanded its Veterans Crisis Line to three call 
centers and increased the number of Veterans served by the Readjustment 
Counseling Service (RCS), which provides services through the 300 Vet 
Centers, 80 Mobile Vet Centers (MVC), 20 Vet Center Outstations, over 
960 Community Access Points and the Vet Center Call Center (877-WAR-
VETS). In the last two fiscal years, clients benefiting from RCS 
services increased by 14 percent, and Vet Center visits for Veterans, 
Servicemembers, and families increased by 7 percent.
    We are committed to advancing our outreach, prevention, and 
treatment efforts to further restore the trust of our Veterans and 
continue to improve access to care and support inside and outside VA.
             electronic health record modernization (ehrm)
    We made a historic decision to modernize our electronic health 
record (EHR) system to provide our nation's Veterans with seamless care 
as they transition from military service to Veteran status. On May 17, 
2018, we awarded a ten-year contract to Cerner Government Services, 
Inc., to acquire the same EHR solution being deployed by DoD that 
allows patient data to reside in a single hosting site using a single 
common system to enable sharing of health information, improve care 
delivery and coordination, and provide clinicians with data and tools 
that support patient safety. The fiscal year 2020 Budget includes $1.6 
billion to continue to support VA's EHRM effort to create and implement 
a single longitudinal clinical health record from active duty to 
Veteran status, and to ensure interoperability with DoD.
    The request provides necessary resources for post Go-Live 
activities completion of Office of Electronic Health Record 
Modernization's (OEHRM) three Initial Operating Capability (IOC) sites 
and full deployment of the remaining sites in Veterans Integrated 
Service Network (VISN) 20, the Pacific Northwest region. Additionally, 
it funds the concurrent deployment of waves comprised of sites in VISN 
21 and VISN 22, the Southwest region. The solution will be deployed at 
VA medical centers, as well as associated clinics, Veteran centers, 
mobile units, and other ancillary facilities.
    We are working closely with DoD to synchronize efforts as we deploy 
and test the new health record. We are engaging front-line staff and 
clinicians to identify efficiencies, hone governance, refine 
configurations, and standardize processes for future locations. We are 
committed to a timeline that balances risks, patient safety, and user 
adoption while also working with DoD in providing a more comprehensive, 
agile, and coordinated management authority to execute requirements and 
mitigate potential challenges and obstacles.
    Throughout this effort, VA will continue to engage front-line staff 
and clinicians, as it is a fundamental aspect in ensuring we meet the 
program's goals. We have begun work with the leadership teams in place 
in the Pacific Northwest. OEHRM has established clinical councils from 
the field that will develop National workflows and serve as change 
agents at the local level.
                      supply chain transformation
    VA has embarked on a supply chain transformation program designed 
to build a lean, efficient supply chain that provides timely access to 
meaningful data focused on patient and financial outcomes. We are 
pursuing a holistic modernization effort which will address people, 
training, processes, data and automated systems. To achieve greater 
efficiencies by partnering with other Government agencies, VA will 
strengthen its long-standing relationships with DoD by leveraging 
expertise to modernize VA's supply chain operations, while allowing the 
VA to remain fully committed to providing quality healthcare and 
applying resources where they are most needed. The fiscal year 2020 
budget includes $36.8 million in IT funding to support this effort.
    As we deploy an integrated health record, we are also collaborating 
with DoD on an enterprise-wide adoption of the Defense Medical 
Logistics Standard Support (DMLSS) to replace VA's existing logistics 
and supply chain solution. VA's current system faces numerous 
challenges and is not equipped to address the complexity of 
decisionmaking and integration required across functions, such as 
acquisition, logistics and construction. The DMLSS solution will ensure 
that the right products are delivered to the right places at the right 
time, while providing the best value to the government and taxpayers.
    We are piloting our Supply Chain Modernization program initially at 
the Captain James A. Lovell Federal Health Care Center (FHCC) and VA 
initial EHR sites in Spokane and Seattle to analyze VA enterprise-wide 
application. On March 7th, 2019, we initiated the pilot kickoff at the 
FHCC for VA's business transformation and supply chain efforts. This 
decision leverages a proven system that DoD has developed, tested, and 
implemented. In the future, DMLSS and its technical upgrade LogiCole 
will better enable whole-of-government sourcing and better facilitate 
VA's use of DoD Medical Surgical Prime Vendor and other DoD sources, as 
appropriate, as the source for VA medical materiel.
                         veterans homelessness
    The fiscal year 2020 Presidents Budget (PB) continues the 
Administration's support of VA's Homelessness Programs, with $1.8 
billion in funding, which maintains the 2019 level of funding, 
including $380 million for Supportive Services for Veterans Families 
(SSVF).
    Over the past 5 years, VA and its Federal partners have made a 
concerted effort to collaborate at the Federal level to ensure 
strategic use of resources to end Veteran homelessness. Coordinated 
entry systems are the actualization of this coordinated effort at the 
local level. Coordinated entry is seen, and will continue to be seen, 
as the systematic approach that is needed at the community level to 
ensure that resources are being utilized in the most effective way 
possible and that every Veteran in that community is offered the 
resources he or she needs to end their homelessness. All homeless 
Veterans in a given community are impacted by the coordinated entry 
system given that its framework is designed to promote community-wide 
commitment to the goal of ending homelessness and utilizing community-
wide resources (including VA resources) in the most efficient way 
possible for those Veterans who are in most need. This includes the 
prioritization of resources for those Veterans experiencing chronic, 
literal street homelessness. The number of Veterans experiencing 
homelessness in the United States has declined by nearly half since 
2010. On a single night in January 2018, fewer than 40,000 Veterans 
were experiencing homelessness--5.4 percent fewer than in 2017.
    Since 2010, over 700,000 Veterans and their family members have 
been permanently housed or prevented from becoming homeless. As of 
December 19, 2018, 69 areas--66 communities and three states--have met 
the benchmarks and criteria established by the United States 
Interagency Council on Homelessness, VA, and the
    Department of Housing and Urban Development to publicly announced 
an effective end to Veteran homelessness.
    Efforts to end Veteran homelessness have greatly expanded the 
services available to permanently house homeless Veterans and VA offers 
a wide array of interventions designed to find homeless Veterans, 
engage them in services, find pathways to permanent housing, and 
prevent homelessness from occurring.
                   opioid safety & reduction efforts
    In October 2017, the President declared the opioid crisis in our 
country a public health emergency. Opioid safety and reduction efforts 
are a Department priority, and we have responded with new strategies to 
rapidly combat this national issue as it affects Veterans. Success 
requires collaboration among VA leadership and all levels of VA staff--
from medical centers to headquarters--Congress, and community partners 
to ensure we are working with Veterans to achieve positive, life-
changing results. The fact that opioid safety, pain care 
transformation, and treatment of opioid use disorder all contribute to 
reduction of suicide risk makes these efforts particularly important. 
The fiscal year 2020 Budget includes $397 million, a $15 million 
increase over 2019, to reduce over- reliance on opioid analgesics for 
pain management and to provide safe and effective use of opioid therapy 
when clinically indicated.
    VA's Opioid Safety Initiative has greatly reduced reliance on 
opioid medication for pain management, in part by reducing opioid 
prescribing by more than 50 percent over the past 4 years. Most of this 
progress is attributable to reductions in prescribing long-term opioid 
therapy by not starting Veterans with chronic, non-cancer pain on 
opioid therapy and, instead utilizing multimodal strategies that manage 
Veteran pain more effectively long-term such as acupuncture, behavioral 
therapy, chiropractic care, yoga, and non-opioid medications.
    We are committed to providing Veteran-centric, holistic care for 
the management of pain and for promoting well-being. We are seeing 
excellent results as sites across the country deploy this ``Whole 
Health'' approach. Non-medication treatments work as well and are often 
better than opioids at controlling non-cancer pain. We want to assure 
Congress--and Veterans on opioid therapy--that Veterans' medication 
will not be--decreased or stopped without their knowledge, engagement, 
and a thoughtful discussion of accessible alternatives. Our goal is to 
make sure every Veteran has the best function, quality of life, and 
pain control.
                             women's health
    VA has made significant progress serving women Veterans in recent 
years. We now provide full services to women Veterans, including 
comprehensive primary care, gynecology care, maternity care, specialty 
care, and mental health services. The fiscal year 2020 Budget requests 
$547 million for gender specific women Veterans' healthcare, a $42 
million increase over 2019.
    The number of women Veterans using VHA services has tripled since 
2000, growing from nearly 160,000 to over 500,000 today. To accommodate 
the rapid growth, VHA has expanded services and sites of care across 
the country. VA now has at least two Women's Heath Primary Care 
Provider (WH-PCP) at all of VA's healthcare systems. In addition, 91 
percent of community-based outpatient clinics (CBOCs) have a WH-PCP in 
place. VHA now has gynecologists on site at 133 sites and mammography 
on site at 65 locations. For severely injured Veterans, we also now 
offer in vitro fertilization services through care in the community and 
reimbursement of adoption costs.
    VHA is in the process of training additional providers so every 
woman Veteran has an opportunity to receive primary care from a WH-PCP. 
Since 2008, 5,800 providers have been trained in women's health. In 
fiscal year 2018, 968 Primary Care and Emergency Care Providers were 
trained in local and national trainings. VA has also developed a mobile 
women's health training for rural VA sites to better serve rural women 
Veterans, who make up 26 percent of women Veterans. This budget will 
also continue to support a fulltime Women Veterans Program Manager at 
every VHA healthcare system who is tasked with advocating for the 
healthcare needs of women Veterans.
    VA is at the forefront of information technology for women's health 
and is redesigning its electronic medical record to track breast and 
reproductive healthcare. Quality measures show that women Veterans who 
receive care from VA are more likely to receive breast cancer and 
cervical cancer screening than women in private sector healthcare. VA 
also tracks quality by gender and, unlike some other healthcare 
systems, has been able to reduce and eliminate gender disparities in 
important aspects of health screening, prevention, and chronic disease 
management. We are also factoring care for women Veterans into the 
design of new VA facilities and using new technologies, including 
social media, to reach women Veterans and their families. We are proud 
of our care for women Veterans and are working to increase the trust 
and knowledge of VA services of women Veterans, so they choose VA for 
benefits and services.
                 national cemetery administration (nca)
    The President's fiscal year 2020 budget positions NCA to meet 
Veterans' emerging burial and memorial needs through the continued 
implementation of its key priorities: Preserving the Legacy: Ensuring 
``No Veteran Ever Dies''; Providing Access and Choosing VA; and 
Partnering to Serve Veterans. The fiscal year 2020 Budget includes $329 
million for NCA's operations and maintenance account, an increase of 
$13.2 million (4.2 percent) over the fiscal year 2019 level. This 
request will fund the 2,008 Full-Time Equivalent (FTE) employees needed 
to meet NCA's increasing workload and expansion of services, while 
maintaining our reputation as a world-class service provider. In fiscal 
year 2020, NCA will inter an estimated 137,000 Veterans and eligible 
family members and care for over 3.9 million gravesites. NCA will 
continue to memorialize Veterans by providing 383,570 headstones and 
markers, distributing 634,000 Presidential Memorial Certificates, and 
expanding the Veterans Legacy Program to communities across the country 
to increase awareness of Veteran service and sacrifice.
    VA is committed to investing in NCA's infrastructure, particularly 
to keep existing national cemeteries open and to construct new 
cemeteries consistent with burial policies approved by Congress. NCA is 
amid the largest expansion of the cemetery system since the Civil War. 
By 2022, NCA will establish 18 new national cemeteries across the 
country, including rural and urban locations. The fiscal year 2020 
request also includes $172 million in major construction funds for 
three gravesite expansion projects (Houston and Dallas, TX and Bourne, 
MA) and additional funding for the replacement cemetery in Bayamon, PR, 
the gravesite expansion project in Riverside, CA, and the new national 
cemetery in Western NY. The Budget also includes $45 million for the 
Veteran Cemetery Grant Program to continue important partnerships with 
States and tribal organizations. Upon completion of these expansion 
projects, and the opening of new national, State and tribal cemeteries, 
nearly 95 percent of the total Veteran population--about 20 million 
Veterans--will have access to a burial option in a national or grant-
funded Veterans cemetery within 75 miles of their homes.
                             accountability
    The fiscal year 2020 Budget requests direct appropriations for the 
Office of Accountability and Whistleblower Protection (OAWP) for the 
first time since it was established. The total request for OAWP in 
fiscal year 2020 is $22.2 million, which is $4.5 million, or 25 percent 
higher than the 2019 funding level. This funding level demonstrates 
VA's commitment to improving the performance and accountability of our 
senior executives through thorough, timely, and unbiased investigations 
of all allegations and concerns. This funding level will also enable 
OAWP to continue to provide protection of valued whistleblowers against 
retaliation for their disclosures under the whistleblower protections 
provisions of 38 U.S.C. Sec. 714. In fiscal year 2018, OAWP assessed 
2,241 submissions, conducted 133 OAWP investigations, and monitored 
over 1,000 referred investigations. These efforts are part of VA's 
effort to build public trust and confidence in the entire VA system and 
are critical to our transformation.
    The fiscal year 2020 budget also requests $207 million, a $15 
million increase over 2019, and 1,000 FTE for the Office of Inspector 
General (OIG) to fulfill statutory oversight requirements and sustain 
the investments made in people, facilities, and technology during the 
last 3 years. The 2020 budget supports FTE targets envisioned under a 
multi-year effort to grow the OIG to a size that is more appropriate 
for overseeing the Department's steadily rising spending on new complex 
systems and initiatives. The 2020 budget request will also provide 
sufficient resources for the OIG to continue to timely and effectively 
address the increased number of reviews and reports mandated through 
statute.
                               conclusion
    Thank you for the opportunity to appear before you today to address 
our fiscal year 2020 budget and fiscal year 2021 AA budget request. VA 
has shown demonstrable improvement over the last several months. The 
resources requested in this budget will ensure VA remains on track to 
meet Congressional intent to implement the MISSION Act and continue to 
optimize care within VHA.
    Mr. Chairman, I look forward to working with you and this 
Subcommittee. I am eager to continue building on the successes we have 
had so far and to continue to fulfill the President's promise to 
provide care to Veterans when and where they need it. There is 
significant work ahead of us and we look forward to building on our 
reform agenda and delivering an integrated VA that is agile and 
adaptive and delivers on our promises to America's Veterans.
    Thank you.

    Senator Boozman. Thank you, Mr. Secretary, very much.
    Secretary Wilkie, Mr. Rychalski, as we discussed 
previously, it's important for the department to share timely 
information with the committee. I appreciate your efforts to 
improve transparency, including the VA providing more frequent 
updates in advance of the June 6th implementation of the 
Veterans Community Care Program established under the MISSION 
Act.
    The committee supports providing the necessary resources 
for veteran health care. However, we are concerned about 
somewhat of a disconnect between the cost estimates provided at 
different points in time.
    I know it's really difficult with health care, you know. 
You have an aging population and it's difficult to predict a 
very new system, but again anything we can do to help you get 
that under control, we will do.
    Based on the latest estimates, factoring in spending to 
date, what additional appropriations are required to fiscal 
year 2020 to fund the expected cost on your best estimates 
today?
    Mr. Rychalski. So I think our request will be adequate. We 
don't at this time foresee any need for additional resources.
    Senator Boozman. Okay.
    Mr. Rychalski. Nor in 2019.
    Senator Boozman. Do we have your commitment from VA to 
continue to share information if that changes and regular 
updates with the committee staff as the program's implemented?
    Mr. Rychalski. Absolutely.
    Senator Boozman. Very good. Dr. Stone, VA will roll out the 
Veterans Community Care Program on June 6th. In addition to 
developing the required regulations, we know that VA has been 
working hard to have contracts and systems in place and tried 
to secure backup options, where possible. Are you ready? Do you 
feel like you're going to be able to meet your goal?
    Dr. Stone. We do. This is certainly a complex rollout and I 
would say that we'll find someplace where there's a bump in the 
road, but we do believe that we've created the appropriate 
safety net around this system that we can transition from the 
Choice Program to the new Community Care Program.
    I say that in spite of the fact that we're still resolving 
protests in Region 1 and 2 and have a pre-award protest in 4 
and so as we work our way through--I'm sorry 2 and 3, we're 
resolving protests. 1, we are moving forward with Optum.
    So as we do this, I think we're ready to go, and I 'm quite 
pleased at the progress that TriWest has made as the safety net 
to all of these programs.
    Senator Boozman. One of the challenges is going to be 
providing the education, the tools to the providers and the 
veterans as far as what their benefit will be. Can you talk a 
little bit about how you're going about that?
    Dr. Stone. I can. We brought the entire leadership of the 
system of the enterprise in last week and met with them. We are 
dedicating ourselves the next six weeks to the rollout of this 
program. We developed tracking tools to track the training, 
almost all of the training for the automated systems as well as 
for the execution of this, our online and web-based training.
    That said, that allows us to track the training 
efficiently. We are standing up in our Health Operations Center 
the appropriate metrics and can share with the committee as we 
progress through the month the actual effectiveness of that 
training.
    At the time we go live, we will put the entire management 
team in VHA on the road into various clinics to assure that we 
have not only fielded the electronic systems appropriately but 
we've also trained appropriately and that we have not adversely 
affected veterans.
    Secretary Wilkie. Senator, I would add that, and I agree 
with Dr. Stone, I don't anticipate a hiccup on June 6th, but we 
have put in place redundancies in the event that the decision 
support tool is 90 percent effective.
    Our goal is to make sure that no veteran is left out and 
that we have the system in place to address the changes that 
this Congress has voted for.
    Senator Boozman. Good. Thank you.
    Senator Schatz.
    Senator Schatz. Thank you.
    A question for the chief financial officer. You've got $8.9 
billion increase within the Medical Care budget and then a $7 
billion increase in the proposed discretionary spending and so 
it seems to me that you want a $7 billion bump but in order to 
get $8.9 billion in total increased spending you have to find 
$1.9 billion worth of savings. Can you tell me about that?
    Mr. Rychalski. Yeah. We don't actually have to find the 
savings. That's a function of obviously three parts.
    First off, our Community Care request in the advanced 
appropriation for 2020 was two billion more. So you could say 
that's two billion of the eight billion. Our second bite was 
4.6 billion and then the balance will be carryover. We 
anticipate to carry my guess would be between two and three 
billion this year.
    So it's all actually covered, you know, through our 
requests. There's no movement of money, for example, from 
Medical Services to Community Care. It's all sort of organic 
growth.
    Senator Schatz. Okay. Secretary Wilkie, I want to preface 
this question by saying that over the past 9 months, your 
judgment in leading the VA has been clear and consistent, but 
to your knowledge, did any individuals outside of the VA have 
an inappropriate or undue influence in the policy or 
decisionmaking of the VA before you became the Secretary?
    Secretary Wilkie. I am not aware of anything along those 
lines. I will say that the individuals that you're talking 
about, and this was addressed in my confirmation hearing, when 
I was acting, I had one meeting when I was down in Palm Beach.
    It was a courtesy meeting and as Pro Publica pointed out, 
the decision that I made on the electronic health record was in 
contravention to what Pro Publica reported the desires of those 
individuals to be and I have not had any meetings with them 
since.
    I'm happy to meet with anyone who wants to talk about 
veterans, but to answer your question is no.
    Senator Schatz. Thank you.
    I am pleased that you will not be contesting the decision 
about the Bluewater Navy. Thank you for that. But we are the 
Appropriations Committee. So the question is how are we going 
to pay for these 90,000 veterans who deserve this decision, 
deserve this care, but it's not a zero cost? So is this 
something we anticipate getting a request for an additional 
appropriation or can we absorb this through our process?
    Secretary Wilkie. Well, we are just at the beginning of the 
process. So let me take a step back and say that there are 
already 30,000 sailors who would fall under the Procopio 
decision who are getting treatment at VA now for conditions 
that would be listed under Agent Orange.
    The second part of this is going to be an investigatory 
exercise. We have already met with the Department of the Navy 
and we're actually having to piece together Navy logs, Navy 
declarations from over 50 years ago, but that process has 
started. So right now, I can't give you a figure.
    Senator Schatz. So this doesn't sound like necessarily a 
current fiscal year cost.
    Secretary Wilkie. No, it doesn't. But we are beginning the 
process.
    Senator Schatz. You're beginning to lay eyes on it and 
you'll let us know.
    Secretary Wilkie. That's right.
    Senator Schatz. And I assume you could probably do a back 
of the envelope sort of outside, if it's 90,000 minus 30,000 
times the average benefit, I mean, you could tell us what this 
is projected to cost?
    Mr. Lawrence. That's certainly true, sir, but I would point 
out the following. It may be 90,000 people who get the 
benefits, but the number of people who will apply, whose claims 
we will process is likely to be much larger.This is the kind of 
computations, the math we're doing that the Secretary talks 
about.
    Senator Schatz. Oh, so you're going to land on 90,000 or 
you anticipate landing on 90,000 who are eligible, which means 
you may have to process hundreds of thousands of claims?
    Mr. Lawrence. That is the math we're going through but 
that's exactly right.
    Senator Schatz. Which means you may have a throughput 
problem, you may have capacity, you may have to hire up for 
this purpose, and all of that, correct?
    Mr. Lawrence. You're describing some of the things we're 
now going through and thinking about. That's right.
    Senator Schatz. Okay. Well, as soon as we can know what 
that looks like, I'm sure we'll be anxious to--
    Secretary Wilkie. And I would also say part of the Sherlock 
Holmes aspect of this, the Navy records are incomplete. Some 
people received Vietnam C Service ribbons because they were 
attached to a ship but they were back in Washington State but 
were part of the ship's manifest. So those are the kinds of 
things that we're going to be looking at.
    Dr. Stone. Senator, if I could, we have done some actuarial 
projections in VHA. If the number ends up to be 90,000, we're 
anticipating just under 700 million in additional health care 
costs.
    Senator Schatz [continuing]. Annually?
    Dr. Stone. Annually.
    Senator Schatz. Thank you.
    Senator Boozman. Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman.
    Secretary, gentlemen, thank you for all you do.
    Secretary, I'm pleased to hear of your very targeted focus 
on the issue of suicide and what we all can be doing to help 
address this grim reality.
    In Alaska, we face a demand for medical providers that 
often exceeds the supply of providers and certainly on the 
mental health side, but under the leadership of Dr. Ballard, 
the Alaska VA Health Care System has been active in recruiting 
some new providers, both for the Anchorage facility and for the 
Sea Block with some success which we're pleased with, but Dr. 
Ballard's concerned that with this impending takeover of the 
Air Force Medical Facility at JBER by the Defense Health 
Agency, that it could actually result in the loss of some 
medical providers that are currently supporting the VA there in 
the state.
    So he has encouraged me. We're working together to explore 
whether joining DoD and VA resources into a single DoD/VA 
Federal health care center would be helpful. I understand this 
similar type arrangement is already in place in North Chicago.
    Dr. Ballard thinks that expanding this model to the state 
would not only create some efficiencies for both the VA but the 
DoD but also ensure that an adequate provider base exists there 
in the state to ensure that we have better access.
    Would you care to comment on Dr. Ballard's proposal?
    Secretary Wilkie. I would first, Senator, like to make a 
comment about your observations about suicide.
    I spent a great deal of time in Alaska. Actually, you and I 
shared a stage but you were calling in from out of the country. 
The first time I did as Secretary was go to the Alaska 
Federation of Natives and I asked them to double the number of 
tribal VA representatives they have to help us find the more 
than half of the veterans in Alaska who are not part of our 
system.
    Senator Murkowski. Which has made a difference and is 
working. Thank you.
    Secretary Wilkie. And I am coming back in the summer to go 
deeper into your state.
    You're absolutely right on the way to the future and that 
is very close DoD/VA what I would call cross-pollination. 
Secretary Mattis and I were very clear on bringing the two 
departments together. I think we already see what DoD/VA 
cooperation can be in Alaska with the co-location of both the 
Air Force and VA.
    The other thing that I would add that Alaska provides is 
the robust Native Health Care System which is an adjunction.
    Senator Murkowski. Putting IHS in with VA/DoD long term is 
a real synergy there.
    Secretary Wilkie. Yes. So what we are doing in Alaska now 
to validate your observation, we are testing out the electronic 
health record. We testing out our new supply chain 
relationships with DoD and what I will be coming back to this 
committee hopefully in the next year is a proposal to create a 
more robust VA-type ROTC Program where we up the amount of 
money that we provide to medical professionals to pay off their 
debts, to relocate them, to offer incentives to go deeper into 
Rural America. This applies as much to Alaska as it does to 
Montana, and I think we're going in the right direction.
    The last thing I will say, having been responsible for the 
Defense Health Agency prior to coming here, I will promise you 
that I will take a look and make sure that if I have a voice in 
it, that there is no diminution of services in Alaska because 
of the consolidation of Defense Health. As someone who is close 
to the department, Alaska's contribution to national defense 
will only get larger and I expect more people, more uniforms 
flowing into Alaska and it would be a mistake for DHA to reduce 
its presence.
    Senator Murkowski. Well, I appreciate you saying that and 
your commitment on that.
    I hope you're going to be able to make another commitment 
to me and that is the implementation, I guess, of the MISSION 
Act. As you know, the implementation of the Choice Act in 
Alaska didn't go well. You weren't there at the time, but we 
were hearing our vets say they called it no choice or bad 
choice. There were a lot of problems with implementation, and I 
have to admit I don't necessarily have a lot of confidence in 
the implementation of the MISSION Act and in the state.
    So what I'm hoping that you can provide to me and to 
Alaska's veterans is that the MISSION Act will be implemented 
in a more veteran-centered manner than we saw with Choice and 
making sure that the Alaska Native Health Care System and our 
community health centers are fully, fully engaged in 
implementation of the Choice Act.
    Secretary Wilkie. Yes, ma'am. I made that commitment to the 
Alaska Native health leaders and I'm coming back to renew that 
shortly after MISSION goes into effect.
    Senator Murkowski. I appreciate that. I look forward to 
your visit.
    Thank you, Mr. Chairman.
    Senator Boozman. Senator Tester.
    Senator Tester. Thank you, Mr. Chairman and Ranking Member, 
and thank you all for being here. I appreciate you, Mr. 
Secretary, and your team, Doctor and Paul and Randy and fellow 
Montanan, who spells his name right. Thank you all for being 
here.
    Look. I'm going to dovetail off of where Senator Murkowski 
talked about and I think everybody around this table can talk 
about the train wreck that the Choice Program was because it 
truly was a train wreck, and we want to make sure that the 
MISSION Act isn't the same train wreck, by the way, because I 
think it could be, you know. I think we need to be aware of 
that.
    So this can be for you, Secretary Wilkie, or you, Dr. 
Stone, but the fact is, is that the largest health provider in 
Montana is not signing up with the TPA right now, which is 
TriWest, because they think back on what a train wreck the 
previous TPA was and it's a problem and this is a pretty big 
provider in Montana, in fact the biggest provider.
    So I'll lay out the scenario and you tell me. They have an 
uneasy feeling with what happened with HealthNet and so they 
don't have an agreement yet and this thing is supposed to go 
live June 6th and it's my understanding that if they're not 
signed up, the vets can't go there, which makes sense, by the 
way, because there's no agreement on how to get them paid.
    So there's no agreement. There's no provider in the private 
sector for them, and it is my also understanding that we've 
already had a pre-protest on the award of the contracts. Tell 
me what the hell's going to happen here.
    Dr. Stone. Senator, this is exactly why the Secretary asked 
us to build a safety net around this just because our 
experience with Tricare in the past when we were on the DoD 
side. We understand that these are often protested.
    Now, although I think we'll be successful in both Region 2 
and 3 as well as in the pre-award, let me say to you this is 
why we built the TriWest piece.
    Now in the state of Montana, we have already signed up to 
TriWest over 4,500 providers. You are absolutely correct that 
one of the large providers or the largest provider has decided 
not to come along.
    Senator Tester. Yeah.
    Dr. Stone. TriWest has been a good partner. TriWest pays 
its bills on time and meets its obligations and we've been 
pleased. So I'd be personally willing to get engaged with this 
provider.
    Senator Tester. Yeah. And I really do appreciate that, but 
my guess is this has happened in Montana, it's probably 
happening in every state in the Union.
    Dr. Stone. The Mayo Clinic.
    Senator Tester. So the question becomes is TriWest is not 
the permanent provider. You can't tell me they're going to be a 
permanent provider today or the pre-protest might work and so 
the question is why would the Billings Clinic in this case sign 
up with TriWest when there's going to be another contract 
awarded in what, a month after June 6th, a year after June 6th?
    Dr. Stone. Well, it hasn't even come out yet. So we have a 
contract with TriWest till September of this year and we have 
one option year in that contract. So it could take us 6 months 
to a year to get this contract out and get it implemented.
    Remember also as these contracts become implemented, they 
go into pilot sites for the first 12 months before they 
actually come out. So I think we're going to be with TriWest 
for a while and I would encourage the Billings Clinic to give 
serious consideration.
    Senator Tester. Well, I just--look, my concern here is, and 
I think you guys get it, is that we've got a situation where 
unless we cut some of the red tape out of this, unless we make 
it more user friendly, it may be, as Senator Murkowski said, 
just as big a problem as Choice.
    Dr. Stone. Senator, I agree with your concern. I meet 
monthly with TriWest. They have over 400,000 providers under 
contract nationwide.
    Senator Tester. Okay. Well, it is a concern to me and I'm 
going to put my faith that we'll get it ironed out. We have a 
bipartisan bill that would allow Guardsmen and the Reservists, 
regardless of duty status, duty access, to have access to vet 
centers, same kind of access we grant to Active Duty folks.
    Is there anything the VA can do right now to make these 
resources--I mean, we've talked about suicide. This is one of 
the things that could help.
    Dr. Stone. Yeah. I think there are some things we can do 
right now. Number 1, any veteran or Guardsman or Reservist 
that's never been activated that's on that edge of whether 
they're a veteran or not, that's never been activated to 
Federal service is welcome to come in if they're in crisis.
    I think secondly, we've reached out with our mobile vet 
centers to Guard and Reserve formations. We've met with 
leadership of the Army Guard and the Army Reserve and we've 
entered into a Memorandum of Agreement with the National Guard, 
with the Army National Guard in order to reach out to them to 
welcome them.
    Senator Tester. Okay. When did that happen?
    Dr. Stone. Within the last 2 months.
    Senator Tester. Okay. Do you anticipate the Air Guard will 
be onboard, too?
    Dr. Stone. I would expect they would be, yes.
    Senator Tester. Okay. That's good. Hopefully Senator Reed 
will come back, but when it comes to DHR and I'm going to close 
it off, you don't have to answer this, but as far as the 
formalized government structure, it still hasn't been done.
    I still think the DoD's going to be driving the bus on this 
and I'm not sure that we want DoD to be exclusively driving the 
bus on electronic health records, not that there's anything 
wrong with the DoD, it's just that I think you guys are pretty 
smart, too. Okay?
    And so the question is, is could we get this addressed? I 
mean, I had the Defense Department in and talked about it and 
they said that, yeah, we're doing it and don't worry about it 
because we know what the VA wants. I'm not sure the VA, they 
know what the VA wants, unless the VA is at the table telling 
them what they want.
    Secretary Wilkie. Before Dr. Stone answers that, I agree 
with you. This time, we're in the unusual position of being the 
biggest customer on the block, much bigger than DoD is, and I 
come to the table with that in my back pocket.
    Senator Tester. Okay. Well, we just need to make sure you 
guys' voices are heard.
    Thank you very much.
    Senator Boozman. Senator Collins.
    Senator Collins. Thank you, Mr. Chairman.
    Mr. Secretary, let me begin by thanking you for your recent 
visit to Maine to attend the groundbreaking on the new Veterans 
Home and also to tour the innovative program called Cabin in 
the Woods, which provides shelter and services to our homeless 
veterans. On behalf of all the veterans of Maine, I want you to 
know that your visit meant a great deal to them.
    Secretary Wilkie. Thank you. It was an honor.
    Senator Collins. I have been working closely with former 
Senator Elizabeth Dole on caregivers, military caregivers. Last 
month, I was pleased to see that the VA had concurred in 
principle with all 12 recommendations of the Veterans Families 
Caregivers and Survivors Federal Advisory Council, a panel 
which includes Senator Elizabeth Dole and many other experts.
    The number one issue identified by caregivers did not 
surprise me. It was the need for more respite care and I know 
in the budget you've included additional funding to accommodate 
the expansion that's in the MISSION Act for respite care.
    Could you give us an update on how the VA intends to 
increase the utilization and the effectiveness of its Respite 
Care Programs, Dr. Stone?
    Dr. Stone. Senator, thank you.
    A recognition of the stressors that go into providing care 
cannot be overstated. The average caregiver has a dramatically 
higher incidence of illness in themselves as they go through 
this process.
    We absolutely believe in the provision of respite for that 
caregiver and we have a number of programs through our 
Caregiver Program to help train them to recognize the need to 
take a break, to take time off, and we have funding, as you 
have mentioned, in our budget in our ability to provide that.
    So I think it is about establishing this ongoing 
partnership with the caregiver. It's one of the reasons we ask 
for regular interaction and recertification of the caregiver's 
interaction with the veteran to make sure that everybody 
remains healthy as the years go by, but I appreciate your 
recognition.
    Let me also say that Senator Dole has been a wonderful 
partner in this and what a treasure she has been. Both the 
Secretary and I have had the chance to meet with her recently 
and I will tell you that it's on target, it's appropriate, and 
we're just very pleased to have this partnership.
    Thank you.
    Senator Collins. She has been absolutely terrific leader in 
this issue and testified at a hearing that I held.
    We also heard from a couple from the state of Maine and it 
all of a sudden occurred to me that the spouse was going to be 
taking care of her husband for the next 50-60 years. We're not 
talking about a short period of time. She'd had to leave her 
job and the stress on her was just extraordinary and I know the 
Dole Foundation is doing a lot in that area.
    Secretary Wilkie. And I would also say that one of the most 
important aspects of the MISSION Act for me because my mother 
fell into that category is that it finally closes the loop on 
the Vietnam era and redresses a wrong that has existed for 
decades.
    Senator Collins. You are so right about that and that's 
something that I worked with Senator Murray on for years to try 
to get that extension.
    Let me quickly cover one other issue. An under-utilized 
element of the G.I. Bill is its apprenticeship and on-the-job 
training programs and, Dr. Lawrence or Secretary Lawrence, I'm 
going to address this to you.
    In fiscal year 2018, fewer than 1,500 veterans participated 
in apprenticeships and approximately 1,400 participated in on-
the-job training and that's out of more than one million 
beneficiaries of VA's Education Programs.
    Now an obvious benefit of apprenticeship and on-the-job 
training programs is these veterans are going to get jobs upon 
completion with the people running these programs in many 
cases.
    What can the VA do to increase awareness of and 
participation in these programs?
    Mr. Lawrence. I believe our staff met with your staff to 
talk through some of these issues and we agree. This part is 
for the trades, if you will, and vet tech in the Forever G.I. 
Bill is much more for high tech, so both of these are great 
programs.
    We have scratched our head, as well, and we agree with you. 
We've done an awful lot of COMs and the like. We actually think 
there's some things in the program that might be worth talking 
about in terms of what we could do together to sort of fix some 
of the things we've gotten some feedback on in terms of the 
administration of it that might also open it up to the people 
willing provide the apprenticeships. So we'd be happy to talk 
to you more about this.
    Senator Collins. Great. Thank you, Mr. Chairman.
    Senator Boozman. Senator Baldwin.
    Senator Baldwin. Thank you, Mr. Chairman.
    I want to start by thanking Secretary Wilkie and Dr. Stone 
for personally spending some time with constituents of mine, 
the Simkusgee family, and the senior level briefings that you 
provided them with the progress of implementation of a law 
named in honor of their son Jason was very much appreciated.

    And I think even more than that, the change in the culture 
at the VA with regard to prescribing highly-addictive opioids 
as well as providing non-addictive medications or non-
medication alternatives for veterans who experience pain is 
something that they have noted and so we certainly have more 
work to do, but I wanted to thank you for your personal 
commitment on this issue, and I would mention that several 
members of this committee, this subcommittee also took the time 
to catch up with the Simkusgee family.
    Secretary Wilkie, on the topic of Jason's Law, can you 
provide the committee in writing with a detailed spend-down 
plan for the $54 million requested for fiscal year 2020 and the 
$56 million requested for fiscal year 2021 for the Jason 
Simkusgee Memorial and Promise Act?
    Secretary Wilkie. Yes, Senator, we can, and I want to also 
emphasize that the entire budget for opioid reduction comes in 
at almost $400 million.
    Senator Baldwin. Yes, you've anticipated my next question, 
which is can you also provide in writing a detailed spend-down 
plan for the $397 million for fiscal year 2020 and the $412 
million for fiscal year 2021 related to opioid prevention and 
treatment under the Medical Care Account?
    Secretary Wilkie. Absolutely.
    Senator Baldwin. Great.
    Secretary Wilkie. I will also say that because of the push 
from the Congress in allowing us to look at new ways to treat 
this national crisis, that we've reduced the percentage of 
prescription of opioids down by 51 percent, which no other 
health care system has.
    Senator Baldwin. There's some very encouraging and 
impressive results and I was pleased last session that this 
subcommittee held a hearing devoted to that specific topic. I 
hope we may think about doing that again.
    I wanted to turn to the Community Care Transition. The VA 
is moving ahead, as you've already discussed, with a June 6th 
transition to Community Care and like my colleagues, I'm 
already hearing from veterans and outside providers who are 
extremely concerned about this rollout.
    I, too, have entire hospital systems who have still not 
signed on to working with TriWest because of how poorly the 
previous third party administrator, HealthNet, had performed.
    Let me give you just one example of how this is affecting a 
Wisconsin veteran. Wisconsin Navy Veteran Alan Rice is 
receiving palliative chemotherapy treatments through Community 
Care with Gunderson Health System in Wisconsin.
    Gunderson has not signed a contract with TriWest as of 
today and because of that, they really cannot tell his family 
what will happen after June 6th.
    Now he and his family are simply trying to have some time 
together in peace, but they're spending a lot of their time 
anxious about and looking into, you know, what sort of access 
to care he will have after June 6th.
    His daughter wrote me and said, ``My daddy just wants to 
stay alive long enough to go fishing this summer with his 
lifelong friends and family. Is he asking too much?''
    So, Secretary Wilkie, I suspect you'll agree that Mr. Rice 
isn't asking too much and this situation is not acceptable and 
so what are we going to do to ensure that before June 6th 
veterans like Mr. Rice aren't cut off from their Community Care 
and, more importantly, what can we do today to fix this so that 
he and his family and others like them are not spending the 
next month scared, anxious, and terrified about what comes 
next?
    Secretary Wilkie. I completely agree with the sentiment, 
and I mentioned earlier that one of the things that I've put in 
place redundancies in the system so that if lighting strikes 
and the computers go down, that we have a process in place to 
continue the care for veterans, such as your constituent.
    Dr. Stone. With the Chairman's permission, this type of 
anxiety in a palliative situation is not tolerable and 
therefore please let me assure you and this family and we can 
do that directly with your staff that--
    Senator Baldwin. Thank you.
    Dr. Stone [continuing]. care that is authorized will be 
completed.
    Now just as I answered to Senator Tester, we would love for 
that health care system to come onboard with us and we can 
assure them, you know, when the Secretary and I arrived last 
summer, our Community Care was processing about a 140,000 
payments a month. They're now processing 2.3 million payments a 
month to providers. We're doing the right thing and trying to 
build the trust back that we've lost and with your help, we 
would appreciate each of these families knowing that we will 
complete all authorized care that's been authorized under the 
Choice Act.
    Senator Baldwin. Thank you. We will follow up, especially 
concerning that constituent family.
    Mr. Chairman, with your indulgence, could I just state a 
question that I'll ask for the record?
    We had lots of discussion this hearing about suicide 
prevention and, Secretary Wilkie, you've talked about the key 
role that tribal and county veterans service officers play in 
connecting veterans with the VA for all services but including 
the capacity to intervene if there's a risk of suicide.
    I'm fashioning a bill that would put some direct Federal 
funding into making a more robust county and tribal veterans 
service outreach capacity and I would like to ask for your 
consultation and feedback on that draft legislation.
    Secretary Wilkie. Absolutely. Mr. Chairman, with your 
indulgence, I've actually had this conversation with Senator 
Udall.
    The goal that I've set for the President's Task Force on 
Suicide Prevention is to open the aperture of Federal funding 
and materiel support to non-governmental agencies but also to 
tribal governments across the country.
    I mentioned earlier my dealings with the Navy, governments 
of Alaska, more than half the veterans in that state are 
outside the system. The only way we can get to them and it 
applies in New Mexico, it applies in Wisconsin and Montana, is 
by going through the local governments and the tribal 
governments.
    Senator Boozman. Senator Hoeven.
    Senator Hoeven. Thank you, Mr. Chairman.
    Thanks to all of you for being here today and for your work 
on behalf of veterans.
    Mr. Secretary, we talked about implementation of the 
missions of the VA Act. I know you're writing the regs and 
moving toward getting that proposed regulation out in order to 
get the final reg out in time, which I think is June.
    One of the things I've talked to you about before is VA 
reimbursement for long-term care and for home- and community-
based care and as you're aware, we worked very hard to include 
legislation in the MISSION Act which basically provides that 
the treatment for veterans going into a nursing home or using a 
home- and community-based care needs to be the same in terms of 
getting reimbursement from the VA as from Medicare or Medicaid.
    Only 20 percent of nursing homes take VA reimbursement 
because they have a whole separate regulatory regime, including 
separate inspections and separate regulations, if they take VA 
reimbursements.
    So we need to know that that regulation implementation will 
in essence provide that for nursing homes and in-home care 
providers that they can follow the same set of regulations and 
inspections and get VA reimbursement as they do for Medicare 
and Medicaid, not two standards, one standard, and this 
regulation is vitally important.
    As you know, I've not only talked to you about it, but also 
the Secretary of HHS and the Secretary of Labor.
    Where are we with this, and can you assure me that it is 
going to be one set of standards and not two?
    Secretary Wilkie. I am confident that we will have the 
final rule based on your efforts when we launch MISSION Act on 
June 6th. I anticipate that being part of the launch of MISSION 
Act.
    Dr. Stone. Senator, I share the Secretary's confidence that 
by June 6th, we'll have the final rule in place.
    You are exactly correct. This is a very complex area. The 
MISSION Act was written such that it gives us the leeway to 
execute at the local level from our local and regional health 
care systems veteran care agreements with long-term care 
facilities that will meet the intent of allowing these great 
providers to accept veterans and be reimbursed appropriately.
    Senator Hoeven. Will you commit to having a webinar with 
the Long-Term Care Association, the Home-Based Care 
Association, with the Providers Association, so that they can 
not only understand the proposed reg but give you important 
feedback on it?
    Dr. Stone. Senator, I will commit to that, but let me say 
to you that with your permission, I would like to have the head 
of our Community Care Program, Kim Matthews, present because 
she's got the expertise in the nuances of this Act.
    Senator Hoeven. But she will conduct a webinar with them to 
make sure that that input is provided?
    Dr. Stone. Yes.
    Secretary Wilkie. And brief you.
    Senator Hoeven. Very good. Thank you. That's very 
important, very helpful, and much appreciated.
    Mr. Secretary, you are coming to North Dakota. We're 
already working on scheduling.
    Secretary Wilkie. Yes, sir.
    Senator Hoeven. We appreciate it very much not only because 
you're going to see our outstanding VA health care facility in 
Fargo and it is tremendous. They do a tremendous job. Having 
you come see what they do, of course, is very important to 
them, but a lot of times we hear about VA centers that aren't 
getting the job done.
    The professionals at our VA center in Fargo, which serves 
all of North Dakota and half of Minnesota, probably more than 
half of Minnesota.
    Secretary Wilkie. More than half.
    Senator Hoeven. They do a great job and the veterans will 
tell you. So we're very appreciative of your coming there, but 
the other thing that's very important is we now have a 
hyperbaric oxygen treatment facility there that you need to see 
because we're working on incorporating it as part of your pilot 
project and so what I would like to understand from you is, 
we've talked a lot with Dr. Clancy and others, are we making 
progress on incorporating that in the pilot project because 
right now, you have facilities in California and Oklahoma and 
Florida.
    Secretary Wilkie. And Louisiana
    Senator Hoeven. And Louisiana. None of which are real close 
to the Upper Midwest, and so we need something up there and I 
want your commitment to help us get that done.
    Secretary Wilkie. Absolutely. And I committed to visiting 
with you the center in North Dakota as well as touring your 
state veterans home because the efforts that you've made. It's 
very important that we see that cooperation between VA and the 
state veterans' home.
    Senator Hoeven. It really is, and there's a great 
confluence of resources on the part of our hospitals and others 
coming into that center that I think is very supportive of 
getting something done and it'd be helpful not only to the VA 
but most importantly, to our veterans in this area.
    Then we have other things along the Historic Line that you 
and I have talked about that I think you'll be pleased to see 
and again we're deeply appreciative of your work across the 
board and the fact that you're coming. So we thank you for 
that.
    Secretary Wilkie. Thank you, sir.
    Senator Boozman. Senator Udall.
    Senator Udall. Thank you, Chairman Boozman, and thank you, 
Ranking Member Schatz, for holding this hearing, an important 
hearing, I think, to address the critical funding for the U.S. 
Department of Veteran Affairs.
    Mr. Secretary, we appreciate you being here to answer 
questions and thank you also for meeting with me in my office 
earlier this year to discuss some of the issues that I planned 
to raise today.
    Last year, Congress appropriated 779 million for medical 
research at the Department of Veterans Affairs. In your request 
to Congress, you recommend cutting that amount by 17 million. 
How do you justify that cut?
    Mr. Rychalski. So it's not an accounting trickery, but it's 
actually not a cut because in 2019, we had a one-time $27 
million increase that was for some work we were doing with 
Department of Energy. So if you set aside that one-time, we had 
actually about a $10 million increase this year and it's just 
because of that one-time anomalous amount.
    Senator Udall. Well, that last year's appropriation of $27 
million supports that partnership.
    Mr. Rychalski. It does.
    Senator Udall. We call the big data science.
    Mr. Rychalski. And that's going to go on for some time and 
that is not included in our request. That was a one-time 
funding issue.
    Senator Udall. And much of the work there is being done by 
researchers at National Laboratories, including New Mexico's 
Sandia and Los Alamos. I would encourage you to continue and 
increase your work with the National Labs.
    Do you support making the big data science program an 
annual appropriation? Do you support expanding the program to 
benefit more veterans? For instance, expand data analysis of 
veterans who were exposed to burn pits?
    Secretary Wilkie. Let me talk about burn pits first. I was 
on public radio yesterday in the Delaware Valley and I said 
that one commitment that I've made to the Congress is that I 
will not see what happened to veterans from Vietnam and Agent 
Orange happen again. I've actually talked with General Petraeus 
about this.
    Saigon fell 44 years ago next week and it wasn't until the 
1990s when we recognized the Agent Orange issue. So I'm 
committed to do everything we can so we don't see a repeat of 
what happened with Agent Orange.
    Senator Udall. Thank you. We really appreciate that. Please 
go ahead.
    Dr. Stone. Senator, certainly the use of the hyper-
computing ability of the Department of Energy is something 
we're going to need on an ongoing basis, especially when you 
look at the Million Veteran Program and the genomic data 
analysis that's necessary.
    I would expect that you will see requests in the future for 
us to expand that relationship.
    We are also in multiple other relationships doing genomic 
data analysis, especially for prostate cancer patients, and 
we're working on a precision oncology program with the National 
Institutes of Health, National Cancer Institute.
    Senator Udall. That's great. To follow up a little bit, Mr. 
Secretary, on burn pits, over the past two years, Congress has 
appropriated $10 million to improve and expand the Airborne 
Hazards and Open Burn Pit Registry, which was established 
through legislation that I introduced in 2011.
    This year, you did not request additional funds for this 
account. Why not, and could you explain how you intend to 
follow up on the commitment you made to make sure we don't 
follow that pattern with Agency Orange? I mean that's very much 
been my experience. You meet Vietnam veterans and they battled 
for years and years and years before it was even recognized.
    Dr. Stone. Just for full disclosure, I'm a burn pit exposed 
veteran from my time in Afghanistan. So I have a special 
interest in this area.
    We've done a good job, I think, of getting people on to the 
registry. We've done less of a good job getting people in for 
examination. Part of that is defining the criteria of 
examination of small airway disease and how to institute that. 
I think we could do a better job of really encouraging those 
veterans in the registry to get in for examination.
    I also worked very early in my training when I was in the 
VA as a trainee, as a resident, I worked Agent Orange clinics 
at a time that we didn't have good data. I feel like a deja vu 
all these years later. So we're working our way through this.
    You are exactly correct. We must continue to work to define 
what the exact effects on exposure to these agents are.
    Senator Udall. Yeah. And then just you don't need to answer 
this but maybe in the record afterwards, the exposure to burn 
pits, many vets are arguing for that to be a presumptive 
service-connected. I'm sure your answer would be today you 
aren't quite there, but I hope that you will aggressively do 
the work to make sure that you can make that determination.
    Thank you.
    Dr. Stone. Yes, Senator.
    Senator Udall. Thank you very much, Mr. Chairman.
    Senator Boozman. Senator Capito.
    Senator Capito. Thank you, Mr. Chairman, Ranking Member, 
and thank you and thank you for your service to our veterans 
and to our country.
    This is a follow-up on Senator Udall's question quickly, 
Dr. Stone, on the burn pit just for my own education purposes.
    Would a burn pit burn possibly PFOA and PFOS, the fire-
fighting chemical that's used on bases?
    Dr. Stone. It's certainly an interesting question. Those 
are chemicals that are surfactants that float to the surface to 
extinguish hydrocarbon fires. There's been tremendous interest 
in them as a neurotoxin. There's been less interest in them as 
a pulmonary destructive agent. There's very little evidence of 
their effect on the pulmonary system but lots of evidence and 
lots of studies in neurotoxicity.
    Senator Capito. Well, that's something I'm interested in. A 
lot of us have this in our surrounding states. Certainly the 
state of West Virginia is one of those.
    I'd like to start just on a brief kind of three things that 
I wanted to call to your attention that I want to thank the VA 
for and some of the things that I was instrumental in seeing 
that we got into our last bill.
    One of them is this support of agritherapy. We're looking 
for diversions for pain medicines. We're looking for--and I've 
seen this actually on the ground in beekeeping in my state, as 
well, are Woody Williams Veterans Affairs Medical Center in 
Huntington is one of the 10 test sites for this.
    I did talk with our Commissioner of Agriculture just this 
week and he said the VA's been a little bit slow trying to find 
people that are really interested in this, understanding that 
things take a while to take off. So I think this has the 
potential to be very positive.
    Secretary Wilkie. And I think, Senator, we have 10 sites 
that are using the agritherapy now.
    Senator Capito. Right. You do, you do, yes. The other thing 
is I'm going on Friday, I believe Senator Manchin's going to be 
there, as well, to the new Princeton VA Outpatient Clinic in 
Southern West Virginia and I'm going to have the opportunity 
there to meet the new VISN--Director Robert Walton, but I thank 
the VA for extending that service with the latest medical 
equipment and technologies to Bluefield, West Virginia.
    Secretary Wilkie. And I will be in Martinsburg tomorrow all 
day.
    Senator Capito. Oh, good, good. Last thing is that came up 
with questioning from Senator Collins, she asked about 
apprenticeship programs and the under-use of the G.I. Bill and 
apprenticeships.
    So I just wanted to call to your attention I'm on a bill 
with Senator Peters, he actually brought it to me, to try to 
harmonize the listing, I'll put it sort of simplistically, 
listing of apprenticeships that are approved through the 
Department of Labor to harmonize them with what the VA is 
offering in terms of the G.I. Bill. Did you know anything about 
that, Dr. Lawrence?
    Mr. Lawrence. No, I was unaware of it until you mentioned 
it, but I think that's a very good idea and one we'd be happy 
to work with you on, even in vet tech, so like the 
apprenticeship for the trades, but has similar features of 
attracting people to all offer to veterans, as well.
    Senator Capito. Right. I mean, it makes sense.
    Secretary Wilkie. Senator, I want to say I'm committed to 
opening the avenues for veterans in the trades and vocations, 
apprenticeships.
    I will give you my prejudice. I think for too long both DoD 
and VA have focused on a four-year degree when America needs 
more people in the vocational world--
    Senator Capito. Right.
    Secretary Wilkie [continuing]. and I'll do everything that 
I can to expand the opportunities in those areas.
    Senator Capito. Yeah. We do know, too, that in the 
technical fields that a four-year degree is not necessarily the 
be-all and end-all, that certain certificate programs and those 
kind of opportunities can really lead to life-sustaining 
occupations.
    Secretary Wilkie. And I've made that clear. I'm a member of 
the President's Council on the American Worker and in the last 
meeting, I made that argument, that we need to spend more time 
focusing in those areas than on those traditional four-year.
    Senator Capito. Right. Just two questions. I'm going to put 
them together because you've covered a lot of this.
    On the Veterans Community Care, Dr. Stone, on the Veterans 
Community Care Program, I guess you testified last month that 
the software that was going to be used for the new program has 
not been fully developed. Could you--and then there's another 
sort of related question on whether the expansion of the Family 
Caregivers Program--you sort of covered that a little bit, but 
whether that's ready to roll out for the timeline that's been 
specified for.
    Dr. Stone. So there are 11 software systems that are 
necessary for the MISSION Act, the Community Care Program. 10 
of them are already fielded and in use.
    Senator Capito. Oh, good.
    Dr. Stone. So we're doing some improvements. There's one 
that brings it all together called the Decision Support Tool. 
The Decision Support Tool is in active testing in the field, 
but a full rollout will not occur till the second half of May. 
There's some risk to that.
    Senator Capito. Right.
    Dr. Stone. But if we fail with the Decision Support Tool, 
it simply is an efficiency tool that will sort of bring it all 
together in a single screen for our schedulers and providers. 
We'll still be seeing patients, still be working this, but 
we're working really had and there's a great partnership with 
our OI&T partners to really finish this up effectively and the 
initial testing in the field looks good.
    Senator Capito. Good, good. Well, we'll look forward to 
seeing what happens. I'll keep my fingers crossed. I'd like to 
say I can contribute to the technology part of it but I don't 
think I could really help out with that.
    Secretary Wilkie. I can't either.
    Senator Capito. Lastly, I'm just going to make one quick 
comment, source of concern for, I think, you all and for really 
our nation is our lack of mental health professionals.
    I know the VA has this. We had an incident at our 
Martinsburg Hospital where we lost our psychiatrist. We have a 
lot of PTSD but we also have a lot of opioid addiction issues 
that are rifling through our communities. So there's a lot of 
competition for expertise in the area.
    So anything that we can do, I think, to support you to get 
the professionals in the mental health area is something that I 
think's going to help everybody, not just veterans but 
everybody across the board.
    Secretary Wilkie. Absolutely. I will say that in the last 
year, we have hired 3,900 mental health professionals. I told 
the New York Times a couple of weeks ago that, as you said, we 
are in the same position that the rest of America is in. 
There's a dearth of mental health professionals.
    But working through the MISSION Act and what this committee 
has appropriated, we're doing our best to provide relocation 
pay, reimbursement at a higher level than the general Federal 
pay scale. I will say what I told the New York Times, and it's 
something that I know that you have worked on, we're not even 
at the Sputnik stage of getting our arms around mental health 
issues and I think as we go down the road on suicide 
prevention, I am not arguing for a singular look at just 
suicide.
    We have to look at the progression of events in an 
individual's life. Some of it is addictive. Some of it is 
homelessness. Mental health overarches the whole thing and a 
one-off look at suicide will not help anyone, but looking at 
the entire continuum of issues that Americans face and 
Americans who come to that terrible decision is the only way we 
can tackle it in mental health is the key.
    Senator Capito. Right, I appreciate that.
    Thank you.
    Dr. Stone. Senator, if I might just add a couple things, 
retaining this workforce is an extraordinary effort. We just 
took a look at our retention rates and I'd like to share some 
figures with you.
    Senator Capito. Okay.
    Dr. Stone. Social workers, clinical social workers turn 
over their jobs at about 11 percent rate per year across this 
nation. VA's at 6.8 percent. Our psychologists on a clinical 
basis turn over, depending on the market, between 10 percent 
and 22 percent a year. We're running at 8.4 percent. That's a 
very stable number.
    So it looks like we're retaining our workforce with the 
tools you've given us and especially the tools the Secretary 
just mentioned are essential to us keeping this workforce in 
place.
    Senator Capito. That's good news. Thank you.
    Senator Boozman. Secretary Wilkie, this really isn't a 
question, but I appreciate the time that you spent in your 
opening statement talking about suicide and how important that 
is and just the national tragedy across the board.
    I'm really excited about the task force. This is a great 
idea. The only thing I would say that as the task force starts 
to develop its work and you see some areas that you're going to 
need some help on to be sure and let the committee know.
    I think I can speak for all of us in the sense that we will 
support that in any way that we can going forward.
    Secretary Wilkie. Yes, sir, I agree with that.
    Senator Boozman. Good, very good. Dr. Stone, coordinated 
services on the Federal, state, and community levels are often 
key to enabling veterans and their family members to secure 
permanent housing and prevent them from becoming homeless. So 
we appreciate the work in that area.
    Last year, Little Rock was named one of 69 areas, 69 
communities and three states that effectively ended veteran 
homelessness. So we can be very proud and I hope--Secretary 
Wilkie, we so pleased with you coming to Little Rock. 
Everybody's really looking forward to that and that's going to 
be great, but that's something you can pat them on the back 
for.
    Secretary Wilkie. Absolutely. I actually called the Mayor 
when I first got that news to thank him and I'll be in Little 
Rock week after next and probably more in the summer.
    Senator Boozman. So we've met those benchmarks and that's 
good. The fiscal year 2020 budget maintains funding to support 
VA's Homeless Prevention Programs at $1.8 billion.
    I guess the question is, is how are we going to continue to 
prevent veterans homelessness under that level, and then the 
other thing is, is that, you have an area that has worked so 
hard to do the right thing and, you know, has gotten their act 
together and really moved in the right direction. I hope 
because they have done such a good job, that all of a sudden, 
funding's not cut off or we're going to be right back in the 
same situation that we were in.
    Secretary Wilkie. I agree with that. This is an issue, and 
I'll refer to Senator Schatz on this because I had a long 
conversation when I was in Hawaii with the Governor, there are 
three communities in the United States that have unique issues 
when it comes to homelessness, Seattle, Los Angeles, and 
Honolulu.
    One of the great eye-openers that I had was when the 
Governor of Hawaii, Governor Ige, told me that the veterans 
homeless population in the state of Hawaii increases because 
veterans find enough money to get a one-way ticket to Honolulu 
and because of the climate, they can live there on the streets 
without the threat that they would see in many other places in 
the country.
    In my discussions with the Governor and also with Governor 
Brown in California before he left office, I said that the only 
way we get our arms around homelessness issues in those three 
communities is to open up our relationship not only with the 
states and localities but also with charities and non-
governmental organizations.
    In Little Rock, in New Orleans, in Houston, in 
Jacksonville, church charities have been involved in aiding 
with the VA and getting homeless veterans into shelter. That's 
a model that I think we can use, although I will say, and this 
is not part of your question, but it is something that affects 
me deeply, one of the saddest sights I've seen in both the 
military and DoD and VA careers, what I saw in West Los 
Angeles.
    At dusk, cars coming into West Los Angeles VA and people 
not getting out of those cars but they are fully employed 
veterans who have jobs, who contribute to the tax base, but 
because of the situation in Southern California with housing 
prices, etcetera, they can't find housing.
    So I was working with the Mayor and the Governor to expand 
the amount of transitional housing but it's one that I care 
deeply about.
    Dr. Stone. Senator, let me just add to the Secretary's 
comments.
    We know that in this nation, the suicide rate per 100,000 
is about 17. Amongst veterans, it is 30, but in the two weeks 
before homelessness occurs, the rate goes to over 80 per 
100,000. It's an incredible risk population. We must not take 
down this infrastructure or the at-risk veteran will not have 
the opportunity to be housed and thus reduce that risk.
    So I appreciate your thoughts on this and please know that 
we intend to continue to fund this even in those areas that 
we've declared that homelessness has been corrected.
    Senator Boozman. Good. Thank you very much.
    Senator Daines.
    Senator Daines. Thank you, Chairman Boozman, and thank you 
for the panel being here today.
    Secretary Wilkie, always good to see you, glad to have you 
leading that very important organization.
    Fiscal Year 2020, the VA has asked Congress for $220 
billion. That's a 10 percent increase from last year, a 34 
percent increase over the past 5 years. While new initiatives 
require adequate resources, I can tell you I'm not convinced 
that more funding alone will necessarily solve the VA's 
problems.
    Montana's veterans, I'm the son of a veteran, my wife is 
the daughter of a veteran, they demand better leadership, 
stronger accountability, and more open communication.
    Last year, Congress provided a one-time $685 million 
increase to clear its growing backlog of state home 
construction projects. Those funds came with instructions from 
this committee to provide a schedule for all outstanding 
projects and their estimated completion dates.
    Secretary Wilkie, do you know, has that schedule been 
provided?
    Mr. Rychalski. Yes, it has.
    Senator Daines. Okay. And do you know when we might have 
that?
    Mr. Rychalski. I do. I have it in my office and I can 
provide that to you.
    Senator Daines. Thank you. You're from Montana?
    Mr. Rychalski. I am from Montana. That's right.
    Senator Daines. Where's your home?
    Mr. Rychalski. Helena.
    Senator Daines. Helena.
    Mr. Rychalski. Capital of the Big Sky country.
    Senator Daines. Great. It is the state capital. That's 
right. Great.
    [Laughter.]
    Senator Daines. Little Trivial Pursuit. Thank you. And the 
reason I ask that, since 2012, the VA has listed a 60-bed state 
home in Butte as a Priority 1, not a Priority 2, project, ready 
to break ground in Montana. Do you know when we could expect to 
see that $8.9 million Federal share?
    Mr. Rychalski. I think that it was approved conditionally 
in October and I think we are actually waiting on the 
documentation from Butte, which is a great city, by the way, a 
great man was born there, and once we have that, the funds can 
start flowing.
    So I think we're in contact with them or waiting for 
documentation from them and then the funds will flow.
    Secretary Wilkie. I mentioned this in a conversation with 
Governor Bullock about six-seven weeks ago and John is correct. 
We're still waiting on the paperwork from the state.
    Senator Daines. Okay. We will work on that together to 
close that gap and Butte's just a little south of your hometown 
of Helena there, as well, on I-15.
    Mr. Rychalski. Right.
    Senator Daines. Shifting gears to Mile City now, going to 
Eastern Montana, VISN-19 is in the process of moving its Mile 
City Clinic into a leased facility which may adversely affect 
up to 30 veterans residing in its community living clinic.
    My question for Dr. Stone, without getting into details of 
the real estate transaction, could you assure me that these 30 
veterans won't be forgotten or sent hundreds of miles away to 
another facility?
    Dr. Stone. I can, sir, as we go through this process.
    Senator Daines. Thank you. And Mile City is a long ways 
from Helena. It's out in the eastern part of our state. So I 
appreciate that.
    As I travel across the state, I receive a great deal of 
questions from Montana veterans about changes under the VA 
MISSION Act. Many remain skeptical, based upon their 
experiences of VA Choice and rightfully so.
    Some of that could be alleviated, I think, with better 
transparency, more transparency, and, frankly, better 
communication.
    Secretary Wilkie, I know you've been hearing a lot. You're 
out there actively working on this. We've discussed the MISSION 
Act at length during this hearing. You've heard a lot.
    Would you commit to improve outreach and to keep our 
Montana veterans informed
    Secretary Wilkie. Absolutely. And one of the things that 
you and I discussed several months ago, I'm not pretentious 
enough to say that I'm going to leave a legacy because I don't 
know how long I'll be here, but the focus that I've had has 
been on Rural America and Native America, reason being (1) 
people don't talk enough about Rural America and Native 
America, but if you look at the percentages of service, the 
rates of service in those communities, particularly for Native 
America, highest per capita rate of service in the military, 
highest per capita rate of holders of the Medal of Honor, and 
that's my commitment to do as much as I can for those two 
communities.
    Senator Daines. Secretary Wilkie, I appreciate those 
comments truly. Thank you. I know that's sincere and straight 
from you.
    I want to shift gears to Bluewater Navy vets. Since 2015, 
I've been working with Senator Gillibrand as the Republican 
lead for the Bluewater Navy legislation. I was pleased that the 
Court recognized Congress's intent in Procopio vs. Wilkie.
    Secretary Wilkie is on record stating--
    Secretary Wilkie. I always wanted to get to the Supreme 
Court but not that way.
    Senator Daines [continuing]. Well, you're as a defendant, 
right, and thank you. You're on record stating the VA does not 
intend to appeal. I understand the Department of Justice may 
indeed appeal the Supreme Court.
    Dr. Lawrence, is the VA willing to stop the delay game for 
these vets and implement the Federal circuit's decision without 
further delay?
    Secretary Wilkie. Well, let me answer that one, Senator. 
You're correct. My recommendation was not to appeal. I don't 
have any particular insight on what other forces are at play in 
Justice and I won't even hazard a guess, but we are preparing 
to implement the Court's decision.
    I will also say that about 30,000--actually, between 30 and 
51,000 Navy veterans who would fall into the Bluewater category 
are treated by VA as a matter of course and they show symptoms 
that would go to Bluewater impacts.
    We are engaged with the Department of the Navy in creating 
the system whereby we identify those Americans who sailed in 
those waters.
    I mentioned earlier that this is a bit of a detective 
exercise because the Navy did not have a uniform system of 
reporting where those ships were and how they recognized 
service in a combat zone to the point where people who are 
assigned to a ship but were left ashore in Bremerton, 
Washington, are given the Vietnam Sea Service Ribbon and yet 
they didn't appear in those waters.
    So we are actively working with the Secretary of the Navy 
to build that database.
    Senator Daines. Thank you. Well, it was good news, 
Secretary Wilkie that you decided to stand down on the appeal. 
We appreciate that, and I think we always want to give the 
certainty to the Bluewater vets here that have a claim.
    Lastly, if I can, I want to talk about veterans suicide and 
the reason for that is Montana has the leading per capita 
suicide rate in the nation. In 2016, 42 Montana veterans lost 
hope and they made an irreversible choice that may have been 
preventable. They fought for our country and now we need to 
fight for them in this time of great need for them.
    In March, I was pleased to stand with President Trump 
focusing our nation's leaders on solving truly this tragedy in 
our country.
    Secretary Wilkie, you spoke in your opening statement about 
the Prevents Initiative. What is the status of the VA's efforts 
to increase outreach prevention and importantly treatment?
    Secretary Wilkie. Well, there's several aspects of this 
process. One is that I representing VA and the head of the 
President's Task Force on Suicide Prevention. It is my goal to 
create a whole health but whole of government approach to 
suicide by bringing HHS, DoD, NIH, and HUD to the table and 
open the aperture of funding to states and localities so they 
can help us and to tribal governments so they can help us find 
those veterans.
    But I will say that this is an issue that goes beyond VA. I 
mentioned earlier that the New York Times and NPR came out 
today with stories about an epidemic of teenage suicides across 
the country.
    This is something that is impacting all aspects of American 
life. We have to start asking the questions as a nation about 
our views of life, how we respect our citizens and how we 
respect ourselves. So it can't be a VA-centric decision.
    We have to go much deeper than the Department of Veterans 
Affairs. I will also say a great tragedy, and I thank you for 
your indulgence, Mr. Chairman, a great tragedy for me as 
someone who became aware of the world and the military and 
government during the Vietnam era, I used to watch my mother 
every Friday, Cronkite would have at the end of his broadcast 
flags behind his head, American flags, South Vietnamese flag, 
and would have the numbers of dead, of casualties, and so I saw 
that growing up experienced in my own families, that the 
tragedy I see now is that the numbers that we have, the 
majority of those veterans who take their lives are from the 
Vietnam era.
    Many of the problems that they had begun when Lyndon 
Johnson was President and we're not going to be able to 
alleviate all of that, but we had better have a national 
debate, a national conversation about this, or we will continue 
to see these tragedies across our society.
    Senator Daines. Secretary Wilkie, I want to thank you for 
your thoughtful answers, your insights, your service, and your 
passion for Rural America, and particularly for Indian Country. 
It's greatly appreciated. Thanks.
    Senator Boozman. Senator Schatz.
    Senator Schatz. Thank you, Mr. Chairman.
    A couple of years ago, we appropriated money for the Aloha 
Vets Center on Oahu. We've appropriated money for the Sea Block 
and Hilo. These are facilities that VA requested. The 
authorizing committee authorized. We made the appropriation, 
and we have get from staff on the Hilo Sea Block this morning 
indicating an e-mail that there is no timeline for the 
development of the Hilo, Sea Block, and the Oahu Vet Center, 
you have--I've forgot if it is GS--you have a lease timeframe 
challenge, and then we appropriate money to the American Battle 
Monuments Commission and suddenly my home office and my 
legislative office here is in the site selection, lease 
management, you know, project execution business, and I just 
don't understand why, when something is requested by you, 
authorized by the authorizing committee, appropriated, then we 
get this sort of we'll get to it when we get to it, and this 
stuff is hard, and I understand this stuff is hard, but this 
stuff is your side of the shop, and so can you assure me, and 
if we can go Hilo, Oahu, and then the ABMC issue, that we're 
going to start getting into the execution business, Mr. 
Secretary?
    Secretary Wilkie. Well, yes, sir, and let me say I have 
been on the big island. I've been in Oahu. I know the need in 
Oahu. This facility will serve 57,000 veterans.
    What I have instructed--one thing that I cannot fight 
against is the statutory impediments that I have with OMB and 
GSA and because of the strictures on minor construction, the 
Oahu project came in at 3.4 million, which is .3 million above 
the threshold that I have to go to OMB and GSA on.
    I told my staff today that they better come up with a way 
to get under that threshold so that we can get this project off 
the ground and not wait for the bureaucratic process to 
continue to delay it. So that is--
    Senator Schatz. Okay. That's Oahu. What about Hilo?
    Secretary Wilkie [continuing]. and Hilo, I will say the 
money's authorized. The land has not been found. Our people 
have been instructed to find that land quickly. I saw it myself 
when I visited the big island, the need. I saw it in December 
and I will personally be involved to make sure this thing goes 
on rapidly, it moves quickly. You have a 129,000 veterans on 
the islands and they need to be served.
    And as for the Battle Monuments issue and all that Randy 
can talk about that, I was at the Punchbowl. I have a different 
perspective from the people who run the Battle Monuments 
Commission.
    They operate cemeteries that are, for all intents and 
purposes, museums. The cemeteries that they oversee in Belgium 
and France, in Luxembourg, in Holland, there will be no more 
internments on those facilities, and they use them really as 
monuments and museums. That's very difficult from the 
Punchbowl.
    The Punchbowl is an active, active cemetery, important both 
historically to the people of Hawaii because of its association 
with the--
    Senator Schatz. Well, I get this and it's a space issue and 
you have 25 years.
    Secretary Wilkie [continuing]. but I cannot, I will not 
agree to a proposal that impacts our ability to serve families 
and to provide the burial space that you want. Randy can talk 
about the alternatives that we've proposed to the Battle 
Monuments Commission, but the proposals that I've seen from 
them would impact our ability to continue using the Punchbowl 
for Hawaii.
    Senator Schatz. So I'm running out of time and it's time to 
wrap up, but I know you've committed to sit down with me. So 
let's do that.
    But I will just say a couple things. First of all, you do 
have ABMC facilities within active cemeteries in Panama and the 
Philippines. I understand the sort of sacrosanct nature of 
Punchbowl in particular. I live at its base. I'm there all the 
time. I understand that. But there has to be a way to work this 
out.
    The other thing I will say is that as we were going through 
the process with ABMC and we made the appropriation, that we 
didn't hear anything from you and so as there were negotiations 
between agencies, pretty much at least from our perspective at 
the last minute, this comes up and we get a solution set that 
is not at all workable.
    They were going to do a land exchange with the Department 
of Hawaiian Homelands and people were going to take shuttle 
buses for 10 minutes from Punchbowl down to, you know, Tantalus 
Mountain and it doesn't make any sense.
    So we're running out of time. This is probably going to be 
a longer conversation, but I need your commitment, too. I get 
your position, but that can't be the end of the conversation. 
That has to be the beginning of problem-solving. This is 
different than the other issues which you just have to execute 
on. This we're going to have to find the solution together.
    Secretary Wilkie. I'm committed to finding the solution 
with the understanding that we don't have any solution that 
impacts on the ability of families to visit their sites and 
also our--
    Senator Schatz. Hold on a second. I mean, I get what you're 
saying and I'm ready to concede that you have equities here and 
VA has legitimate concerns here, but let's not pretend that 
Battle Monuments of the Pacific facility within Punchbowl would 
somehow materially impact the visitor experience. It's not 
going to cause hundreds of additional tour buses. It's not 
going to cause but perhaps a half a year or a year's worth of 
the 25 remaining years of internment capacity remaining.
    So there are equities here, but it's not going to crush 
Punchbowl to accommodate this. This is just a decision that 
you've made that you don't want to accommodate it.
    Secretary Wilkie [continuing]. Senator, if I may interject, 
there have been discussions with ABMC over a number of years, 
most notably 2011, 2015. I must point out that there have been 
no formal agreements at any point between NCA, the VA, or ABMC 
on placement of an interpretative center there.
    I'm sorry to say that ABMC proceeded with things, such as 
spin plans and that, without collaboration or any input.
    Senator Schatz. Right. But you're the Executive Branch and 
when they come to us and ask for funding and then we do the 
funding, and you say that agency didn't talk to us,that seems 
to be an Executive Branch problem that you're supposed to sort 
out, not something that again I'm supposed to get in the middle 
of wrangling between these agencies. So I actually have to go.
    Secretary Wilkie. Yes, sir.
    Senator Schatz. So we're going to have to wrap this up, but 
I do want to continue this in person and without shouting.
    Secretary Wilkie. Yes, sir.
    Senator Schatz. Thank you.
    Secretary Wilkie. Thank you.
    Senator Boozman. Thank you all very much for appearing 
today and I think this hearing was very, very helpful, and we 
are looking forward to your visit in Arkansas, Secretary 
Wilkie. We're very proud of your relationship with our state.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Boozman. For members of the subcommittee, any 
questions for the record should be turned in to the 
subcommittee staff no later than Wednesday, May 8th.

                          SUBCOMMITTEE RECESS

    Senator Boozman. And with that, the hearing's adjourned.
    [Whereupon, at 4:31 p.m., Tuesday, April 30, the 
subcommittee was recessed, to reconvene subject to call of the 
Chair.]