[Senate Hearing 116-137]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 116-137

 FISCAL YEAR 2020 BUDGET AND 2021 ADVANCED APPROPRIATIONS REQUESTS FOR 
                   THE DEPARTMENT OF VETERANS AFFAIRS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 26, 2019

                               __________

       Printed for the use of the Committee on Veterans' Affairs




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                     COMMITTEE ON VETERANS' AFFAIRS

                   Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas                  Jon Tester, Montana, Ranking 
John Boozman, Arkansas                   Member
Bill Cassidy, Louisiana              Patty Murray, Washington
Mike Rounds, South Dakota            Bernard Sanders, (I) Vermont
Thom Tillis, North Carolina          Sherrod Brown, Ohio
Dan Sullivan, Alaska                 Richard Blumenthal, Connecticut
Marsha Blackburn, Tennessee          Mazie K. Hirono, Hawaii
Kevin Cramer, North Dakota           Joe Manchin III, West Virginia
                                     Kyrsten Sinema, Arizona
                       Adam Reece, Staff Director
                Tony McClain, Democratic Staff Director 
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                            C O N T E N T S

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                             March 26, 2019
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     3
Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    21
Cramer, Hon. Kevin, U.S. Senator from North Dakota...............    23
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    25
Moran, Hon. Jerry, U.S. Senator from Kansas......................    27
Boozman, Hon. John, U.S. Senator from Arkansas...................    31
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    33
Blackburn, Hon. Marsha, U.S. Senator from Tennessee..............    34
Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......    36
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    38
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    40
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    42

                               WITNESSES

Wilkie, Hon. Robert L., Secretary, U.S. Department of Veterans 
  Affairs; accompanied by Paul R. Lawrence, Ph.D., Under 
  Secretary for Benefits, Veterans Benefits Administration; 
  Richard A. Stone, M.D., Executive in Charge, Veterans Health 
  Administration; and Jon Rychalski, Assistant Secretary for 
  Management and Chief Financial Officer.........................     6
    Prepared statement...........................................     8
    Response to posthearing questions submitted by:
      Hon. Johnny Isakson........................................    47
      Hon. Jon Tester............................................    50
      Hon. Sherrod Brown.........................................    71
      Hon. Richard Blumenthal....................................   143
      Hon. Mazie K. Hirono.......................................   154
      Hon. Joe Manchin III.......................................   160
      Hon. Kyrsten Sinema........................................   175

                                APPENDIX

Co-Authors of the Independent Budget; prepared statement.........   177

 
 FISCAL YEAR 2020 BUDGET AND 2021 ADVANCED APPROPRIATIONS REQUESTS FOR 
                   THE DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


                        TUESDAY, MARCH 26, 2019

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:09 a.m., in 
room 418, Russell Senate Office Building, Hon. Johnny Isakson, 
Chairman of the Committee, presiding.
    Present: Senators Isakson, Moran, Boozman, Cassidy, Rounds, 
Tillis, Sullivan, Blackburn, Cramer, Tester, Murray, Brown, 
Blumenthal, Hirono, Manchin, and Sinema.

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

    Chairman Isakson. I call the Senate Veterans' Affairs 
Committee to order and welcome everybody to the Committee 
today. Thank you to Secretary Wilkie, in particular, and all 
the members of the VA staff for being here today. You are going 
to get a lot of questions, I know, and hopefully give us a lot 
of good answers. Then, we will hopefully get some good results 
at the end of the year and be moving in the right direction.
    The Committee and the VA had a good year last year. We got 
a lot of things squared away that had been needed to be 
addressed for some time. We get some laws passed you all wanted 
for some time, you said you needed for some time, and we want 
to--we gave them to you and we are going to look for the 
results this year. That is what we are going to be reviewing, 
is making sure we are making progress with results, not just 
promises, and I think we will be able to do that.
    This is an important hearing today. This is our annual 
review of the budget. The President's budget came out a few 
days ago. The VA's budget is a significant one, and 
significantly increased.
    We have a unique situation. We get more money than anybody 
in increases every year, as a percentage, however you want to 
calculate it. Money is not our problem. Now I know there are 
some people in this room who say, ``Oh, yes, it is. I need this 
much more. I could do this,'' but we have been--we have looked 
out for our veterans. We know we are paying for benefits they 
have earned and we know we have got to finance them. I am proud 
the President's budget is up 9.1--is that right?--9.5, and $220 
billion. Right? That is a huge budget.
    But, what I want to do this morning, in my opening remarks, 
is really just focus a little bit on this year and then how we 
came to where we are.
    The first thing I want to do is thank the VSOs. I changed 
the way we do this meeting. Used to be they came in as a second 
panel. The first panel was the Secretary, the second panel was 
all the VSOs. That took a lot of time, it diminished the value 
of each person's testimony, and we have just finished with 
meetings with all the VSOs--almost all the--well, all the VSOs, 
over the last 5 weeks anyway.
    So, the important thing I asked the VSOs to do was to 
submit their testimony in writing and submit the questions they 
want specifically to have answered in writing, and then we get 
those. They submitted some terrific questions, which prompted 
great thought on my part and other Members' part as we went 
over those and reviewed those questions. They will be sent for 
answers to the Secretary; and, Mr. Secretary, I am going to 
expect an answer on all of them.
    I want to thank the VSOs for the time they put into it, and 
make sure you know that just because I did not include you in 
terms of verbal testimony at this meeting, it is not because we 
did not want to hear from you. I wanted to see that what we 
heard from you actually got done. So, I asked you to submit it 
in writing and we will submit that to the VA and then we will 
follow up on it, rather than having it lost somewhere in the 
ecosystem once you have set it here and it is gone wherever it 
goes.
    The second thing I want to do today is talk about two 
meetings we have coming up that I am going to insist on. I 
promised Members; I try to keep my promises. We have done 
amazingly well on that, and it is because we have cooperation 
by all of the Committee, particularly the Ranking Member. But, 
number 1, Senator Manchin had asked for a discussion on burn 
pits and toxic exposure, et cetera. We are going to have a 
meeting on toxic exposure. It will come later in the year, 
after we have begun to swallow the Blue Water Navy. My 
understanding is that--is this true, Secretary Wilkie, that the 
Blue Water Navy court decision is not being challenged? Is that 
right.
    Secretary Wilkie. That would be my recommendation from VA.
    Chairman Isakson. VA has recommended that, which I 
appreciate, and I have offered that opinion as well. I think 
that is what is going to end up happening. If that happens, we 
are going to be in the process of beginning to swallow a big 
bite, and chew it, and dissolve it, and get it--I was happy to 
learn from the Secretary that 51 people have already been 
treated, that would have been eligible, that benefited--Blue 
Water Navy benefited anyway. Is that correct?
    Secretary Wilkie. Fifty-one thousand.
    Chairman Isakson. Fifty-one thousand. I appreciate the 
Secretary and the VA doing such a thorough job as far as Blue 
Water Navy is concerned, and in anticipation of what this 
Committee and the other Committee in the House did on Blue 
Water Navy. Hopefully, that will continue.
    The other topic is access standards. The big fellow sitting 
to my right has made it clear to me that access standards are a 
big thing with him. Well, they are a big thing with me too, 
because if you really think about it, if the recently-
published-for-comment rules and standards for access of 
community care, once those are finished then in Alaska and in 
Kansas and North Dakota, South Dakota, Georgia, Montana, 
everywhere, our more rural veterans in more rural areas--how it 
is working for them to get them the care they need as quickly 
as we can, get a system that works so doctors want to be a part 
of it. Get a third-party administrator working to make sure 
that they have got a good repertoire of doctors available, to 
be chosen from, to meet the standards. It is just terrific.
    So, I am going to focus on access standards at our next 
meeting, which we have on April 10. Is that right?
    Mr. Reece. Yes, sir.
    Chairman Isakson. We are going to focus on access 
standards. I want to encourage everybody to be there, because 
if we do one thing this year, if we can get that working--that 
is the part of Choice that was hard, that is the part of Choice 
that had the most problems--if we can get it working right for 
the VA and veterans, and right for us, then we are going to 
have taken care of our single biggest problem in terms of 
operations out there on a daily basis, which are veterans' 
benefits.
    With that said I will end my opening remarks and turn to--I 
guess I should--have I welcomed the Secretary yet? I will let 
you have your opening run and then I will welcome the 
Secretary.
    Senator Tester.

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

    Senator Tester. Thank you. Thank you much, Mr. Chairman. I 
do not want to beat you to the punch, but I want to welcome 
Secretary Wilkie, Dr. Lawrence, and Dr. Stone----
    Chairman Isakson. I think you just did.
    Senator Tester [continued]. Mr. Rychalski to the hearing 
today. I look forward to learning from you today and I want to 
thank your team, and thank you for what you guys do every day.
    The Chairman talked about access standards and access 
standards will be talked about a lot today. We have talked 
about privatization. Nobody around this table, and I do not 
believe any of you want to see that happen. But, it is 
something I am very concerned about because the big boss talks 
about it all the time, and in the end we need to make sure 
that, as the VSOs told us a couple of a week ago during joint 
House and Senate Veterans' Affairs Committee, they prefer the 
care that you guys provide.
    That is a good thing. I think that is a very good thing. 
That means you guys are doing some things right, OK? We will 
talk about a few things you might not be doing so right today, 
and I will apologize ahead of time, but the truth is that these 
are folks that have served our country and we need to make sure 
we live up to the promises, as you well know, Mr. Secretary, 
the promises we made to them.
    Look, over the past few years this Committee has heard from 
the VA about what it needs to be successful. We have engaged 
with VSOs, as we did for the last couple of weeks, to see what 
they wanted in their VA, and I will tell you this Committee 
listened, and we acted, leading the way on a number of 
monumental reforms that, quite frankly, a lot of people did not 
think we could ever get done, but we did last Congress, on 
behalf of our Nation's veterans.
    This is an important part of our job, providing you, the 
VA, with the tools that you need to do your job. Equally 
critically, though, is your job of deciding how the new 
authorities, and the resources, are executed and utilized, 
which is where, as I have said already, my concerns tend to 
lie. In my view, the level of commitment from Congress to 
address health care vacancies and critical infrastructure needs 
at the VA needs to be matched by the Department.
    I have talked about my parochial interest in Montana--and I 
am going to talk about it again today--Fort Harrison. By the 
way, if you run back about 15 years, it was one of the top VA 
facilities in the country. Fort Harrison today has one primary 
care physician, a part-time doctor who sees a handful of 
patients. I have got CBOCs in Montana, as you know, Mr. 
Secretary, with no primary care doctors, no advanced primary 
care clinicians, and where that care is only provided through 
telehealth.
    Now I am going to tell you--telehealth is a great 
innovation and it does some great things with folks that have 
mental health issues--but it cannot replace all types of health 
care. So, you get my frustration, that VA primary focus seems 
to be expanding eligibility and investments in the community 
care, but I do not want it to be at the expense of capacity-
building initiatives.
    I am going to say that again. I do not want our investments 
in community care to be at the expense of capacity-building 
initiatives.
    As you and I have discussed, there is certainly a role for 
the private sector, especially in a rural State like Montana. I 
am sure Senator Sullivan would agree in Alaska, and other 
States, too. But, I think we have got to be careful that we do 
not take the Department down a dangerous path. And, when it 
comes to veterans, you can outsource the care but you cannot 
outsource the responsibility. When they are sent to the 
community care option without first knowing if that care can be 
provided in a timely manner and if it is quality care, we are 
going to pay the price for that later, because, quite frankly, 
the veteran is going to come back and ask, ``Why?''
    So, I think we need to hold our VA providers to one set of 
standards and community care providers to that same set of 
standards. After all, none of us want a flood of veterans going 
to community care if it is lower and less--lower quality and 
less timely. And, we certainly cannot head down a path without 
a firm grasp on how much it is going to cost the American 
taxpayer.
    For example, we received multiple estimates from the 
Department on how much it would cost to implement access 
standards in the month leading up to the budget request. None 
of those estimates matched the number that finally appeared in 
the budget request, and as we go forth I would like you to 
clarify that if you could, why that is.
    It is not clear how that estimate came about. It is also 
not clear whether the technology you need to implement this 
program, such as the decision support tool, will be ready in 
time for implementation. I have been receiving conflicting 
reports about the readiness of this tool. I am frustrated we 
continue to hear about IT solutions that may not be executed 
properly. There is a huge chunk of money in this budget for IT. 
If it is not spent properly we have wasted taxpayer dollars and 
we have not delivered the services to our veterans that they 
have earned.
    As you know, the VA has struggled for many years in the 
field of IT, earning a place on the GAO's high-risk list this 
year again. I recently had a great meeting with Jim Gfrerer but 
there is no OIT representation from the Department here today, 
so I hope that is not a reflection of how this issue is being 
prioritized. I know the table is short so you have to pick and 
choose. But, we have seen how flawed IT rollouts impact 
veterans and the progress the VA is making on replacing an 
antiquated system that cannot afford to be plagued with 
shortcuts.
    By the way, we are here today with the MISSION program as a 
direct result of IT failures in Arizona. So, this is a big 
thing. We need to work. You have got a great team around you, 
Mr. Secretary. I have said it before and I will say it again. I 
think you are a great guy. I think you are the right guy for 
this job, and I am glad you are there. But, we need to find out 
the details of this budget, and as we move forward I certainly 
do not want to see VA care dollars transferred to community 
care because we ran out of money in the community care budget.
    With that I would just say thank you all for being here. 
Thank you, Mr. Chairman, for the opportunity to speak, and I 
look forward to this hearing.
    Chairman Isakson. Thank you, Senator Tester. For 
everybody's benefit here I think I heard, without exception, at 
our hearings with the VSOs, ``We ain't going to privatize'' 
said 100 times. I did not have a single person write me, call 
me, trip me up, throw me down the steps, or anything else, 
wanting to privatize the VA, and I have no interest in doing 
so. So, let us just put that sign behind the bathroom door 
rather than the front door, and let us talk about making the VA 
the best VA we can make it and be what our veterans want it to 
be.
    Jon is right. They like their VA and that is why they call 
it ``my VA.'' They just want it to be a little bit better, 
which is what we want to make it, a little bit better--better 
in its accountability and better in its results. So, that is 
what we will be talking about.
    With that said, talking about better, we have the best guy 
you could ever have, in terms of Secretary of the VA. Robert 
Wilkie--I did not know Mr. Wilkie until he was nominated, I 
guess. That is the first time we met. I have heard quite 
frequently that he has got a good bedside manner. He is really 
easy to talk to. He just has a resonant voice. He is very easy-
going, knows some great jokes. They are all clean. He is just a 
terrific guy all the way around. But, the good thing about it 
is he does not just have a good personality and a good 
demeanor, he likes to get the job done, and he talks in 
measures that are accountable, that hold himself accountable. I 
appreciate that.
    I think with his type of persona we already are seeing 
improvements and results with the VA. We have got a long way to 
go, but they do a lot of things well and we are proud of those 
things. We want to do the things we do not do well better and 
take some of our problems that have been hanging on with us for 
a long time and get those problems solved. I think Robert 
Wilkie is the man to do it and I am really pleased to work with 
him, plus Senator Tester, and the Members of our Committee in 
the Senate to see to it we finish the job--we will never finish 
the job--but continue the job of improving the Veterans 
Administration for the benefit of our vets.
    With that said I could go over your military background, 
the fact that you are a good Southern boy, and all those good 
things, Robert, but instead I would just like to say we have a 
great Secretary of the Veterans Administration and I am proud 
to work with Robert Wilkie, I appreciate what he does, and I am 
proud to introduce him for as much time as he might consume, 
except remind him that how much he does consume may consider 
how much we enjoy what he has to say, so do not take too much 
of it.
    Secretary Wilkie. Well----
    Chairman Isakson. Introduce your other----
    Secretary Wilkie [continuing]. Yes, sir.

STATEMENT OF HON. ROBERT L. WILKIE, SECRETARY, U.S. DEPARTMENT 
 OF VETERANS AFFAIRS; ACCOMPANIED BY PAUL R. LAWRENCE, PH.D., 
UNDER SECRETARY FOR BENEFITS, VETERANS BENEFITS ADMINISTRATION; 
 RICHARD A. STONE, M.D., EXECUTIVE IN CHARGE, VETERANS HEALTH 
  ADMINISTRATION; AND JON RYCHALSKI, ASSISTANT SECRETARY FOR 
             MANAGEMENT AND CHIEF FINANCIAL OFFICER

    Secretary Wilkie. Well, first of all, thank you for the 
courtesy and thank you for the kindness that you have shown me. 
I am going to take a point of personal privilege and thank you 
and Senator Tester for all the support that you have given me.
    As you know, I came to this position having been the Under 
Secretary of Defense for Personnel and Readiness. I was raised 
in the military world. My service, compared to my ancestors, is 
incredibly modest, but it is service, nonetheless, and I have 
been privileged to see the military life from many angles. 
There is no higher honor than to be sitting here before you.
    I am pleased to have with me, and I will start on the left 
side, Jon Rychalski, who is our project guru, our Assistant 
Secretary for Management and our Chief Financial Officer; Dr. 
Richard Stone, who is our Executive in Charge of VHA; and our 
most recent award winner, who has just received an award for 
being the government's best senior executive, and that is Dr. 
Paul Lawrence, our Under Secretary for Benefits, and I thank 
them for coming.
    When I last reported to this Committee, Mr. Chairman, in 
December, I said that the state of VA is better. I believe, 
from the statements that you have made and from the statements 
Senator Tester has made that you believe that as well. I count 
that to the support of this Committee.
    Earlier this morning, I addressed the House Doctors Caucus, 
and I said the changes made in VA were not driven by the 
Executive branch. The changes made in the VA came from the two 
authorizing committees. I argue that it is the most 
transformative period in the history of this Department, going 
all the way back to Omar Bradley's day, and I do not believe 
that we are any longer on the cusp of transformation. We are 
actually in the middle of it.
    Before I talk about that I do want to talk about the 
trajectory that VA is on. In the last month we have had--the 
last few months--we have had some excellent news. In most of my 
career in and out of government VA has always been rated 16 of 
17 or 17 out of 17 in terms of the best places in government to 
work. The Partnership for Public Service, for the first time, 
said we are no longer there. We are in the top third and we are 
actually moving in a higher direction. So, if we have customer 
service amongst ourselves we will provide good customer service 
to those that we are honored to serve.
    The Annals of Internal Medicine said, as Senator Tester 
implied, that the medical care that VA gives is good or better 
than any medical care in any region of the country, and we are 
proud of that. And last, the Journal of the American Medical 
Association said that our wait times in the four most important 
categories of medical care or as good or better than any in the 
private sector. That is an indication as to where we are headed 
in our Department.
    The major driver of transformation is the MISSION Act. As 
you know, it simplifies and consolidates VA's seven Community 
Care Programs into a single, streamlined, simple-to-use 
program. It extends the Choice Program, expands the Caregiver 
Program, and provides a new urgent care benefit as well as 
other access improvements. Regulations setting new access 
standards, ensuring greater choice for veterans, will be 
completed in June. We have proposed a 30-minute average drive 
time standard for primary care and mental health care and a 60-
minute average drive time standard for specialty care.
    We have also proposed appointment wait time standards of 20 
days for primary care and mental health care and 28 days for 
specialty care from the date of request, with certain 
exceptions, and I want to also begin to address the 
privatization argument. Obviously, I come from the conservative 
Republican side of the aisle. The issue that has been raised 
many times about privatization is just not borne out by our 
budget, by the directions of this Committee, and I am here to 
say, as Senator Tester said, that the care in the private 
sector, 9 times out of 10, is probably not as good as care in 
VA.
    I will give you an example. One of your colleagues gave an 
interview in one of his State's newspapers, saying that he was 
disappointed in the wait times for certain services at VA in 
one of his major metropolitan areas. The wait time was 12 days 
for VA. In the major metropolitan area it was 78 days. That 
also is an indication that we are moving in the direction that 
you have pointed for us and the direction that veterans 
deserve. Things are not always greener on the other side of the 
hill.
    At the same time, we are trying to move out in making VA a 
modern 21st century health care administration. No longer will 
we have an ad hoc supply chain. We are tying in with the 
Department of Defense and their computerized systems for 
medical supplies. The days where VA doctors at the DCVA have to 
run across the parking lot to MedStar to find equipment have to 
be over if we are going to continue the road of improvement.
    The other part of our major transformation is the 
electronic health record, where we tie in with the DOD the 
minute that young American walks into the military entrance 
processing station, so that we have a complete picture of that 
veteran's health.
    The Chairman mentioned burn pits. For the first time, when 
this is online, VA doctors will be able to see everything that 
had happened in that soldier's life, from exposures to toxins 
overseas, from exposures to toxics in the continental United 
States, and we will then know better how to serve that veteran.
    I have been asked to lead the National Suicide Prevention 
Task Force. That is one of three areas that VA is moving out on 
in response to this Committee. For Senator Manchin it is the 
opioid epidemic, and how we begin to change the way we treat 
our veterans when it comes to the use of opioids.
    Homelessness is another area; and then finally, suicide 
prevention. In the last year we have hired over 3,900 mental 
health professionals. We now provide same-day mental health 
service for veterans in need.
    As part of the continued transformation we are also 
engaging in the creation of a modern H.R. system. Right now 
there are 140 H.R. offices across VA. We are consolidating 
those down to 18, and for the first time bringing in H.R. 
professionals to create a modern human resource capability that 
will send doctors, nurses, and health care professionals to 
those parts of the country where they are most needed.
    As for the budget, the Chairman is right, a $220 billion 
budget. That is a 9.5 percent increase over what VA had last 
year. That is $97 billion in discretionary spending, a $123.2 
billion in mandatory spending, and funding for 393 full-time 
employees, which is an increase in 13,000 for those working at 
VA.
    That means that for the MISSION Act, 19 percent of the 
funding will go to community care but 81 percent for VA care; 
$1.6 billion to the electronic health record; $184 million for 
a modern, integrated financial acquisition management system; 
and $36 million for us to continue to adopt the Defense Medical 
Logistics Standard Support system; $8.1 million to continue the 
improvement in customer service, the prime directive for those 
in VA; $547 million for women's health; and $1.6 billion for 
capital investment.
    The last item on my list is to continue my pledge to you 
that we be an open department. We are joined at the hip with 
this Committee and with the Committee of the House of 
Representatives. We all have the same mission in mind. Again, I 
thank you for your courtesy. I thank you for allowing me the 
honor of serving in this capacity, and I look forward to your 
questions.
    [The prepared statement of Mr. Wilkie follows:]
        Prepared Statement of Hon. Robert L. Wilkie, Secretary, 
                  U.S. Department of Veterans Affairs
    Good morning, Chairman Isakson, Senator Tester, and distinguished 
Members of the Committee. Thank you for the opportunity to testify 
today in support of the President's Fiscal Year (FY) 2020 Budget for 
the Department of Veterans Affairs (VA), including the FY 2021 Advance 
Appropriation (AA) request. I am accompanied today by Dr. Richard 
Stone, Executive in Charge, Veterans Health Administration (VHA), Dr. 
Paul Lawrence, Under Secretary for Benefits, and Jon Rychalski, 
Assistant Secretary for Management and Chief Financial Officer.
    I begin by thanking Congress and this Committee for your continued 
strong support and shared commitment to our Nation's Veterans VA. In my 
estimation, two Federal Government departments must rise above partisan 
politics--the Department of Defense (DOD) and VA. The bipartisan 
support this Committee provides sustains that proposition. To continue 
VA's momentum, the FY 2020 budget request fulfills the President's 
strong commitment to Veterans by providing the resources necessary to 
improve the care and support our Veterans have earned through sacrifice 
and service to our country.
                  fiscal year (fy) 2020 budget request
    The President's FY 2020 Budget requests $220.2 billion for VA--
$97.0 billion in discretionary funding (including medical care 
collections). The discretionary request is an increase of $6.8 billion, 
or 7.5 percent, over the enacted FY 2019 budget. It will sustain the 
progress we have made and provide additional resources to improve 
patient access and timeliness of medical care services for the 
approximately 9 million enrolled Veterans eligible for VA health care, 
while improving benefits delivery for our Veterans and their 
beneficiaries. The President's FY 2020 budget also requests $123.2 
billion in mandatory funding, $12.3 billion or 11.1 percent above 2019.
    For the FY 2021 AA, the budget requests $91.8 billion in 
discretionary funding including medical care collections for Medical 
Care and $129.5 billion in mandatory advance appropriations for 
Compensation and Pensions, Readjustment Benefits, and Veterans 
Insurance and Indemnities benefits programs in the Veterans Benefits 
Administration (VBA).
    For VA Medical Care, VA is requesting $84.1 billion (including 
collections) in FY 2020, a 9.6 percent increase over the 2019 level, 
and a $4.6 billion increase over the 2020 AA, primarily for community 
care and to transition the Choice Program workload to VA's 
discretionary Medical Community Care account. This Budget will provide 
funding for treating 7.1 million patients in 2020.
    This is a strong budget request that fulfills the President's 
commitment to Veterans by ensuring that they receive high-quality 
health care and timely access to benefits and services while 
concurrently improving productivity and fiscal responsibility. I urge 
Congress to support and fully fund our FY 2020 and FY 2021 AA budget 
requests--these resources are critical to enabling the Department to 
meet the evolving needs of our Veterans and successfully execute my top 
priorities.
                            customer service
    It is the responsibility of all VA employees to provide an 
excellent customer service experience (CX) to Veterans, Servicemembers, 
their families, caregivers, and survivors when we deliver care, 
benefits, and memorial services. I am privileged to champion this 
effort.
    Our National Cemetery Administration has long been recognized as 
the organization with the highest customer satisfaction score in the 
Nation. That's according to the American Customer Satisfaction Index 
ACSI). And that's across all sectors of industry and government. We 
need to work to scope that kind of success across all benefits and 
services.
    That's why I incorporated CX into the FY 2018-2024 VA Strategic 
Plan. Last year, I issued VA's first customer service policy. That 
policy outlines how VA will achieve excellent customer service along 
three key pillars: CX Capabilities, CX Governance, and CX 
Accountability. I am holding all VA executives, managers, supervisors, 
and employees accountable to foster a climate of customer service 
excellence. We will be guided by our core VA Values of Integrity, 
Commitment, Advocacy, Respect, and Excellence (I-CARE). These values 
define our culture of customer service and help shape our standards of 
behavior.
    Because of VA's leadership in customer experience, our Veterans 
Experience Office has been designated Lead Agency Partner for the 
President's Management Agenda (PMA) Cross-Agency Priority (CAP) Goal on 
Improving Customer Experience across government.
    Our goal is to lead the President's work of improving customer 
experience across Federal agencies and deliver customer service to 
Veterans we serve that is on par with top private sector companies.
    This is not business as usual at VA. We are changing our culture 
and putting our Veteran customers at the center of our process. To 
accomplish this goal, we are making investments in Customer Service, 
and we are making bold moves in training and implementing customer 
experience best practices.
    Veterans Experience Office. The Veterans Experience Office (VEO) is 
my lead organization for achieving our customer service priority and 
providing the Department a core customer experience capability. VEO 
offers four core customer experience capabilities, including real-time 
customer experience data, tangible customer experience tools, modern 
technology, and targeted engagement. For FY 2020, VEO is shifting from 
a full reimbursable authority (RA) funding model to a hybrid of a RA 
and budget authority (BA) model. The FY 2020 request of $69.4 million 
for the VEO ($8.6 million in BA and $60.6 million in RA) is $8.1 
million above the FY 2019 enacted budget. The budget increase and the 
transition to a BA highlights VA's commitment to customer service and 
the institutionalization of CX capabilities within the Department to 
improve care, benefits and service to Veterans, their families, 
caregivers and survivors.
                       mission act implementation
    The VA MISSION Act of 2018 (the MISSION Act) will fundamentally 
transform elements of VA's health care system, fulfilling the 
President's commitment to help Veterans live a healthy and fulfilling 
life. It is critical that we deliver a transformed 21st century VA 
health care system that puts Veterans at the center of everything we 
do. The FY 2020 budget requests $8.9 billion in the VA Medical Care 
program for implementation of key provisions of the MISSION Act: $5.5 
billion for continued care of the Choice Program population; $2.9 
billion for expanded access for care based on average drive time and 
wait time standards and expanded transplant care; $272 million for the 
Urgent Care benefit, and $150 million to expand the Program of 
Comprehensive Assistance for Family Caregivers.
    Access to Care. Over the past few years, VA has invested heavily in 
our direct delivery system, leading to reduced wait times for care in 
VA facilities that currently meet or exceed the quality and timeliness 
of care provided by the private sector. And VA is improving access 
across its more than 1,200 facilities even as Veteran participation in 
VA health care continues to increase.
    From FY 2014 through FY 2018, VA saw an increase of 226,000 unique 
patients for outpatient appointments (a four percent increase). Since 
FY 2014, the number of annual appointments for VA care is up by 3.4 
million. There were over 58 million appointments in VA facilities in FY 
2018--620,000 more than the prior fiscal year. We have significantly 
reduced the time to complete an urgent referral to a specialist. In FY 
2014, it took an average of 19.3 days to complete an urgent referral 
and in FY 2018 it took 2.1 days, an 89 percent decrease. As of 
December 2018, that time was down to about 1.6 days.
    Still, our patchwork of multiple separate community care programs 
is a bureaucratic maze that is difficult for Veterans, their families, 
and VA employees to navigate.
    The MISSION Act empowers VA to deliver the quality care and timely 
service Veterans deserve so we will remain at the center of Veterans' 
care. Further, the MISSION Act strengthens VA's internal network and 
infrastructure so VA can provide Veterans more health care access more 
efficiently.
    Transition to the New Community Care Program. We are building an 
integrated, holistic system of care that combines the best of VA, our 
Federal partners, academic affiliates, and the private sector.
    The Veterans Community Care Program consolidates VA's separate 
community care programs and will put care in the hands of Veterans and 
get them the right care at the right time from the right provider. On 
January 30, 2019, we announced proposed access standards that would 
determine if Veterans are eligible for community care under the access 
standard eligibility criterion in the MISSION Act to supplement care 
they are provided in the VA health care system. The proposed regulation 
for the program (RIN 2900-AQ46) was published in the Federal Register 
on February 22, 2019, and was open for comments through March 25, 2019.
    New Veterans Community Care Program Eligibility Criteria

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

    Proposed Access Standards. VA's proposed access standards--proposed 
for implementation in June 2019--best meet the medical needs of 
Veterans and will complement existing VA facilities with community 
providers to give Veterans access to health care.
    1. For primary care, mental health, and non-institutional extended 
care services VA is proposing a 30-minute average drive time from the 
Veteran's residence.
    2. For specialty care, VA is proposing a 60-minute average drive 
time from the Veteran's residence.
    3. VA is proposing appointment wait-time standards of 20 days for 
primary care, mental health care, and non-institutional extended care 
services and 28 days for specialty care from the date of request, 
unless a later date has been agreed to by the Veteran in consultation 
with the VA health care provider.

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

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

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

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


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

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

    Chairman Isakson. Thank you very much, Mr. Secretary. We 
appreciate it and I appreciate your acknowledgment of what I 
had said earlier about the amount of money we were talking 
about. We are not here complaining about what we have to spend 
it on. We are looking for answers to spend it better and to see 
our veterans get better services, and we will work it out 
better all along. We have got a good budget to work with. We 
are not begging for more. We are looking for results.
    Which brings me to my first question that I will ask. The 
private sector today, in health care, the whole answer to 
most--whatever the question is, the answer is outcomes. They 
are trying to measure outcomes for everything, from 
reimbursement, to being a network, to anything else.
    When you refer to the improvements that you referred to, 
how do you measure your outcomes in the VA? Do you take them 
from the senior person in charge or do you take them from 
evaluations or do you take them randomly? How do you gauge your 
outcomes for the services you provide to our veterans?
    Secretary Wilkie. A combination, Mr. Chairman. I really 
look to the veterans first. I have been very aggressive in the 
8 months that I have been in this chair, in reaching out to 
veterans in terms of surveys, in terms of interviews. What I 
have seen is that our customer satisfaction rates are moving in 
an upward direction, where we have, I think, an 89 percent 
customer satisfaction rate amongst veterans.
    In terms of other metrics, opioids is the outstanding 
example. How are we changing the way that we approach this 
national tragedy? We approach it in changing the way that we 
treat our veterans, by providing things that would have been 
anathema to somebody like my father, 30 or 40 years ago, with 
alternative medicines, tai chi, acupuncture, yoga. We are on 
the cutting edge both of alternative treatments to our 
veterans, we are on the cutting edge of telehealth, as Senator 
Tester said, and we are on the cutting edge in terms of 
tackling the national epidemic of suicide and homelessness.
    So, the answer is: it is a combination of things, but for 
me the most important is listening to what our veterans say.
    Chairman Isakson. On that answer let me say this. In your--
in the budget, in the recommendations you have, it includes 
funding for retiring two IT systems that currently exist within 
the VA. You and I have talked about this before, but it seems 
like the VA is a place where you collect software and systems, 
where people have bought things over the years, and they have 
piled up. They do not talk to each other, they do not work 
together, and we are not getting good bang for our buck.
    You obviously are trying to clean that up, and I would like 
for you to talk about those two recommendations in terms of 
retiring those programs and the overall picture in terms of 
VA's IT system, getting it improved and getting it better.
    Secretary Wilkie. Well, I told you 8 months ago that the 
overall condition of VA's IT system was bad. As a result of 
that, this Committee is looking at, as Senator Tester said, a 
massive increase in our budget, $4.2 billion, I believe. But, 
that money, in the past, has been spent on redundant systems, 
going down the same road that led to the failure in the Forever 
GI Bill as well as other systems.
    What we are doing, and you, I believe, will have the CIO up 
here for testimony in the next few weeks, is we are beginning 
to migrate our legacy systems out and bring the VA in line with 
the rest of America, through the cloud. We now have 8,000 
employees who are dedicated simply to that transition. We will 
ask for a bit of patience on some of these, but the migration 
to the cloud is the wave of the future and it is the way that 
we will maintain, I think, the trajectory that VA has undergone 
in terms of its overall customer service.
    But, you are absolutely right. The reason the Forever GI 
Bill crashed and burned, the directions from this Committee 
were placed on a 40-year-old IT system. It was bound to fail, 
which is one of the reasons why I stopped us going down that 
same old road and pivoted just so we can make sure that our 
veterans got their checks.
    Chairman Isakson. Well, let me say one thing. I am not 
going to ask you another question, but I am going to make a 
statement, and I will make an admission, too.
    The State of Georgia brought me in when they lost their 
superintendent of schools in the middle of an election cycle, 
to take over the Board of Education in Georgia, and the 
Department of Education, going through Y2K. Now I had a pretty 
good company in terms of dealing with technology and stuff like 
that, and I learned that you can buy every trick in the book 
when the salespeople come in and start talking to you, because 
they have got an advantage. They know what they are talking 
about and you do not know, and you do not understand it. If you 
are as old as I am, you really do not understand digits and 
clouds and all the other stuff.
    I want to find that damn cloud one of these days too. I 
want to see where that thing is. Everybody always says that is 
the solution. Well, I think it may be the problem. I just 
cannot find it anywhere.
    Anyway, my point is this. So many times when we go to clean 
up a system of technology and information, we end up buying 
more stuff to clean up the mess, and we have a bigger mess when 
it is over than we had before, plus we have not solved the main 
problem, which is the workability and the interoperability of 
the IT systems we had. So, let me just encourage you to make 
sure we have got the right people, who know what they are 
talking about, making the decisions or the recommendations to 
you on the final decision, those that understand technology and 
what it can and cannot do, and do not buy every bid and promise 
that comes through the front door, because that gets expensive 
and it can cause you lots of problems.
    The VA is so big, the number of employees is so large, the 
budget is so big, you are talking about any little problem in 
the VA is a big cost, particularly if it is the IT system. So, 
I encourage you to continue what you are doing and I appreciate 
what you are doing on that.
    Mr. Tester.
    Senator Tester. I will yield to Senator Manchin.
    Chairman Isakson. Senator Manchin.

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

    Senator Manchin. Thank you, Mr. Chairman, and, Secretary, 
thank you for being here. I have not met a veteran yet in my 
State--and we have a high percentage of veterans--who want the 
VA to be privatized. I have not heard that from any of you all 
and I do not think you do either.
    But, here is the troubling thing that we have. Your request 
is a 44 percent decrease in funding levels for construction 
programs. That was in the budget that you all submitted. I know 
that we are investing heavily in Community Care. We are leaving 
our current VA facilities. Let me give you a few examples.
    In a rural State such as mine, in West Virginia, our rural 
mobile unit in Clarksburg is totally inoperable, totally 
inoperable. Our medical centers have not had any update nor 
increase in residential rehab centers since the '50s and '60s. 
Most of our facilities require basic maintenance, deferred 
maintenance as we call it, for roofs, HVAC, all of the above.
    I am worried that even though our intent in the verbal 
agreement that we have, that we do not want to privatize 
because of starving some of the things, people are going to 
say, ``Well, I would rather not go to VA because it does not 
have proper services. They do not have updated equipment.''
    It leads me right into another question, is that there are 
over 40,000 vacancies at any time, in any moment, in the VA. 
This morning there were 138 positions posted on USA Jobs, in my 
State--138. I have got pulmonologists, cardiologists in 
Huntington, psychology in Beckley, practitioners in 
Martinsburg. We are hurting all over the board.
    So, even though the intent might not be there it looks like 
the signs we are moving in that direction because of demand 
from our veterans. If our veterans are not getting the care 
they are going to say, ``I just need better care. I am not 
getting it.'' And, if a facility is not worth even going to 
because it is not in good enough shape--so you can see the 
concern, Mr. Secretary, of what we have and what we have to 
answer to. They are still totally, overwhelmingly supportive of 
the VA.
    Secretary Wilkie. Well, let me take your comments seriatim. 
First, I would be lying to you if I told you that we are 
anywhere near turning the corner on capital investment. My 
estimate is that we need $60 billion over the next 5 years to 
come up to speed. That is an incredible number.
    Let me tell you what else we are dealing with. More than 
half of the buildings that I am responsible for age in range 
from over 50 years to 100 years. This Committee has provided 
the way forward. We are now engaged--and I believe it was 
Senator Moran's idea--with market assessments of our national 
infrastructure and our human resource needs that will then 
inform, when they are done, what this Committee told us to 
create, and that is the Asset Infrastructure Review Commission, 
to bring our facilities up to speed where the veterans are.
    Again, this is a monumental problem. My first job is to do 
as much as I can to ensure that the basic health needs of the 
veterans are taken care of, and, unfortunately, there are cost/
benefit analyses that have to be made. I cannot come to you and 
say, ``Give me $60 billion to repair all of those facilities.''
    As for the human resource side, you are absolutely right, 
but let me tell you where we have been and where we are headed. 
My first week in office I had two senior leaders give me two 
different numbers as to how many employees we had. Now that is 
outrageous. And, I asked a military question--where is your 
manning document? A manning document in the military is one 
where you have your requirements and you have the people to 
match them. We never had one.
    Finally, we now have a modern H.R. team in place that has 
come on in the last few months, at my direction. I have 
consolidated, or am in the process of consolidating 140 
individual H.R. offices into 18, so that we have an even 
distribution of resources across the enterprise.
    We have asked for the resources to hire 13,000 people. As 
Senator Tester knows, my emphasis, as the head of VA, has been 
for rural America, rural America and native America, those two 
sections of the country that provide the highest per capita 
number of men and women in uniform, and for the native 
populations, the population that provides the highest number of 
holders of the Medals of Honor and combat decorations.
    So, it is a complex problem, as I said. I would be lying to 
you if I think we are anywhere near turning the corner, but I 
understand it.
    Senator Manchin. Let me just say--and I am sorry, my time 
is up, but I just want to make this comment. I speak to 
veterans all over my State and anywhere I can, and I tell them, 
``I do not believe that we intend to build brand-new VA 
facilities.'' Then, they say, ``Can't you at least take care of 
what we have?'' That is the biggest concern they might have, 
and I would hope that you all would understand it. They are 
scared to death that they are being set up, that this thing is 
going to go private because the demand will switch. Demand will 
switch if the facilities are not adequate enough to give them 
the service they need.
    Secretary Wilkie. Mr. Chairman, let me--let me ask your 
indulgence. That means we have to be much more creative. 
Senator Tillis is here, and he has one of the fastest-growing 
veteran populations in the country. In Fayetteville, my 
hometown, which sits underneath Fort Bragg, two massive VA 
facilities. The new one is leased. The VA center director does 
not have to worry about HVAC, does not have to worry about the 
lawn. He concentrates on taking care of veterans.
    We have to be more creative in terms of two things: one, 
how we manage our infrastructure, which the MISSION Act tells 
us to do better; and two, giving more incentives--and I want to 
come to this Committee and talk about it--something like a 
veterans' Peace Corps, to get medical professionals out into 
areas like rural West Virginia, western North Carolina, and 
provide the means to serve those veterans in communities that 
are hard to reach, yet provide the highest percentage of 
service of anyone in the country.
    Senator Manchin. Thank you. Sorry, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Manchin.
    Senator Cramer.

       HON. KEVIN CRAMER, U.S. SENATOR FROM NORTH DAKOTA

    Senator Cramer. Thank you, Mr. Chairman, and thank you, Mr. 
Secretary, for being here. Thank you for our previous 
discussion and to all of those who are with you.
    I will ask my questions specifically to you and you can 
defer them to others if it is more appropriate. You mentioned--
you talked a fair bit in your testimony about alternatives to 
pain management, alternatives certainly to opioids, and you 
talked about some things like acupuncture and other types of 
care. You did not mention hyperbaric oxygen chamber treatment, 
particularly for pain. We have found it to be quite effective, 
I think, in other types of treatments, particularly Post 
Traumatic Stress, brain injuries, things common to veterans, 
athletes, and others. I just wonder why and what do you think 
the potential is for that?
    Secretary Wilkie. Well, it certainly was not for lack of 
appreciation of the treatment. I pledge to you that I will be 
out in Fargo to look at the headquarters of one of America's 
largest hyperbaric chambers.
    No, we have to be more creative, particularly as treatments 
become more complex for more complex injuries, particularly the 
injuries of the brain. I think we are not even at the Sputnik 
stage when it comes to exploring the brain and how it responds 
to trauma, how it recovers. Dr. Stone is probably the better 
expert when it comes to the actual medical conditions that that 
treatment addresses.
    Dr. Stone. Certainly, as a practitioner who has spent much 
of my career doing wound management, hyperbaric oxygen is 
something we have worked with for a long time. Using hyperbaric 
oxygen to actually heal the brain or to do some of the work 
that you have been discussing is work that has been studied for 
at least a decade, in both the DOD as well as in VA.
    What we know is that hyperbaric oxygen chambers have a 
dramatic effect in improvement of individuals with both PTSD as 
well as brain injuries. What we do not understand is what the 
addition of oxygen to the presence in that chamber does. There 
have been multiple studies done by all three uniformed services 
as well as by the VA, demonstrating that, and we look forward 
to further research on it. Brain rest remains one of the 
mainstays at this time, and certainly going into a chamber 
where there is silence has great value. Whether the addition of 
oxygen under pressure remains in debate.
    Senator Cramer. That would be interesting to see, because 
my understanding is that the presence of more oxygen could have 
the alternative impact, because, of course, it is stimulative, 
I would guess.
    Dr. Stone. Senator, I agree with you, and as a practitioner 
who has done wound management in the presence of trying to 
penetrate oxygen into wounds, that is exactly correct.
    Senator Cramer. Well, we would love to help you with that 
experimentation in Fargo, so we can talk further about that 
later.
    The other thing I wanted to mention, because you have 
mentioned it both in your testimony and in your answer to 
Senator Manchin, you talked about 13,000 more people. You are 
in the people business. It requires practitioners to do the 
work that you do, and they do it very well. And, by the way, 
they do it really well in Fargo. We are very pleased and proud 
of the service they provide our veterans.
    But, it is getting harder to find good people and to 
attract them, to keep them, and particularly, in an economy 
like North Dakota has, as you are aware, it is even really 
elevated there. The challenge is amplified, I think, in an 
economy and in a region like ours, and, probably like other 
rural States.
    That said, can you elaborate a little bit on specific 
programs, whether it is loan repayments--what are some of the 
tools that you have available, or that we could, you know, help 
you with, to attract and maintain and keep good people?
    Secretary Wilkie. Well, I will say the Chairman and the 
Ranking Member inserted into the MISSION Act the first 
monumental step in addressing the needs of rural veterans by 
giving us the authority--extra authorities on relocation pay, 
reimbursement, the ability to pay off medical school loans up 
to $200,000. Those are absolutely needed.
    My goal, though, is to try to even--to try to create even a 
more robust relationship with our universities and also with 
the armed services. General Bradley's goal is to have at least 
half of the doctors and nurses coming off of active duty coming 
into VA. General Mattis and I spoke a great deal about that. We 
are now telling doctors that when they decide to leave active 
service, come to VA to continue your service to those who have 
worn the uniform. I want to go back to the future on that, but 
this Committee has given us a start, particularly when it comes 
to rural America.
    Senator Cramer. Thank you, and thank you, Mr. Chairman.
    Chairman Isakson. [Off microphone]--for all of his games. 
It must work some--he is a pretty good quarterback. I just 
heard that. I do not know if that is true or not. It sounds 
good.
    Mr. Moran. No. Mr. Blumenthal. I am sorry, and then it is--
OK.

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

    Senator Blumenthal. Thanks, Mr. Chairman. I hesitate to 
interrupt Senator Moran, but I will.
    Senator Moran. I am anxious to hear what you have to say.
    Senator Blumenthal. Thanks, Mr. Chairman. Thank you, 
Senator Moran. Thank you, Secretary Wilkie, and your team for 
being here today. I want to congratulate and thank you on your 
announced decision that you would not be appealing the ruling 
of the court in the Blue Water Navy case.
    Secretary Wilkie. That is my recommendation. I do not know 
what other departments will do.
    Senator Blumenthal. Well, I think your recommendation will 
be key; it is instrumental. I would, perhaps, with all due 
respect, Mr. Chairman, express on my behalf, and I hope on 
behalf of the Committee on Veterans' Affairs, that that 
recommendation be adopted and endorsed heartily to bring 
fairness and justice to our Blue Water Navy veterans. It would 
culminate a crusade that has been bipartisan, involving almost 
everyone on this Committee. It has been a team effort and I am 
grateful to you for making that recommendation.
    I also want to submit, for your consideration, the Agent 
Orange Exposure Fairness Act, which would extend the basic 
principles of that court decision, and suggest also that there 
are other toxic chemicals and poisons on today's battlefield 
that are worth the research and attention that the VA should 
give them in deciding what kinds of benefits and disability 
compensation our veterans deserve. The potential for poisons on 
the battlefield is one of the great challenges of our time, one 
of the areas of unknown consequences to our heroes in uniform, 
and as the father of two veterans who have fought in recent 
wars and a friend of many, I hope that we can carry forward the 
spirit of that court decision and of your support for it.
    I want to move to the Veterans Affairs' health care system, 
especially, in particular, the VA facility in West Haven. I 
think you are familiar with my letters to you on this topic. I 
understand that sterilization processes there essentially have 
been stalled so that the operating facilities are at one-third 
of capacity. To put it very bluntly, two-thirds of the veterans 
who need surgery at the West Haven facility are either sent 
elsewhere or their surgeries are delayed or possibly denied. 
That is because the sterilization capacity is limited.
    The surgical facilities were closed for about 3 months 
because of flooding. They are back open now, but the tools and 
equipment used in those surgeries cannot be properly 
sterilized. A mobile trailer is planned for a year from now. 
That is way too long. A permanent facility, 5 years from now--
much too long. I would like to know what the plans are, Mr. 
Secretary, for expediting the availability of that surgical 
capacity, in other words, the sterilization process facility.
    Secretary Wilkie. I know how important West Haven is. Dr. 
Stone is supervising that.
    I do want to step back, though, and say I agree with you, 
and some of your earlier statements about burn pits. We do not 
want to go through what we went through with Agent Orange. I 
certainly saw that in my family. I worked for Senator Tillis on 
the Burn Pit Registry legislation that he and Senator Klobuchar 
introduced and had passed a few years ago. So, it is important 
to me. Now I will let Dr. Stone talk about West Haven.
    Senator Blumenthal. Thank you.
    Dr. Stone. Senator, we appreciate your role and your 
activism in this, in the recovery of West Haven.
    Clearly this goes back to the fact that this is an older 
facility. We have got a steam line running underneath the 
sterilization area, and as we have worked to recover that 
facility let me reassure you that the surgery being performed 
in that facility today is safe and sterilization is a safe 
process.
    Senator Blumenthal. I do not doubt that it is safe, and I 
want to emphasize that the docs, physicians, staff are doing 
their best. They have one hand tied behind their back. In no 
way are they compromising the safety or effectiveness of the 
surgeries they do. They are to be commended. But, I think the 
VA here is failing them by failing to expedite the 
sterilization processes which limits their capacity.
    Dr. Stone. My understanding is that the mobile trailers 
that would bring the ionized water and the sterilization 
materials in will be installed by June of this year, and that 
the major hold-up was because of utility issues on that area as 
well as the building of the trailer. The actual funding of a 
new sterilization facility will take 3 to 5 years. That said, 
my expectation is that as soon as that mobile unit is installed 
this June we will begin to recover the surgery that needs to be 
done at that facility.
    Senator Blumenthal. Will it go to 100 percent?
    Dr. Stone. That is my intention, absolutely.
    Senator Blumenthal. Can you make that commitment?
    Dr. Stone. I have--absolutely.
    Senator Blumenthal. Thank you.
    Secretary Wilkie. I will make it.
    Senator Blumenthal. Thank you, Mr. Secretary, and I would 
like to continue our conversation--my time has expired and I 
thank the Chairman--about the possibility of expediting a more 
permanent facility, but I appreciate your commitment today.
    Chairman Isakson. Thank you.
    Senator Moran.

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

    Senator Moran. Chairman, thank you. Thank you and Senator 
Tester for conducting this hearing. Mr. Secretary, thank you 
for being here. I join both the Ranking Member and the Chairman 
in expressing my gratitude for your continued service to those 
in uniform and I appreciate the job that you are doing at the 
Department of Veterans Affairs.
    I will have a chance, in Senator Boozman's Appropriations 
Subcommittee here in a few days to have more conversations 
about the spending and the budget recommendations. I have a 
couple of things that I think are timely that I want to ask you 
today, while I have this chance.
    First of all, I would like to highlight for you, in 2014, 
we authorized legislation. We are now working with Senator 
Brown of Ohio in furthering this legislation. The National 
Academy of Medicine was required to do a toxic exposure 
analysis to determine if there is any medical and scientific 
evidence related to, or whether there needs to be further study 
on this topic of the relationship between affliction, problems, 
now challenges effecting generations of the service man or 
woman now face as a result of that toxic exposure. We look 
forward to continuing to find the answer to that question.
    There may be a whole other generation. It saddens me 
because I cannot imagine anyone served their country thinking 
they may harm their children or their grandchildren by their 
service, but that very well may be the case and we are working 
to get the medical and scientific evidence to demonstrate that.
    I also want to highlight a piece of legislation that 
Senator Tester led, and I joined him in introducing related to 
mental health and suicide prevention, and I look forward to 
getting input from all my colleagues, with Senator Tester's 
leadership on it.
    Secretary Wilkie. That is the Guard and Reserve issues.
    Senator Moran. Actually, there are two of them. That is one 
of them and in addition to that the Commander John Scott Hannon 
Veterans Mental Health and Suicide Prevention Act, John Scott 
Hannon being a veteran who lived in the State of Montana.
    For my two questions on the timeliness of this hearing, 
staff of this Committee, the House Committee, and the staff of 
our individual Senators on the Committees met with your staff 
in regard to the Veterans Hearing Aid Access and Assistance 
Act. For as poorly as Senator Tester and I get along this is 
another one that he and I sponsored. It was passed into law in 
December 2016.
    And, the takeaway from that meeting--first of all I should 
indicate that that legislation in 2016, the law mandates that 
the Department of Veterans Affairs determine the criteria for 
hearing aid specialists, then with the goal of integrating them 
into the care of veterans that the VA serves.
    But, the unfortunate circumstance is that since 2016, we 
can find no evidence of the VA taking any steps to implement 
that mandate, and the meetings that I think I would describe 
the takeaway as little interest in meeting that mandate. I 
highlight, and the reason it is timely is that we asked for a 
response from VA officials by today's hearing, knowing that you 
would be here, yet we have received none to date. Perhaps--Dr. 
Stone appears to be interested in talking about this 
conversation.
    Dr. Stone. Senator, thank you. I appreciate it. I was 
unaware of the letter. If we have not responded you have my 
apologies. We will correct that today.
    Senator Moran. I had intended to send a letter. We did not 
send a letter. It was a conversation with officials at the VA, 
saying, ``OK, the Secretary is going to be here on Tuesday. 
Could you please get back to us by then? Otherwise, we need to 
raise this topic with the Secretary.''
    Dr. Stone. You happened to be looking at a hearing-
compromised veteran from my combat service, so I am deeply 
appreciative of what the VA has brought to me and my family, as 
we have sought care for my hearing loss due to combat. So, I am 
well aware of the issues that you bring up. Let me say to you 
that we, last year, performed over 1 million visits for 
hearing-compromised veterans, with our audiologists and our 
technicians. We have continued to grow that. We refer out about 
38,000 visits a year and we appreciate the legislation on 
hearing aid specialists.
    But, the question is do we need to move into the specialist 
area? Clearly you and I may have a different understanding of 
the role of the specialist. Today I have enough audiologists 
and enough technicians in order to provide that vast, vast 
majority of the care that is needed, including less than a 10-
day waiting period in order for veterans to come in for care or 
for their appliances. In addition, we have an under-two-week 
waiting period in order to take outside prescriptions and fill 
them on behalf of the veterans.
    Senator Moran. Let me suggest this, Dr. Stone, that maybe 
with Senator Tester and I's staff we could have this 
conversation. In the zero seconds I have left, Mr. Secretary, I 
am in Emporia, KS, on Saturday, 4 days from now. Emporia has a 
CBOC. The CBOC has 2 days of service and rarely has a 
physician. It has a mid-level practitioner. The Department, the 
Eastern Division in Kansas, has announced the closure of that 
CBOC. One would expect me to be angry about the closure of that 
CBOC. I am hopeful that with the closure of the CBOC and 
conversations with the VA that the MISSION Act now provides 
additional opportunities for care for veterans, because we go 
from a 2-day CBOC with virtually--with often no physician and 
one mid-level, to an opportunity for a multitude of community 
resources being available to those veterans in that area.
    I am going to meet with--your folks in Kansas are joining 
me in Emporia on Saturday. What message would you like for me 
to deliver about the opportunities that MISSION or the VA now 
can provide?
    Secretary Wilkie. The MISSION Act is about veteran-centric 
care. It is not about protecting the institution or guarding 
the status quo. It is about giving that veteran the option to 
be the guardian of his own or her own future. For rural 
America, offering the widest aperture possible on access to 
medical care is meeting the intention of this Committee. As 
long as we keep the veteran's health at the center of 
everything that we do then the system will work.
    Senator Moran. I will convey that to those veterans who 
join me on Saturday.
    Mr. Chairman, thank you.
    Chairman Isakson. In keeping with our bipartisan Committee 
commitment I am going to excuse myself for just a minute and 
turn it over to Senator Tester to continue the hearing, and it 
is also his turn to ask questions. I will be back in a second. 
Senator Tester?
    Senator Tester [presiding]. Thank you, Mr. Chairman. I 
assume that means I can just expand the time that I use.
    Chairman Isakson. It means you have to behave.
    Senator Tester. Oh, I have to behave. Damn it.
    Thank you all for being here once again. I hesitate to talk 
history with somebody who probably knows history far better 
than I do, especially military history; nonetheless, this is 
pretty elementary.
    In the 1930s, this country did not want to go to war. 
President Roosevelt turned our car factories into airplane 
manufacturing and prepared for war, and then came the bombing 
of Pearl Harbor and we were ready for war. Pretty simple. 
Pretty ingenious.
    Everybody on this Committee, I believe, has said no 
privatization, and all the VSOs have said no privatization. The 
President has said something different. You have said no 
privatization and your staff has also said that.
    The questions are asked here today, and I have talked about 
our vacancies in Montana. Manchin talked about his vacancies, 
his facilities, that needed improvement. Blumenthal talked 
about West Haven surgical that was at one-third capacity. Even 
Senator Moran, even though is not mad about it, is talking 
about a CBOC that is going to be closed because of the lack of 
staffing. Everything that I am hearing and everything I am 
seeing says something different.
    Then, I look at the budget and the budget--and you had said 
earlier that you needed $60 billion in capital investments--and 
the budget request for major and minor construction was 
decreased by 43 percent for major construction and 50 percent 
for minor construction. We are talking about the needs that are 
out there. By the way, we can go down the list in Montana. It 
is pretty reflective.
    I was at the meeting 6 days ago when you guys said you 
cannot get the money out the door; nonetheless, you talked 
about $60 billion in capital expenditures and reducing those 
accounts by 40 and 50 percent.
    Putting all that together, how can we justify that?
    Mr. Rychalski. Senator Tester, I can probably shed some 
light on that. First let me say that as Department CFO I feel 
dirty not asking for more money, to be honest. But, the fact--
--
    Senator Tester. The issue is not that you are just asking 
for more money. I do not care if you ask for more money, but if 
you have got $60 billion in needs over the next 5 years, and we 
are reducing those same accounts that will meet those capital 
expenditures, something does not jive. That is all.
    Mr. Rychalski. Let me explain. I was being a little bit 
facetious.
    The fact of the matter is we do have a requirement. There 
is no question. We have older facilities and we do have a 
substantial facility requirement. As you know, we had a 
substantial plus-up in 2018 and 2019. The fact of the matter is 
that we sort of, very quickly, executed our shovel-ready 
projects and they are in the works. We are at a point now, when 
you sort of divide the amount of money we have in the works by 
the number of facilities, we have about 19 to 20 projects per 
facility going, and they have limited capacity in a lot of 
areas, of moving clinics around, moving people around. We are 
now hearing from a number of facilities, they have actually 
some shovel-ready projects that they just cannot execute 
because it is too disruptive.
    We are going to end up carrying some of that money forward, 
from 2019 into 2020, and we are going to carry about $1 billion 
of the plus-up in NRM. We are also going to carry some minor 
construction money for----
    Senator Tester. Gotcha. So, I am going to do some quick 
math for you, not that you do not know this already. If you 
divide 60 by 5, it is $12 billion a year. And, if that need is 
out there and we cannot execute the amount of money we have got 
so far, how do we not privatize the VA?
    Secretary Wilkie. Well, we do not privatize the VA because 
we still have the largest health care system in the country----
    Senator Tester. Got it.
    Secretary Wilkie [continuing]. 170 hospitals.
    Senator Tester. Yep.
    Secretary Wilkie. Our veterans are voting with their feet.
    Let me just say, this is not a libertarian VA. If it were, 
I would be giving myself a card that says ``veteran'' and I go 
out in the private sector and get anything I want.
    Senator Tester. I hear you.
    Secretary Wilkie. That is not happening. Again, I fall 
back, not on anecdote but on the stats. Our veterans are happy. 
They are going where people speak their language and their 
culture. I support that and this Committee supports that.
    Senator Tester. Mr. Secretary, I agree with you, but I go 
back to the example of history. If we are short on manpower, if 
our facilities are short and substandard, if we are not making 
the HVAC additions that we need to, eventually those veterans 
that are going to the VA, they are going to say, ``Nope. Not 
anymore.''
    Secretary Wilkie. Well, you gave me--this Committee gave me 
the answer, and that is the market assessments----
    Senator Tester. Yes.
    Secretary Wilkie [continuing]. And then the Asset 
Infrastructure Review Committee, which does exactly what you 
said, and I think I am going to come to you and ask to 
accelerate the beginning of that commission.
    Senator Tester. Of the AIR Act?
    Secretary Wilkie. Yes, so that it moves more rapidly than 
the timeline that this Committee has given it.
    Senator Tester. Really quickly, I do not have a problem 
with that. Can you give me an idea on how quick--because it is 
set to go into effect in 2021 or 2022? OK.
    Secretary Wilkie. I would like to do that earlier because 
our market assessments are already underway.
    Senator Tester. I would love to visit with you about that, 
moving forward. OK.
    Now we have Senator Boozman.

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

    Senator Boozman. Thank you very much, and we do appreciate 
you and Senator Isakson. We can be very proud that the 2019 
appropriations, because of your two's leadership in the 
Committee, was significantly increased, and I think again we 
are going to see that going into the next fiscal year. We 
appreciate your leadership, Secretary Wilkie, and your team, 
especially in grappling with the Forever GI Bill and getting 
that under control. I know that was a hard thing to do. Also 
your work with veteran suicide. I think that we are coming up 
with a method now that is going to have significant results, so 
we really do appreciate that and appreciate that in your 
leadership style, again with your team.
    One thing I would like to understand, I was in Arkansas 
last week in a lot of our smaller communities that will be 
impacted by the MISSION Act. I guess what I would like to 
understand is there is a little bit of confusion as to what is 
going to happen in June. So, we will have the rules and 
regulations in place, going forward. For the veteran in 
Mountain Home, AR, who is being told he is ineligible for 
Choice because of the nearby location of the CBOC, even though 
it does not provide the medical service he needs, what is going 
to happen to him in June, if anything? Will he be able to talk 
to VA on June 6 to get authorized for care from a private 
hospital, or what is the process?
    Dr. Stone. The process is that the veteran will continue to 
talk to his provider or his scheduler in order to really 
authorize care and make the best decision on behalf of the 
veteran. Frankly, June 6 should also be a non-event for the 
veteran. Today we authorize--well, today we will do over 
300,000 visits in our direct care system. We will authorize 
about 50,000 visits in the community care system. That is all 
done on a manual basis by our providers and schedulers.
    On June 6, it is our hope to have something called a 
decision support tool that will automate that process. Should 
we fail with the decision support tool it will look just 
exactly like it does today. Now, there will be an enhanced 
number of veterans eligible to make a decision of whether they 
want to go out for care or not, but the system will look very 
similar to what it does today, as far as a veteran sitting in 
front of a provider or a scheduler or on the phone, making a 
decision on whether they stay or they go out for care.
    Senator Boozman. So, for those that are eligible on June 6 
for--theoretically for enhanced care, in the sense that, you 
know, they are going to fall into the new parameters, if they 
call will they be told ``do this and this,'' or will it be ``We 
are phasing this in. Call back?''
    Dr. Stone. Senator, this will be--they will be told what 
they need to do for care. There should be no increase in wait 
times. There should be no increase in wait for care.
    Now our problem is that in most areas of America the 
commercial health care system is not as responsive as we are. 
Please remember, of those 300,000 visits we are going to 
conduct today over 22 percent are same-day visits. In the 
commercial space it is not as responsive. As the Secretary has 
said previously, in an urban area in the Southeast, it was 
found that the wait time for the commercial space was 
dramatically higher than ours.
    Senator Boozman. I would like to talk--and again, mine was 
more in the context of the travel time versus the wait time, 
but we will talk about that.
    The veteran suicide, the collaboration with these groups 
that seem to be doing a good job, the Secretary and I were in a 
meeting earlier this morning and one of the Congressmen talked 
about a program that they had a 70 percent reduction in suicide 
as a result of. Can you talk about the efforts of the 
collaboration so that we can get these public-private 
partnerships going that seem to work well? Again, we need to 
make sure the metrics are there and all of those things.
    Secretary Wilkie. Yes, sir. So, the budget calls for $222 
million for suicide prevention programs. I have just been named 
as the chair of the National Task Force on Suicide Prevention. 
You know the terrible statistics--20 veterans a day take their 
lives, 14 of those are outside of our VA.
    I think the most important part of the task force, other 
than a whole health approach to suicide prevention, is the 
opening of the window for monies to flow into the States and 
localities, to help us find those veterans.
    Example--I was in Alaska with Senator Sullivan. More than 
half of the veterans in Alaska are not in the VA system. I 
asked the Alaska Federation of Natives to double the number of 
VA tribal representatives that they have, to go out into the 
hinterland of Alaska and help us find those veterans who are 
not in our system. It sounds simple. Sometimes simple solutions 
are the better solutions. The States and localities know better 
than we do, in many of these instances, where veterans are and 
where they are in need.
    A couple of things. I am not going to give you a metric 
saying that we are going to achieve zero suicides. The majority 
of veterans who take their own lives are Vietnam era, my 
father's generation. Some of these Americans have problems that 
began building when Lyndon Johnson was President. We are not 
going to be able to cure all of that, but we can--and if the 
Chair will indulge me--as the former Under Secretary of Defense 
for Personnel, General Mattis and I both began a system of 
education throughout an individual's military career that 
focused on mental health wellness and taught a soldier, sailor, 
airman, Marine, to look for the signs of danger, so that for 
the first time in our military history we actually have people 
coming out of the service who at least have had some 
educational grounding throughout their term of service in what 
to look for, when to ask for help, not only for themselves but 
for others.
    The deepening of the relationship between VA and DOD is 
absolutely essential, so we never again have those numbers that 
we have now, that began to build in Southeast Asia 50 years 
ago.
    Senator Tester. Thank you.
    Senator Hirono.

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

    Senator Hirono. Thank you, Mr. Chairman. Mr. Secretary, 
thank you for recommending that the Blue Water decision not be 
appealed. At this point, appealing that decision is not what we 
should be using our resources for, so use your persuasive 
powers to make sure that that happens.
    There was an article recently--oh, by the way, I understand 
that the Chairman is going to have a hearing later on your 
proposed access standards. That is good because a lot of us 
have expressed concerns about how those standards were 
developed and the fact that we heard from many VSOs that they 
were not consulted during that process. So, that will be 
happening in April, I understand.
    A few weeks ago, Mr. Secretary, the New York Times 
published a story with the heading, ``Treated like a piece of 
meat: Female veterans endure harassment at the VA.'' Have you 
read that article?
    Secretary Wilkie. I have.
    Senator Hirono. So, it paints a pretty dire picture of the 
kind of experiences and harassment that the women veterans who 
go to the VA endure. What is the VA going to do to make sure 
women veterans are respected by the VA staff and other 
patients? I realize that there needs to be some kind of a 
cultural change, but I do not know. Posting signs, whatever you 
need to do so that this is not the horrendous experience of 
women veterans, as described in this article.
    I want to know whether the VA is conducting any research 
into the best practices or models of care that increase women 
veterans' utilization of and satisfaction of VA services. Your 
testimony mentions that 91 percent of VA's community-based 
outpatient clinics have a women's health primary care provider. 
So, when can we expect that number to be 100 percent, because 
you are almost there? Can you respond to those two?
    Secretary Wilkie. Well, that is certainly the goal, and in 
our--Senator, in our previous relationships, from my former 
capacity as the Under Secretary of Defense, you and I discussed 
that the first thing that I had to do as the Under Secretary 
was promulgate the first DOD regulations on sexual harassment 
and equal opportunity, which we did. So, that tells you my 
commitment.
    You hit on it. It is a cultural change. I do not believe 
that what was in the New York Times story is apparent in all of 
our VA facilities. I am not going to be able to tell you with a 
straight face that I can change the attitudes of every person 
who works in the VA, but we are changing the culture. We are 
putting in women's health centers in all of our VA hospitals.
    One of my goals is to make sure that there is an actual 
privacy barrier, separate entrances, that in the case of this 
New York Times story, those things will probably less likely to 
occur just by changing the way we bring our women veterans into 
the system.
    I can say that we now--we had 500,000 appointments last 
year for women veterans. That is a sea change. I will also say 
that the culture that you talked about is now beginning to 
change within DOD. I think the longer that that goes on, the 
less likely you will see an end product such as you described 
in VA. But, I think we are on the right path.
    Senator Hirono. One would think that when you make those 
cultural changes that you may not need to expend resources on 
separate kinds of facilities, but obviously that is something 
that the women veterans very clearly want at this point.
    I want to get to the lack of progress that I have heard on 
various VA health care projects. For example, the Advanced 
Leeward Outpatient Healthcare Access, the ALOHA project, in 
Hawaii, on Oahu, was scheduled for a lease award early calendar 
year 2018, but has been delayed a number of times and a lease 
has still not been awarded.
    The project was scheduled to be completed originally by 
fiscal year 2020, and I know that these kinds of outpatient 
clinics are really helpful because they are usually closer to 
where the veterans live, and in Hawaii the Tripler Hospital is 
very crowded, you can hardly get any parking, and it is a pain 
in the okole, as we say in Hawaii.
    So, you know, can you commit to seeing that the ALOHA 
project is completed on time with no further additional delays?
    Secretary Wilkie. Senator, as you know I spent a great deal 
of time in Hawaii last year. I talked with the Governor about 
this lease. I will get you more information. My understanding 
was that there were contractual problems with those responsible 
for improving the facility. That was what I discussed back in 
December in Honolulu, but I will get you more information on 
that.
    Senator Hirono. Thank you, because I would like to see this 
and other CBOCs come through.
    Thank you, Mr. Chairman.
    Chairman Isakson [presiding]. Thank you, Senator Hirono.
    Senator Blackburn.

       HON. MARSHA BLACKBURN, U.S. SENATOR FROM TENNESSEE

    Senator Blackburn. Thank you, Mr. Chairman, and I want to 
thank you all for being here. Secretary Wilkie, I thank you for 
the time you have spent with me prior to this, to talk about 
the needs that some of our veterans in Tennessee have, and to 
look at how we fulfill that promise of providing for them and 
for their health care.
    I want to start with the EHRs (electronic health records) 
and your deployment, the modernization that you are doing 
there. As we have talked, many of our folks would like very 
much to be able to, under the MISSION Act, seek that care at 
home, because they are a good distance away from a facility. 
And, as we have talked before, interoperability is an 
imperative in making this work.
    I want to know where you are, what control measures you 
have that have been implemented to ensure that you are going to 
meet your milestones as you go through this deployment, as that 
begins to take place.
    Secretary Wilkie. Senator, we will go live in March of next 
year in the Pacific Northwest to reach our initial operating 
sites. That is on schedule. There are issues that we need to 
work our way through. These are old facilities. We need to 
rebuild our communication closets, and that is going to go on 
this summer. We also need to work our way through all of the 
internet of medical devices and make sure that they are 
appropriately----
    Senator Blackburn. OK. Let me ask you this. As you are 
doing that, are you working on a plan so that when someone 
enlists, day one, they begin a cloud-based, encrypted record 
that will follow them the rest of their life.
    Secretary Wilkie. Yes. That is the goal. I use my father as 
an example. The days of somebody carrying around an 800-page 
paper record are gone.
    Senator Blackburn. Right. But, I think it would be 
instructive and helpful to us if you could provide us with your 
timeline of when you are going to achieve this.
    Now, in the Health Committee today, they are doing a 
hearing on the EHRs, and we know that whatever you do that you 
have to have a strategy so that this is going to be 
interoperable with commercial best practices. So, you have that 
in place.
    Secretary Wilkie. Yes, we do, and obviously you mentioned 
the goal is to begin building that record the minute that young 
American walks into a military entrance processing station, and 
then there is a handoff. I expect--and I do not know when there 
will be new changes in leadership at the Department of Defense, 
that I will continue the relationship that I had with General 
Mattis. I expect to come to this Committee with the 
announcement of a joint program office, which will be the 
first--I believe the first joint program office between two 
departments, so that we combine the resources of both 
departments to build this record.
    Senator Blackburn. OK.
    Secretary Wilkie. It will be interoperable. I did--I would 
have never approved it if it could not be interoperable with 
the private sector.
    Senator Blackburn. OK. Telehealth. I was recently in 
Gallatin, TN, to open a veterans clinic there, which is one of 
the whole-of-life clinics. The day after that I was over at the 
Nashville VA for the new mental health center. We were walking 
through that. I think that those are important components to 
have, because the telehealth helps to bring those services to 
them, especially in behavioral health.
    I want to know how you are--what is your strategy and your 
timeline on moving more facilities so they are functioning with 
telehealth and have that whole-of-life approach to the clinic. 
We have got a lot of clinics, people cannot get to health care, 
long waiting lists, and this helps to speed the process.
    Dr. Stone. You are exactly correct. About three-quarters of 
a million veterans consumed telehealth visits last year. That 
is about 13 percent of the veterans that are enrolled with us. 
This year's budget will move that to 20 percent. We believe 
that in order to keep veterans in their homes, especially at-
risk veterans, instead of hospitalization, expanding telehealth 
services is absolutely essential. So, we will move to 20 
percent under this budget.
    Secretary Wilkie. I would say this Committee has given us 
authority that no other health care system in the country has, 
and it allows our doctors to practice across State lines. This 
is the front line of our attack on the problems of mental 
health, as you mentioned, with behavioral health. It provides 
our veterans with the opportunity to stay at home, stay in a 
comforting surrounding, and stay with people who look after 
them, their friends, their families, without forcing them to go 
into a larger facility.
    Senator Blackburn. I appreciate that. I know my time has 
expired. I just want to say listening to you all, as you talk 
about the budget and you talk about urgent needs, things should 
never have gotten into this shape--never--and it comes from 
mismanagement. My hope is, as you set these timelines for 
implementing technologies that are going to enable greater 
access, that you also are utilizing technology to make certain 
that there is not the gross mismanagement that has taken place 
in times past.
    Chairman Isakson. Senator Murray.

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

    Senator Murray. Thank you very much, Mr. Chairman, and 
thank you, Secretary Wilkie, and your team for being here. Let 
me start with the fact, Caregivers. I am sure you are shocked I 
am going there. But, the October 1 deadline that the 
Caregivers' IT system was to be certified to begin the 
expansion process is quickly approaching, and the VA still has 
a lot of work to do before then. We have now heard rumors in 
the press and in briefings that the VA might not make that 
deadline. I do really appreciate your personal understanding of 
the challenges caregivers face. I know you can appreciate how 
much our prior era caregivers and veterans need this support.
    For the record, will you meet the October 1 deadline to 
certify the IT system and begin expanding eligibility for the 
caregivers program?
    Secretary Wilkie. If I do not I will be back up here, but 
let me take a step back. The reason that I made the decision 
not to remove anyone from the Caregiver program was because of 
not only your work and your insistence but because this process 
has been mismanaged in the past. So, that was the right thing 
to do, and that is why I made that decision, based on your 
recommendation.
    The date is October 1. The statute says that I have to 
certify that the system is working. If I do not certify that no 
one will be removed. We will continue to manually process the 
checks. Right now there are 24,000 stipends that go out. It is 
manually done. But, as long as those checks get to our veterans 
that is fine with me.
    We do have a new commercial office shell technology, and if 
you have not been briefed I will get you someone to brief it--
--
    Senator Murray. OK.
    Secretary Wilkie [continuing]. That we brought on board 
February 22. That is the template that we will be using, 
hopefully, to be ready on October 1.
    The other side of this is that we have increased the 
budget, primarily because of your work, to about $720 million. 
I expect that to go up in the next few years. But, we are also 
using that money to hire professionals to staff out our 
Caregiver program.
    Senator Murray. OK.
    Dr. Stone. Senator, if I might add, this is a manual 
program today and there are over 24,000 families receiving 
benefits. Their checks are manually written every day. As we 
move to this commercial office shell software system, what we 
will need to do is to migrate all of the data over and then 
assure that we can then, on an automated basis, write the 
checks every month before we are ready to expand. And, although 
we have made a decision on a software system, the migration of 
that data we have not recommended a certification date yet on 
the software system and the expansion.
    Secretary Wilkie. I am not going to do it unless it is 
right.
    Senator Murray. OK. I appreciate that. At first glance, 
your request for Caregivers looks strong and appears 
comprehensive. However, several components of the program are 
in need of resources. You mentioned staffing, the IT system, 
the planned expansion of support services provided to 
caregivers. All of those will need an increase during 
expansion. And, your budget requests $150 million for expansion 
of the Caregiver program, leaving $555 million for the needs of 
the existing program. As I have made clear in previous 
settings, I want to be sure this request is not individually 
underfunding expansion or the needs of the existing program.
    I wanted to ask you, how will this funding, especially for 
the expansion, be allocated, and to which areas of need?
    Dr. Stone. The basic management structure of this program 
was done at individual medical centers, resulting in 
dramatically different criteria for inclusion and removal from 
the program. The first thing you will see is a stand-up of a 
regionalized management system to look at who is eligible and 
who will be removed. No one will be removed until we can assure 
you that we are doing this in a clear manner that is 
transparent to America's veterans and to the American people.
    As we stand up that regionalized process, that will occur 
under the chief medical officer of each VISN. We will move from 
the individual caregiver being the gatekeeper of this program 
to a regionalized board process, and then institute an appeal 
process at the VA central office.
    So, the entire management structure, in order to do this to 
the Secretary's standards and the standards that you expect, 
needs to be stood up and put together. We have introduced this 
concept to the VISN leadership last week and have begun talking 
to the chief medical officers about the hiring and stand-up of 
this system.
    Now----
    Secretary Wilkie. Let me--the last thing I will say, 
Senator--I have used your time--we are retraining our clinical 
staff across the country with the most modern techniques and 
information on how to deal with families and caregivers. I 
would say that I think VA is really the only health care system 
in the country that has concentrated on this. As the son of a 
Vietnam soldier it is vital to me.
    Senator Murray. OK. I appreciate it, and I know this is 
something you personally care about, too.
    As you know, I am going to stay absolutely on top of this. 
We want to implement it. We want to implement it correctly. We 
do not want to deny people this care that they have been 
waiting for, this help and this support. I appreciate your 
response today, but I will stay in close touch. Thank you very 
much.
    I do have other questions, Mr. Chairman, that I will submit 
for the record.
    Chairman Isakson. Thank you, Senator Murray.
    Senator Tillis.

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

    Senator Tillis. Thank you, Mr. Chair. Gentlemen, welcome. 
Secretary Wilkie, it is great to see you.
    First off, I want to thank you all for, in your budget 
request, funds to expand the CBOC down in Jacksonville. How do 
you see that--well, first off, for people who would suggest 
that there is a trend in the VA, or Members of Congress to 
privatize, it seems like budget requests for the expansion of 
the CBOC, the opening of 1 million square feet in three 
different health care centers in North Carolina, with a 
different model, that you mentioned earlier when I was here, 
seems to suggest that you believe the brick-and-mortar VA 
presence is a very, very important part of the future.
    So, I would not--I would like you to maybe touch on that. 
But, tell me how that CBOC expansion in Jacksonville, in 
combination with the PACT teams, are going to help improve care 
there, and then how do you leverage the PACT model for the rest 
of the veterans across the country?
    Secretary Wilkie. Well, Senator, let me talk about business 
processes that have led us to that stage. As I mentioned 
earlier, we are in the process of doing market assessments 
across the country to lead into the Asset Infrastructure Review 
Commission. The demographic changes that I see for veterans are 
changes that mirror those in the rest of the country. By 2027, 
North Carolina will have the fourth-highest number of veterans 
in the country. It will begin to nip at the heels of 
California.
    Senator Tillis. And, it will be the eighth-largest State.
    Secretary Wilkie. Yes. For those--like Senator Brown just 
came in--Ohio remains in the top 10. Because of the large 
populations in those States--and Georgia is in the top 10, as 
far as we can see in the future--we have to be more creative. 
We have to not only combine the brick-and-mortar facilities 
that we have, we have to manage them more efficiently, but we 
also have to create an environment where our teams can reach 
rural areas of our States and be more creative when it comes to 
things like telehealth. But, we are moving our resources to 
where the veterans are, and I think Dr. Stone has your PACT 
answer.
    Dr. Stone. The PACTs will continue to expand across the 
Nation as we hire. In Montana alone we have 38 primary care 
providers. We have got offers out to 8 additional primary care 
providers that will come in and expand that rural area.
    The Secretary is exactly correct, that we are seeing growth 
in north Florida, we are seeing growth in south Georgia, we are 
seeing growth in your State, sir, and we will continue to 
expand this.
    Now let me talk about brick-and-mortar. Veterans are not 
different than the rest of Americans. Our parents' generation 
stayed in the same house on a generational basis. We do not and 
our children do not. They move. We must be able to move from 
place to place in order to follow where the veterans go. 
Therefore, lease authorities are incredibly important to us, 
and enhanced lease authorities that would allow us not just to 
provide housing, but to also be able to provide ambulatory 
medical facilities that we can move every 5 to 10 years as to 
follow where America's veterans are.
    Much of the non-recurring maintenance that you hear about 
and the cost of our infrastructure is for our inpatient 
facilities. Our inpatient facilities, in many cases, are aged 
and need substantial improvements, but our ambulatory 
facilities, more than 1,000 of them, need to be able to be 
mobile when the veteran moves each decade.
    Senator Tillis. Thank you. I want to talk a little bit 
about access standards and the MISSION Act. I think I could 
infer, at least, from some comments from some of my colleagues 
that it is almost like we are giving some of our veterans too 
much choice. In some States I think you have 100 percent access 
to Choice if you want it, which there may be a variety of 
reasons why you need that. My colleague just came in from 
Alaska. He has got a very diverse population over a geography 
that almost spans the United States, from tip to toe, so I can 
see why you have to have a different solution for different 
States.
    But, what would happen, what would be the negative 
consequence if Congress succeeded in rolling back the access 
standards that you are putting in place now, in combination 
with the MISSION Act?
    Secretary Wilkie. Well, Senator, it would no longer be a 
veteran-centric, patient-centric approach to health care. That 
was the clear mandate of the MISSION Act, not institutional 
prerogative, but the health care of a veteran.
    So, let me beg the Chair's indulgence and describe what 
this is not, as I mentioned earlier. This is not a libertarian 
VA. This is not giving Dr. Stone or me a card and saying, 
``Thank you very much. Go out and find whatever doctor you want 
to take care of you for the rest of your life.'' What this says 
is that if we cannot provide a service then you have the option 
to seek that service in the private sector.
    I will give you an example. If there is no rheumatologist, 
and there probably is, in Fayetteville, and you meet the 
criteria for that service, then we tell you that you have the 
option to go to Duke or to Chapel Hill or to Cape Fear Valley, 
in my hometown, to get that service. It is based on the needs 
of the veteran, and veterans come first. If we cannot do what 
the veteran needs then we will provide him the opportunity to 
seek that.
    Senator Tillis. I think it is very important, Mr. Chair, 
just to close out my questions, that is why I think a broader 
understanding of what you are trying to accomplish with the 
patient aligned care teams. It is not like you are giving them 
a card and sending them on their way. I mean, you are going to 
spend a lot of time making sure that the outcomes are going in 
the right direction, that they are getting their appointments 
filled when they need to, and you will always have that brick-
and-mortar presence, if necessary. I, for one, think the access 
standards need to continue to move forward and the work that 
you are layering on top of it is going to provide a better 
standard of care for the veterans. I thank you for your work.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Tillis.
    Senator Brown.

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

    Senator Brown. Thank you, Mr. Chairman. Secretary Wilkie, 
thanks for your letter back to me regarding the VA History 
Center at the VA in Dayton, OH. We are excited to get the next 
phase of this project up and running. My staff and I look 
forward to a briefing on how this project is progressing. We 
will be in touch with you about that.
    I will be brief. I have a number of questions. Senators 
Tester and Boozman and I have been working for years to push VA 
to track and report an overpayment in veteran debt. I have had 
constituents who have reported a change in status or a 
dependency to VA and VA did not take action, leading to an 
overpayment in debt. We were able to get some provisions 
through last year, as you know. Last week we introduced our 
updated bill to clearly outline the reporting process for 
veterans and their families to foster better interagency 
coordination, reduce overpayments.
    I would like your commitment that VA will continue to work 
with the three of us.
    Secretary Wilkie. Yes, sir.
    Senator Brown. Thank you.
    Over the past month--this is a bit of a follow-up to 
Senator Moran's comments and question about toxic exposure. 
Over the years you and I have discussed this issue, whether it 
is Agent Orange or burn pits. It took this country far too long 
to come to terms with Agent Orange, so each veteran did not 
have to apply individually and go through that pain. I 
appreciate the decision not to appeal on the Blue Water Navy. 
That is really important.
    Secretary Wilkie. That is my recommendation, Senator. I do 
not know what other departments are doing.
    Senator Brown. That is your recommendation. OK.
    My question is this, I would like to know when VA intends 
to make a decision regarding the National Academy's 
recommendations on Agent Orange bladder cancer, 
hyperthyroidism, hypertension, and Parkinson's-like syndromes.
    Dr. Stone. Yeah. We are working our way through that right 
now and it would be my hope within the next 90 days that we 
will have some decisions made.
    Senator Brown. OK. Then, you make the decision and it 
quickly is ratified by Secretary Wilkie. Is that how it works?
    Dr. Stone. Sir, I would not presume when the Secretary 
would----
    Senator Brown. He is sitting right next to you. You might 
ask him.
    Dr. Stone. Yeah.
    Senator Brown. OK. Thank you.
    Secretary, thank you for that. You said that Congress put 
real expectations on an outdated IT system for the Forever GI 
Bill. Respectfully, sir, VA's IT and programmatic offices 
should be able to flag these issues for leadership, and 
leadership should respond accordingly and update Congress.
    Secretary Wilkie. If I said that I probably misspoke. I 
should have said that the VA systems were not capable of 
handling the changes that Congress mandated.
    Senator Brown. But, they will be.
    Secretary Wilkie. They will be, yes.
    Senator Brown. VA went through similar issues with IT for 
caregivers expansion. Why did that take 6 to 7 months as well?
    Secretary Wilkie. That I cannot tell you, based on my 
tenure here. What I--my short tenure. What I can tell you is 
that, once again, because we were not ready to implement the 
programs required to support our caregivers I made a command 
decision, based on my discussions with Senator Murray, to make 
sure that no one was removed from the program, that the checks, 
the stipends that went out to 24,000 caregiver families were 
done manually, but they were done, and I do expect to come to 
this Congress by the deadline on October 1, hopefully 
certifying that the commercial, off-the-shelf technology that 
we purchased to support caregivers is in place.
    But, I will say I am not going to certify anything that 
does not work. We have been down that road before and that led 
to the problems with the Forever GI Bill. That led to the 
problems with caregivers. So, you have my commitment that 
nothing moves unless we are convinced that it helps veterans.
    Senator Brown. Thank you, and I want to reiterate what the 
Chairman said about the legacy IT systems, getting them to work 
together, to work for all of our veterans. That is so 
important.
    One more comment and one last question. The comment is--
well, the question is when can we expect nominees for Deputy 
Secretary and Under Secretary for Health? When is that going to 
happen?
    Secretary Wilkie. Hopefully soon. We have made the 
recommendations, and I hope there will be an announcement from 
the White House shortly. I will thank the Committee for 
approving the nominees for the Office of Whistleblower 
Protection and CIO.
    I do want to say one thing, though. There is an added layer 
of approval for the Under Secretary for Health. The law, unlike 
for any other position in Federal Government, requires the 
convening of a commission to meet, deal with candidates, 
deliberate, and then pass a recommendation on to me. That was 
the reason for the delay in the 8 months that I was here, 
because the commission had to be convened.
    Senator Brown. My last comment. I heard your--thank you, 
Mr. Chairman, for your forbearance--I heard your Senator, your 
junior Senator from North Carolina, his laying out Choice and 
privatization, and I know how he stands on that. I have been 
disappointed that you are not quite as opposed to privatization 
as I thought you were during the nomination process. I just ask 
you--I am not asking a question, particularly, but just ask you 
to listen to the veteran service organizations and what they 
think about this President's philosophical commitment to 
privatization that I hope the VA does not follow.
    Secretary Wilkie. I will say, Senator, with your 
permission, Mr. Chairman, I think I have been very clear about 
where I stand and where I think the Department is heading. I 
think the legislation was right on target when it said that the 
veteran is at the center of everything that we do. I also think 
that the veteran is voting with his feet, or her feet. Our 
customer satisfaction rates are at an all-time high. I look at 
that as the gauge as to how well we are doing.
    I also believe, and I am not one to use a lot of anecdotes 
but I can say, as someone who has spent an entire life in and 
amongst the military, that our veterans, no matter what age 
they are, will go primarily to someplace where people speak the 
language and understand the culture, because there is nothing 
else like it in the United States. And, I stand by what I have 
done in the last 8 months.
    Senator Brown. I understand and appreciate that, but I also 
understand that the way that Congress appropriates or withholds 
money can have a whole lot to do with people voting with their 
feet, so I hope you will keep that in mind.
    Thank you, Mr. Chairman.
    Chairman Isakson. Senator Sullivan.

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

    Senator Sullivan. Thank you, Mr. Chairman, and, Mr. 
Secretary and your team, thank you for being here. I also am 
interested in the nominees, you know, for Under Secretary, very 
important, so we need to get those out the door. I also want to 
mention to my Democratic colleagues they also need not to delay 
the nominees once they are on the floor. There has been very, 
very unprecedented obstruction of very basic nominees for their 
confirmation. So, we get them out the door and we will have 
guys like Senator Brown move them quickly as opposed to 
delaying them, because that is not helping at all. It was not a 
nice try. It is actually a really serious issue, so they need 
to help. They cannot just say, ``Give us nominees'' and then 
delay them for 10 months. It is ridiculous, and that is what 
has been happening.
    Let me mention--first of all, congratulations on these 
national awards. I think that what you are talking about for 
your team, it should be commended. Sometimes you guys come 
here, you get the wrath of the Congress, and we rarely 
recognize when there has been improvement. I am going to 
recognize it and I appreciate it. So, keep up the good work on 
these things.
    You may have also noticed the Alaska VA health care system 
was also awarded, with the most improved inpatient experience 
for the entire country in 2018. I want to thank all of you for 
that.
    Secretary Wilkie. Dr. Ballard is one of the best.
    Senator Sullivan. Dr. Ballard does a great job. But, it is 
help from the top. You know, the VA out in the Mat-Su Valley, a 
huge veteran population, finally has not just one, not just 
two, but three doctors. It only took 5 years but now we have 
some doctors. Thank you for that, and, Mr. Secretary, I also 
want to thank you--it is not exactly in your purview but you 
may have seen my Alaska Native Vietnam Veterans Equity 
Allotment Act was recently signed into law, and when the 
President cited the broader bill it was in he highlighted this 
very important bill for Alaska that helped our Vietnam veterans 
overcome a huge injustice----
    Secretary Wilkie. May I----
    Senator Sullivan [continuing]. And the fact that the 
President highlighted that in his signing ceremony made me very 
happy.
    Secretary Wilkie. I will add to that, Senator. I mentioned 
that the caregiver legislation closes one of the last loops of 
the Vietnam era. Sadly it has been 44 years since the fall of 
Saigon. I think the Alaska allotment issue was one that sadly 
took almost as long, and I think that also closes a loop, 
particularly for a State that has the highest per capita number 
of veterans in the country.
    Senator Sullivan. Well, I appreciate that, Mr. Secretary, 
and you weighing in on that, former Secretary Zinke weighing in 
on that. Again, previous administration, remarkably they were 
opposed to it, so you guys at the Cabinet level weighing in 
really helped make it happen. Thank you for that.
    I wanted to talk about what the Veterans Benefits 
Administration is working on--and I know it is a big issue for 
you--identifying off-the-VA-grid veterans who have yet to make 
contact with the VBA and its services. I know you are looking 
at possibly doing a case study in Alaska. You know; you have 
been out there. So, thank you. I look forward to your visit and 
Dr. Stone's visit here soon again.
    Can you just talk a little bit about that, whether it is 
the pilot program in Alaska. We do have enormous challenges on 
this issue, but also how you are working it in other rural 
communities throughout the country.
    Mr. Lawrence. Certainly. You may recall that at 
confirmation time when I visited with you, you spoke about your 
reference to engage your constituents. So, after I was 
confirmed I did not forget that conversation. I set in motion 
to try to figure out how we might actually do that, our 
presence augmented by our relationship with the county and 
State VSOs, as well as tribal and communities to better 
understand how that network should be set up so that if you 
cannot touch us you can touch somebody who can touch us.
    That is what we are trying to do, and we are using Alaska 
by engaging those groups to figure out exactly how the workings 
of that take place and what we can do in terms of the ways we 
communicate and the effectiveness by way we are able to do 
that. So, we are trying to use that in understanding how do we 
mobilize all the resources that are in the veteran community, 
VSOs included, to figure out how we do those touches and engage 
folks effectively.
    Senator Sullivan. How about the pilot program you are 
looking at in Alaska?
    Mr. Lawrence. It is just--I am happy to come brief you on 
some of the details. We are just getting started, in terms of 
how that all works.
    Senator Sullivan. OK. Well, I appreciate you guys focusing 
on that.
    Mr. Secretary, I know you have been asked earlier by 
Senator Boozman and others on how you are feeling with regard 
to the MISSION Act launch date. You know, Alaska has been 
carved out, its own region, Region 5. There have been some 
concerns that we are behind the power curve there a little bit 
relative to the rest of the country. Can you just give me a 
quick update on that and how you are feeling about that launch?
    Dr. Stone. Actually, because of the uniqueness of the 
geography and the dispersion of the population I worry about it 
a lot. We are on schedule, though, for getting out the 
contract. So, when I say that the bid should be out, I think it 
is this fall.
    Senator Sullivan. What can we do to ameliorate your 
concerns and worries? I share them.
    Dr. Stone. I think just a continuing dialog with your staff 
and yourself. I am looking forward to my visit up there where 
we can dialog and really walk our way through it. But, it is a 
unique area with geographical challenges, and you are exactly 
correct, in our previous conversations. It should be handled 
locally.
    Secretary Wilkie. And, I will add, if you go down the 
list--and I have said this to folks in Alaska, the Federation 
of Natives, and I have said it on Alaska television--if you go 
down the list and look what we are prototyping in VA, my 
philosophy on electronic health, on logistics, on VBA, and here 
with MISSION is: if we can make it work in Alaska it will work 
anywhere, because of the unique challenges that Alaska presents 
by its massive size, but also because of the impact that 
veterans have on the population of the State. It is a unique 
situation.
    Senator Sullivan. Thank you. Well, we look forward to you 
getting back up there, Mr. Secretary, and Dr. Stone, your visit 
as well. Thank you.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Sullivan.
    Senator Moran had one additional question, so if you do not 
mind, Mr. Secretary, and I will have one very short statement 
after his question.
    Senator Moran. Unfortunately, the Chairman almost tells the 
truth. I have two. One developed while I was waiting to ask the 
one.
    Chairman Isakson. We better hurry.
    Senator Moran. Yes, sir.
    I wanted to go back to the hearing aid specialists, just 
for a moment, and this really is to you, Mr. Secretary. I 
understood what Dr. Stone said, that the VA may have reached 
the conclusion it does not believe that additional 
professionals in this arena are necessary. But, I want to 
highlight a complaint I have had with the Department of 
Veterans Affairs for as long as I--which is now 23 years that I 
have been on a Committee on Veterans' Affairs, is can we get 
the Department to abide by the Congressional law, the mandate 
that you have, and the issue of whether or not the specialists 
are necessary at the VA, that is a different issue than abiding 
by the law that requires you to determine what the 
qualifications would be for that profession at the VA.
    I do not want to diminish this issue. It is important to 
many people and it is important to many people who are hearing 
specialists who want to provide those services, who want to 
serve our veterans. It is important to veterans that they have 
the care necessary. Knowing you, Mr. Secretary, I want to 
highlight the importance of the folks who work for you not 
making an independent decision whether or not they get to abide 
by the law, the mandate that Congress gave them to act in any 
particular way.
    Secretary Wilkie. Yes, sir. I did not know that that was 
occurring. That is my honest answer, and you know my background 
so they will be told to abide by Congressional will.
    Senator Moran. I think it is true when you were confirmed--
it is true as I recall it--every confirmation hearing for 
Secretary at the VA that my question has been, ``Will you make 
certain that the people who work for you work with Congress, 
provide the information that we need, answer our letters,'' 
and, of course, a given is abide by the law. I just want to 
highlight for you the importance of that.
    We raised the issue of toxic exposure and I told you about 
a study that was completed by the National Academy of Medicine 
in November 2018. That law that created that study requires 
you, Mr. Secretary, to determine, based upon that report, 
within 90 days, if--there is a trigger in that law. It requires 
you to make a determination about now how to proceed. I just 
learned that March the 22nd, which is just a day ago, you have 
sent a letter to the Committee. You are now--you were not in 
compliance, I do not know, at the 90 days, but you are in 
compliance by responding, and I appreciate that. You now have a 
responsibility that I want to work with you to make certain 
that there is action taken. Again, we are talking about the 
generational consequences. The National Academy determined 
there is no medical research that determines the relationship 
between toxic exposure and the next generation of the veteran.
    There is a great opportunity, and a necessary opportunity, 
for you and the Department of Defense to proceed in determining 
that relationship, but also getting the facts in place so that 
we can determine who those veterans are, and you are a perfect 
person with your relationship and history at the Department of 
Defense to accomplish this goal.
    I will digest your March 22 letter in a more timely 
fashion, but this is something I wanted to highlight for you. 
Thank you.
    Thank you, Chairman.
    Chairman Isakson. You are welcome. Senator Sullivan was 
inspired to ask one more question, and I want to grant him that 
privilege.
    Senator Sullivan. Thank you, Mr. Chairman, and it will just 
be one.
    Mr. Secretary, this goes to the issue of infrastructure 
improvements, streamlining expansion, where you see the 
populations that are growing in certain areas of the country 
and States, populations that are declining. And again, in 
your--I know that broadly the VA has repurposed or disposed of 
175 of 430 vacant or mostly vacant buildings since June 2017. I 
think that makes a lot of sense. But, you have also talked to 
me about, you know, areas. If the VA is looking at expansion 
with regard to leases or even facilities, I know you were 
struck by some of what was going on in Alaska in that way, 
given that you mentioned not only more vets per capita, the 
size, but also I think we are one of the few States that does 
not have a full-service VA hospital, not even one.
    Can you just give me an update on what you are thinking 
with the VA's prioritization of leases that are in the budget 
request? We have--in Fairbanks, we are looking at the 
possibility of a new campus and also outside of JBER, you may 
remember that kind of big parking lot area that we were talking 
about after our tour.
    Secretary Wilkie. The simplest answer is that we are going 
where the veterans are, and this is only the first step. The 
legislation requires market assessments to be done throughout 
the country. We are in the process of doing that. That develops 
a knowledge base on population trends, the services available 
in those areas to inform an Asset Infrastructure Review 
Commission. I mentioned earlier that I expect to come to this 
Committee to ask for an accelerated date for the beginning of 
the deliberations on the Asset Infrastructure Review 
Commission, because we have to go where the veterans are.
    I also mentioned earlier that what you said is only the 
beginning of many different processes. More than half of our 
buildings, 57 percent, are between the age of 50 and 130 years 
old. Because of that, the leasing option and co-locating--and I 
am not going to say that we are in the process of doing, but I 
saw a number of facilities in Alaska that present us with an 
opportunity to be more creative about co-locating with entities 
outside of the Federal structure.
    Senator Sullivan. Thank you. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Sullivan.
    Let me conclude the meeting by thanking the Secretary and 
his staff and each of the department heads for their being here 
today and for your thorough answers. I appreciate what you all 
are doing for our vets. We all have the vets at heart, the vets 
in mind, and the vets in soul, and we are going to see to it 
they are taken care of as best as possible.
    I want to thank the VSOs for not being offended by my 
request for them not to testify, but rather to submit questions 
and statements. Mr. Fuentes is sitting in the back of the room 
and just taking copious notes, and I am sure he is going to 
make sure that I keep every promise I have made, just like they 
are going to keep every promise that they make. But, I want the 
VSOs to be sure to remember that. I have asked you to submit 
the question you want answered.
    Mr. Secretary, I not going to give you a deadline because 
that does not do any good, I do not think, but I want to give 
you the encouragement to, as quickly as possible, answer those 
questions and copy the Committee staff with the answers to 
those questions.
    Secretary Wilkie. Yes, sir.
    Chairman Isakson. They are very good and they are very 
thoughtful, particularly on the priorities of the budget and 
what some of the statements, and your statements have meant, 
and what actually, when they materialize, will mean. So, it is 
very important.
    If this works well I think we will get better responses 
because we consume so much time when we have too many witnesses 
that we do not get to points that we really need to get to, as 
demonstrated by Mr. Sullivan and Mr. Moran, who had instant 
thoughts toward the end. They were both very good and 
appreciative.
    I want to thank you for being here, thank all of our 
veterans for the service they provide to all of us. I wish all 
of you a very nice day and a very happy week, and I look 
forward to seeing you soon. Please recognize the record will 
stay open for 5 days on submissions to the Committee for this 
hearing, and the Secretary will respond as quickly as possible 
to the questions. If you will get those questions to the 
Committee they will make sure that it gets to the Secretary, 
and that we have a copy to trail.
    Thank you very much.
    Secretary Wilkie. Thank you, sir.
    [Whereupon, at 12:04 p.m., the Committee was adjourned.]
 Response to Posthearing Questions Submitted by Hon. Johnny Isakson to 
                  U.S. Department of Veterans Affairs
    Question 1. At its March 11 budget briefing, VA officials stated 
that the FY 2020 budget request was predicated on a carryover of 
approximately $3 billion from FY 2019 appropriations, but offered no 
details or further explanation.

    Question 1a. Exactly, how much ``carryover'' is assumed in the FY 
2020 budget request and how did VA determine less than halfway through 
FY 2019 that such a large amount of funding could not be used to meet 
veterans health care needs?
    Response. Please see details of the Budget-assumed carryover into 
FY 2020 for the Veterans Health Administration's (VHA) accounts and 
programs in the table below:

 
------------------------------------------------------------------------
                                               Projected
                 Account                   Unobligated Start    CJ Page
                                             of Year ($000)
------------------------------------------------------------------------
Base Carryover:
  Medical Services.......................     $1,000,000         VHA-34
  Medical Community Care.................       $300,000         VHA-34
  Medical Support & Compliance...........        $50,000         VHA-34
  Medical Facilities.....................       $150,000         VHA-34
                                          ------------------------------
    Total Base Carryover.................     $1,500,000
 
Medical Facilities Infrastructure:
  P.L. 115-141 sec 255...................       $402,801         VHA-34
  P.L. 115-244 sec 248...................       $624,305         VHA-34
                                          ------------------------------
    Total Infrastructure Carryover.......     $1,027,106
 
Mandatory
  The Veterans Access, Choice, and               $34,887         VHA-34
   Accountability Act of 2014 (VACAA) sec
   801...................................
  Veterans Choice Fund...................       $781,500         VHA-35
                                          ------------------------------
    Total Mandatory Carryover............       $816,387
                                          ------------------------------
    Grand Total VHA Medical Care              $3,343,493
     Carryover...........................
------------------------------------------------------------------------

    Carryover estimates for the four main accounts in the base were 
informed by actual carryover levels in recent years. In addition, VA 
carried more than $1.34 billion in the Medical Services appropriations 
from 2018 into 2019. This, combined with Congress's enactment of a 
generous 2019 advance appropriation, yielded the large estimated 
carryover into 2020.
    Regarding the no-year Infrastructure funding in the Medical 
Facilities account, Congress directed VA to fully fund the total costs 
to complete an identified list of maintenance projects. The carryover 
reflects the timing of these projects' phased execution. Mandatory 
carryover estimates reflect remaining Section 801 funds for unawarded 
leases and future graduate medical education program growth, as well as 
the planned wind-down costs associated with the sunset of the Veterans 
Choice Program.

    Question 1b. What are the specific dollar amounts being carried 
over and from what specific accounts, and into what accounts and for 
what purposes will this carryover funding be used in FY 2020?
    Response. Carryover in the four main accounts will be used to meet 
Veteran demand for care, both in the direct care system and the 
community. The carryover no-year Infrastructure funding will support 
continuation of the specifically identified projects. Carryover in the 
Veterans Choice Fund will be used for the leases and the Graduate 
Medical Education (GME) program as well as wind-down costs associated 
with the sunset of the Veterans Choice Program.

    Question 2. As discussed above, VA officials indicated that there 
would be zero new dollars necessary for the Medical Community Care 
account as a result of the new wait time access standards proposed 
because VA assumes it will be able to meet those standards 100 percent 
of the time within VA facilities. VA indicated it will do this through 
workload recapture, greater efficiency, and a 30 percent increase in 
the total number of VA primary care providers.

    Question 2a. What new initiatives will VA undertake and what are 
the specific increases in productivity that each will achieve?
    Response. The Office of Veterans Access to Care is partnering with 
several VHA program offices to lead an initiative called Increasing 
Capacity, Efficiency, and Productivity (ICEP).
    The main goals of ICEP are the following:

     Ensure accuracy of labor mapping, person class code, and 
Primary Care Management Module data;
     Ensure sustainment plan for maintaining continued accuracy 
for the data in sub-bullet one;
     Balance supply and demand by using present resources and 
full care teams more efficiently by maximizing individual providers 
capacity for direct patient care; and
     Partner with workforce development to hire additional 
staff where applicable.

    Overall, the focus of ICEP Phase 1 for Primary Care is to review 
the expected versus actual bookable time in direct patient care. This 
includes face-to-face (F2F) appointments, video appointments, telephone 
care, and secure messaging. Sites that need improvement can expect up 
to a 10 percent increase in productivity together in these four 
appointment modalities. For Primary Care, some sites are seeing an 
appropriate increase in panel sizes that meets national benchmarks. A 
similar review is being done for Mental Health and Specialty Care, with 
increases of up to 10 percent in productivity expected at some sites.
    Additionally, VA is enhancing Same Day Primary Care and Mental 
Health services and leveraging virtual care modalities to provide 
Veterans convenience while increasing access.

    Question 2b. What are VA's detailed plans and projections for 
increasing primary care providers by 30 percent, and how will these new 
providers be in place at the beginning of FY 2020?
    Response. There is a national shortage of Primary Care (PC) 
providers, thus VA competes with the private sector to recruit this 
limited resource. VA facilities will increase their efforts to 
aggressively recruit for PC providers through the following incentives:

     Tier exception for increased salary in hard-to-recruit 
areas;
     Utilization of Relocation, Recruitment, and Retention 
bonuses; and
     Expand opportunities for telework via telehealth.

    VHA is challenging facilities to follow the support staffing 
guidelines for core Nursing and Administrative staff as well as 
extended team members including Clinical Pharmacists, Social Workers, 
Psychologists, and Dieticians. This enables PC providers to focus on 
their important patient care activities and work at the top of their 
licenses.
    Facilities are also increasing efforts to work with their 
University affiliates to provide a meaningful outpatient experience in 
their VA continuity clinics in an effort to recruit our trainees.

    Question 3. What factors did VA consider in reaching its decision 
to cut research spending for the emerging field of genomics research in 
FY 2020 by 2 percent at a time when medical research inflation is 
estimated to be 2.8 percent?
    Response. The FY 2020 Congressional Justification does not reflect 
a reduction in funding for genomics research from FY 2019 to FY 2020. 
Requested funding for the Million Veteran Program (MVP) increased from 
$83.9 million in FY 2019 to $85 million in FY 2020 (Volume II, Page 
361), an increase of 1.3 percent.
    The FY 2019 appropriation enacted a onetime addition of $27 million 
for collaboration with Department of Energy (DOE) on a big data science 
initiative and high capability computing (this funding is enacted with 
a 5-year period of funding expiring in 2023).
    The total request for research in FY 2019 is $752 million. For FY 
2020, VA requested an increase of $10 million to support the growth of 
all other initiatives, from $752 million to $762 million. That $10 
million growth represents an overall program growth of 2 percent.

    Question 4. In the full budget documents made available on 
March 18, the Veterans Benefits Administration budget request seeks 
appropriations to support the exact same level of FTE for FY 2020 as it 
does in FY 2019. However, the Direct Labor estimate for the Disability 
Compensation program shows a decrease of 51 FTE in FY 2020. This small 
decrease in claims processors occurs at a time that the VA budget is 
projecting that number of pending claims for disability compensation 
will rise to over 450,000 by the end of FY 2020, almost a 50 percent 
increase in just the past three years.

    Question 4a. Why is VA requesting fewer claims processing staff in 
FY 2020 when its own data shows that the number of pending claims is 
rising dramatically?
    Response. VA's FY 2020 budget request reflects a small decrease 
(51) in Compensation Direct Labor full-time employees (FTE). While the 
bulk of Compensation Direct Labor FTE are Veterans Service 
Representatives and Rating Veterans Service Representatives, direct 
labor FTE also include a significant number or Claims Assistants, 
quality review staff, and coaches not directly related to rating-
related claims production. The decrease in Compensation Direct Labor 
FTE will not impact the FTE directly responsible for processing rating-
related claims. Despite this small decrease in direct labor FTE, VBA 
expects that rating-related production for compensation claims in FY 
2019 will be sustained in FY 2020. The reported year-end inventory 
increase for all claims results from an expected substantial increase 
in receipts. In FY 2020, VA will continue its commitment to look for 
innovative ways to improve claims processing through people, processes, 
and technology to mitigate the projected growth in inventory.

    Question 5. VA budget documents state that the Vocational 
Rehabilitation and Employment (VRE) program will meet and sustain the 
congressionally-mandated goal of 1:125 counselor-to-client ratio. 
However, the latest data in the VA budget document also shows that from 
2016 to 2018, the number of VRE participants fell from 173,606 to 
164,355, more than a five percent decrease. During that same period, 
VRE's caseload also dropped from 137,097 to 125,513, an 8.4 percent 
decline. It would appear that VRE is able to meet the 1:125 goal by 
serving fewer veterans.

    Question 5a. Given how important and beneficial the VRE program is 
to disabled veterans--providing many of them with the ability to 
increase their economic independence--why are fewer veterans taking 
advantage of this program?
    Response. In 2018, Vocational Rehabilitation and Employment (VR&E) 
program participants achieved over 15,000 positive outcomes while 
participants decreased by 5 percent. VR&E Service attributes the 
decrease to a combination of the following factors:

     Applicants found eligible for the VR&E program are not 
reporting to their initial orientation and, therefore, not entering a 
plan of services; and
     The number of Veterans successfully exiting the program 
have increased each year (positive outcomes).

    With the number of new plans remaining stagnant and despite the 
steady mix of eligible and entitled applicants, more Veterans are 
exiting the program than entering. However, VR&E continues to work on 
plans to hire additional Vocational Rehabilitation Counselors (VRC) to 
reach a Veteran-to-Counselor ratio of 125 to 1 or below, implement a 
new case management system, and use other technological solutions to 
keep Veterans engaged throughout the lifecycle of their program 
participation (remote entitlement, VA Video Connect (tele-counseling), 
appointment reminders, etc.). These changes are expected to increase 
the number of participants.

    Question 5b. Has VRE instituted any new policies or practices that 
have deterred disabled veterans from seeking VRE services and what 
actions is VRE taking to increase awareness about the availability and 
benefits of VRE services?
    Response. No, VA's VR&E program has not instituted any new policies 
or practices that would deter Servicemembers or Veterans with service-
connected disabilities from seeking VR&E benefits and services. To the 
contrary, over the past several years, VR&E has taken several actions 
to meet Servicemembers and Veterans where they are and in the manner 
they wish to be met. These actions, coupled with legislative changes, 
were expected to increase participation in the VR&E program. These 
actions include the following:

    1. In accordance with Public Law 114-223, Section 254, Veteran-to-
Counselor ratio should not exceed 125 to 1. VA's VR&E Program began the 
process of reducing the average Veteran-to-Counselor ratio to 125 to 1 
or below through the hiring of 169 VRCs. This will help improve service 
to Veterans with service-connected disabilities and employment 
barriers, as well as help provide them with expanded services to 
improve their ability to transition to the civilian workforce.
    2. The placement of 145 VRCs on 71 military installations across 
the Nation provides outreach and rehabilitation services to 
Servicemembers and their families prior to discharge from active duty 
service.
    3. The placement of 87 VRCs on 104 college campuses across the 
Nation provides outreach and rehabilitation services to Servicemembers, 
Veterans, and their dependents.
    4. On September 29, 2018, the Department of Veterans Affairs 
Expiring Authorities Act of 2018, Public Law 115-251, Section 126, made 
the authority to provide automatic entitlement to VR&E benefits and 
services to Servicemembers who are awaiting discharge due to a severe 
illness or injury incurred during active duty service.
    5. VR&E expanded its Tele-counseling policy to allow its use during 
all aspects of the rehabilitation process. This practice allows VR&E 
VRCs to meet virtually with a VR&E participant via an application that 
can be used on a computer or smart device. This practice saves travel 
time for the participant and allows for greater access to the program.

    VR&E continues to increase awareness and share information on VR&E 
benefits and services. VR&E reviews and updates all VR&E fact sheets 
and Web sites each year as needed as well as promotes, monthly, all the 
marketing material that is available on line. VR&E promotes the online 
marketing materials in a variety of ways, including by email, social 
media, outreach events, and conference calls with VR&E's field staff. 
They have developed an overview whiteboard video which was distributed 
to the field offices. The video provides an overview of VR&E's benefits 
and the types of assistance available and is a tool for the VRCs to 
promote the VR&E program. VR&E has also provided numerous trainings on 
how to promote early intervention into VR&E to active duty members on 
the military installations. Last, VR&E is changing the performance 
standards for the VRCs on military installations to focus more on 
ensuring Servicemembers are entering the VR&E program.
                                 ______
                                 
   Response to Posthearing Questions Submitted by Hon. Jon Tester to 
                  U.S. Department of Veterans Affairs
    During the hearing, Dr. Stone indicated that the impact of 
construction projects on health care operations was a consideration 
that factored into how much construction funding VA can execute each 
fiscal year. In other words, he indicated facilities cannot do all the 
construction projects they want in a given year because they would 
disrupt care delivery.

    Question 1. Please provide a list of the top ten projects from a 
patient safety perspective that are in need of construction work but 
are hampered by the competing priority of not wanting to take the space 
out of use due to the impact on care delivery.
    Response. A list of projects is not available as it is site-
specific and more of a coordination issue that creates a maximum volume 
of construction that a single facility can handle. For any given 
renovation to take place in space that is providing care, something 
must be done with that service during construction, to which there are 
a set number of options available.
    The first option is to relocate to ``swing space'' on campus 
(vacant space specifically set aside for this purpose). Issues with 
this approach are that it simply may not be available as most 
facilities do not have the square footage to spare for this purpose. 
Also, this space may need to be renovated itself prior to use, 
increasing cost of the original construction project and swing space is 
usually in a less than ideal location, adding inconvenience to the 
patients.
    The second option is to bring in temporary space in the form of 
modular buildings or trailers; this is, however, dependent on land 
being available on campus in a suitable location. This type of space is 
also not always ideal for health care and will add cost as the expenses 
of renting this space is required to be included in the total project 
cost of construction.
    Another option is to contract out care during construction, which 
adds significant costs and creates an issue with staff needing assigned 
to other areas. There is also a loss of synergy with other services 
offered at the VA facility.
    The last option is to simply reduce the capacity of the department 
under construction. For instance, when renovating an Inpatient Medical 
Ward, the facility can choose to temporarily reduce the number of 
available operating beds and phase the project over several years.

    Question 2. Please provide details regarding the VA's use of swing 
space, temporary medical units, trailers, etc. as a strategy to ensure 
medical care continues to be delivered uninterrupted while construction 
projects move forward at VA medical facilities.

    Question 2a. Please describe the cost to use these types of 
temporary space options and explain the considerations VA takes into 
account when determining whether to use the temporary space units, etc. 
at a particular facility and/or project.
    Response. As detailed in the response to question 1, VA has the 
option to use swing space as well as temporary medical units and 
trailers to provide care while construction occurs within the space 
where clinical services are normally offered. When the need for use of 
these options arise, any financial costs occurred (rental costs, 
renovating swing space, etc.) must be included within the total project 
cost of construction and be accounted for as an impact cost to 
construction. This further limits the funds available for actual 
construction when impact costs are used as it is accounted for within 
the same budget and program limits as the construction itself.
    The monetary cost for swing space involves any renovation necessary 
to make the space usable as well as the cost to physically relocate the 
staff and equipment needed to provide care. For temporary units or 
trailers, there is a cost for making the required utilities available 
as well as the recurring costs to rent the unit. The issues needing 
consideration beyond the financial cost are the difficult-to-measure 
impacts on patients, such as the space being less than ideal for health 
care or in a location on campus that is inconvenient to locate or 
travel to.

    Question 2b. At what level of the organization are temporary space 
decisions made within the organization (facility, VISN, VACO) and is 
there a dollar threshold on the cost of temporary space options that 
determines decisionmaking authority?
    Response. The decision to use temporary space is made at the 
facility level with Veterans Integrated Services Network (VISN) and VA 
Central Office (VACO) support offering guidance and recommendations. As 
the temporary space being required is a result of a specific project, 
the costs associated with them are deemed to be an impact to that 
project and all expenses count toward the total cost of that 
construction. These costs are therefore limited by the program limit of 
the construction type (currently $20 million for Non-Recurring 
Maintenance renovations and Minor Construction projects).

    Question 3. In Senate Report 115-130, which accompanied S. 1557 in 
the 115th Congress, the Committee on Appropriations included language 
stating ``the Committee directs VHA to form a corporate planning 
function patterned after high performing commercial healthcare delivery 
systems. Such function must include representation from VHA clinical 
leadership, and leaders from VHA offices that control, oversee, or 
manage facility investments, transition, facility operations, and 
organizational change, as well as the appropriate VA offices that are 
dedicated to the planning and procurement of capital infrastructure, 
whether built or leased by VA.'' Senate Report 115-269, which 
accompanied S. 3024 contained similar language.
    What is the status of the formation of the corporate planning 
function and the other requirements of this section of the report 
language?
    Response. VHA actions to meet the corporate planning function 
requirement are the following:

     Strategy: Market Area Health System Optimization Workgroup 
(MAHSOW) produced an eight-step methodology for VISNs and VA medical 
centers to drive market area health system optimizations, which will 
inform VISN action plans, national realignment strategy, capital 
investments, and removal of legislative barriers;
     Corporate planning function: MAHSOW, which includes 
representation from all appropriate VA and VHA offices, managed by VHA 
Office of Policy and Planning, which is responsible for corporate 
planning activities related to a high-performing integrated health 
network; and
     Vision: ``To deliver a high-performing provider network to 
better serve Veterans. This network consists of all VA health care 
assets in VISNs, federally-affiliated providers in the Department of 
Defense (DOD), federally Qualified Health Centers (FQHC), Academic 
Affiliates, and other community providers and health systems with a 
track record of providing high quality health care and understanding 
the needs of Veterans.''
     Goals:

          1. Veterans choose VA for easy access, greater choices, and 
        clear information to make informed decisions;
          2. Veterans receive timely and integrated care and support 
        that emphasizes their well-being and independence throughout 
        their life journey;
          3. Veterans trust VA to be consistently accountable and 
        transparent; and
          4. VA will modernize systems and focus resources more 
        efficiently to be competitive and to provide world-class 
        capabilities to Veterans and employees.

    Question 4. What resources does the budget provide specifically for 
the support of VistA over the next decade to ensure a safe patient 
experience?
    Response. VA's Office of Electronic Health Record Modernization 
(OEHRM) is working the overall pivot strategy in cooperation with the 
Office of Information and Technology (OIT) to ensure continuous care 
for our Veterans as we transition from the various VistA-based legacy 
systems to the new Cerner Millennium EHR platform. VistA and Millennium 
will operate in parallel for a period of time, with efficiencies and 
corresponding strategies/plans for the sunsetting and/or transitioning 
of legacy systems. It currently costs VA approximately $426 million to 
sustain VistA in FY 2019. As part of the final pivot strategy 
development, OEHRM will include projected sustainment costs for VistA 
over the 10-year Cerner implementation, as well as sustainment cost for 
the Cerner Millennium solution following the initial 10-year contract 
period. Currently there is no VistA sustainment cost reduction directly 
tied to the electronic health record (EHR) rollout. VistA will be in 
operation until all VA medical centers have migrated to Millennium, at 
which time the redundant VistA modules will be decommissioned. VistA 
modules that are not replaced by the Cerner solution will be maintained 
until replacement solutions are developed/ deployed.

 
------------------------------------------------------------------------
                       Funding Type                            FY 2019
------------------------------------------------------------------------
                                   HPS
FTE's.....................................................           106
Burdened Rate.............................................      $153,967
FTE Pay...................................................   $16,320,502
DME.......................................................           $--
O&M.......................................................   $22,292,477
                                                           -------------
    Total.................................................    38,612,979
                                                           =============
                                  EPMD
FTE's.....................................................           275
Burdened Rate.............................................      $153,967
FTE Pay...................................................   $42,340,925
DME.......................................................   $21,028,161
O&M.......................................................   $34,082,695
                                                           -------------
    Total.................................................    97,451,781
                                                           =============
                                  ITOPS
FTE's.....................................................           419
Burdened Rate.............................................      $153,967
FTE Pay...................................................   $64,512,173
DME.......................................................           $--
O&M.......................................................  $224,758,359
                                                           -------------
    Total.................................................   289,270,532
                                                           =============
                               Grand Total
FTE's.....................................................           800
Burdened Rate.............................................      $155,507
FTE Pay...................................................  $123,173,600
DME.......................................................   $21,028,161
O&M.......................................................  $281,133,531
                                                           -------------
    Total.................................................   425,335,292
------------------------------------------------------------------------


                                 FY 2019
------------------------------------------------------------------------
                                                               $ FY19
                   Sub-Project [BF Line]                       Amount
------------------------------------------------------------------------
Ancillary and Surgery Requirements Updates................    $7,957,121
CPRS Enhancements Phase 2.................................    $4,000,000
Fileman 24 Interface......................................    $1,427,752
Methadone Dispensing Tracking Phase 2.....................    $2,800,000
National Clozapine Coordination Phase 3...................    $3,000,000
Pharmacy Re-Engineering -PRE Inbound ePrescribing Version     $1,843,288
 3........................................................
                                                           -------------
    Total.................................................   $21,028,161
------------------------------------------------------------------------


                                 FY 2019
------------------------------------------------------------------------
                                                               $ FY19
                   Sub-Project [BF Line]                       Amount
------------------------------------------------------------------------
Medication Permissions and Dispensing Updates.............    $1,691,000
Methadone Dispensing Tracking.............................    $2,044,377
National Clozapine Coordination Phase 3...................    $3,712,000
Pharmacy Re-Engineering--PRE Inbound ePrescribing.........    $1,905,612
Pharmacy Re-Engineering--PRE Inbound ePrescribing.........    $1,123,353
Pharmacy Re-Engineering--PRE Medication Order Check Health    $1,325,000
 care Application (MOCHA).................................
Pharmacy Re-Engineering--PRE Medication Order Check Health    $2,154,527
 care Application (MOCHA) Phase 2.........................
Pharmacy Re-Engineering--PRE Pharmacy Product System          $1,230,000
 National (PPS-N).........................................
Pharmacy Safety Updates Phase 2...........................    $3,146,007
Standards and Terminology Services (STS)..................    $3,711,000
Veterans Data Integration and Federation VDIF.............    $3,205,350
VistA Computerized Patient Record System (CPRS)...........      $400,000
VistA Integration Adapter (VIA)...........................    $1,059,999
VistA Scheduling Enhancements Phase 2.....................    $3,892,000
VistA Security Remediation................................    $3,482,470
                                                           -------------
    Total.................................................   $34,082,695
------------------------------------------------------------------------


                                 FY 2019
------------------------------------------------------------------------
                  Sub-Project [BF Line]                    $ FY19 Amount
------------------------------------------------------------------------
Enterprise Application Maintenance......................      $6,559,226
Occupational Health Record-Keeping System (OHRS)........        $310,353
Primary Care Management Module Rehost--PCMMR............          $9,949
VistA Imaging...........................................      $3,771,868
VistA Maintenance.......................................     $11,641,081
                                                         ---------------
    Total...............................................     $22,292,477
------------------------------------------------------------------------


                                 FY 2019
------------------------------------------------------------------------
                                                               $ FY19
                   Sub-Project [BF Line]                       Amount
------------------------------------------------------------------------
Dental Record Mgr (DRM)...................................    $1,606,305
Event Capture.............................................    $1,276,919
Fee Basis.................................................   $24,681,528
Insurance Buffer Card (IBC)...............................    $7,653,055
Intersystems Cache........................................   $87,843,032
Maintenance of VistA and VistA Imaging (MSV III)..........   $39,211,999
Mental Health SW Maint....................................    $4,319,051
Release of Information (ROI)..............................    $3,144,017
VistA Maintenance.........................................   $39,211,999
Central VistA Imaging Exchange............................      $320,700
Vista Integration Adapter.................................      $387,139
Veterans Health Information Systems and Technology              $196,571
 Architecture (VistA) VistAWeb............................
Vista Blood Establishment Computer Software...............    $2,616,978
Vitria/VistA Interface Engines............................    $4,889,466
Vista Maintenance Project.................................        $1,441
VistA--e-Pharmacy Claims software/ VistA--Electronic             $51,284
 Claims Management Engine.................................
VistA--Functional Independence Measurement................       $70,558
VistA--Home Based Primary Care............................       $20,007
IAA with DOI--(GS35F0701M) Financial Interface Tech             $923,760
 Support Contract.........................................
R1/2/3 DISA DECC..........................................    $5,963,000
R4 RDC....................................................       $14,650
VistA Migration contractor................................      $319,200
Backup Tapes for VistA imaging............................       $35,700
                                                           -------------
    Total.................................................  $224,758,359
------------------------------------------------------------------------


                                                                  FY Annual Labor Rates
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                VA On-Board                                                                 VA New Hires*
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                       %
                     Fiscal Year                           VA      Increase     GS-09       GS-11        GS-12        GS-13        GS-14        GS-15
--------------------------------------------------------------------------------------------------------------------------------------------------------
2018................................................    $152,443   1.00%       $82,852     $100,242     $120,147     $142,870     $168,830     $198,588
2019................................................    $153,967   1.00%       $83,680     $101,244     $121,349     $144,299     $170,518     $200,574
2020................................................    $155,507   1.00%       $84,517     $102,257     $122,562     $145,742     $172,223     $202,580
2021................................................    $157,062   1.00%       $85,362     $103,279     $123,788     $147,199     $173,945     $204,605
2022................................................    $158,633   1.00%       $86,216     $104,312     $125,026     $148,671     $175,685     $206,651
2023................................................    $160,219   1.00%       $87,078     $105,355     $126,276     $150,158     $177,442     $208,718
2024................................................    $161,821   1.00%       $87,949     $106,409     $127,539     $151,659     $179,216     $210,805
2025................................................    $163,440   1.00%       $88,828     $107,473     $128,814     $153,176     $181,008     $212,913
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source:
VA On-Board
  Budget Database / Forms / Budget and Contract Administration Forms / Labor Rates
* OPM salary data based on Grade / Step-5; Washington Locality Pay; 30% to cover benefits; added
VA amount updated and based on actual Station 116 salary expense / on-board FTE
Future years are an increase of 1% per year, which is an estimate only for projections


    Question 4a. Please provide amounts for both development and 
sustainment.
    Response. It currently costs VA approximately $426 million to 
sustain VistA in FY 2019. VistA will be operated until all VA medical 
centers have migrated to Millennium, at which time the redundant VistA 
modules will be decommissioned. VistA modules that are not replaced by 
the Cerner solution will be maintained until replacement solutions are 
developed/deployed.

    Question 5. According to VA officials, a report on the 
recommendations for a joint governance structure between the VA and the 
Department of Defense (DOD) was submitted to the Department on 
February 28th.

    Question 5a. When will that report be made available to this 
Committee?
    Response. On March 1, 2019, the Federal Electronic Health Record 
Modernization Working Group (FEHRM WG) presented the draft Plan of 
Action and Milestones (POA&M) to leadership from DOD and VA. The report 
will be made available to the Committee once the internal process is 
complete.

    Question 5b. What process was utilized, and who participated, in 
the creation of this report?
    Response. In response to the September 2018 DOD/VA Joint Commitment 
Statement, DOD and VA chartered the FEHRM WG, consisting of governance 
and subject matter experts, and key DOD/VA leaders, to make 
recommendations for a joint governance structure. The FEHRM WG meets on 
a weekly basis to provide progress updates and discuss key decisions to 
advance the analysis.

    Question 5c. If a decision has been made as to what joint 
governance structure VA and DOD will be utilizing, please provide 
details as to who made this decision and what criteria was used.
    Response. Executive leaders within the FEHRM WG preliminarily 
approved the POA&M draft. The FEHRM WG applied the following evaluation 
criteria for each course of action in the POA&M: rapid decisionmaking, 
agile decisionmaking, EHR deployment risk, and change management risk. 
FEHRM is working to jointly select a lead and deputy with concurrence 
from both Departments. The lead will act as a neutral arbiter ensuring 
timely decisionmaking regarding the requisite architecture and 
operations to support the core technology.

    Question 6. When will VA be providing a full accounting of how many 
veterans were affected by late and inaccurate GI Bill payments last 
fall?
    Response. VA underpaid approximately 322,000 beneficiaries an 
average of $202 for the fall of 2018 terms.

    Question 6a. Provide details as to what extent these veterans were 
affected and when they will be made whole.
    Response. On December 8, 2018, VA installed the 2018 uncapped 
monthly housing allowance rates. Until the information technology (IT) 
solution is in place, VA will pay students the current year's uncapped 
rate. Beneficiaries who were underpaid from the fall 2018 term received 
a separate payment for any difference owed to them. Veterans who were 
overpaid were not held liable for any debts. On December 1, 2019, all 
VA processing systems will be updated functionality to process claims 
in accordance with sections 107 and 501. For section 501, the rate 
tables will be expanded to house both the capped and uncapped rates. 
The IT solution will also allow training facilities to accurately 
report all locations where their students are attending the majority of 
their classes, so VA can process housing payments in accordance with 
section 107.

    Question 7. This budget states that the Office of Electronic Health 
Record Modernization (OEHRM) plans to reach a goal of hiring 170 out of 
230 FTE by the end of 2019

    Question 7a. When does OEHRM anticipate completing the hiring 
process of all 230 permanent FTE?
    Response. OEHRM's approved organizational chart has a total of 274 
FTEs as of January 10, 2019. OEHRM anticipates that all permanent FTE 
will be onboarded by third quarter FY 2020.

    Question 7b. How many of these hires are anticipated to be 
previously detailed or matrixed personnel who have been permanently 
reassigned to OEHRM? And from what departments were these FTE 
reassigned?
    Response. OEHRM expects to permanently reassign 41 FTEs previously 
detailed or matrixed personnel to OEHRM from VHA, OIT, Office of 
Management, and Office of Finance.

    Question 8. There are several programs/projects that have received 
a cut in funding for both Development and Operations and Maintenance in 
this budget. Please provide justification, including what specific IT 
functions or projects will not be funded, for the decreases in the 
following programs:

     Digital Health Platform
     Purchased Care
     Education Benefits
     Human Resources
     Data Integration and Management
    VA Response.

     Digital Health Platform (DHP)--There are several key 
factors affecting the FY 2020 Budget request for this Congressional 
Project. As project development comes to an end, the priorities shift 
to sustainment, which can sometimes be accomplished at a much lower 
cost. Additionally, with the acquisition of the Cerner Millennium 
product, it is anticipated that some associated work will be funded via 
OEHRM.
    In the FY 2020 President's Budget request, VA assumed that FY 2020 
funding would decrease due to the following reasons:

    (1) The Cerner migration.
    (2) Contractor support carryover into FY 2020 (one-year's savings).

Of note: In FY 2019, the DHP program has $25M in requirements and a 
current Budget Operating Plan (BOP) of $17.558M, giving the program a 
$5.009M Unfunded Requirement (UFR). Ancillary, Surgery, and VistA 
Security Remediation are major pieces of the reduced FY 2020 budget 
request.
     Ancillary is still in the award phase of its initial 
contract and plans to have support carryover in FY 2020 resulting in a 
reduced request (one-time savings).
     VistA Security Remediation was broken into three parts: 
VistA Security Remediation, Enterprise Encryption Key Management System 
(EEKMS), and VistA Security Scanning. The program manager is discussing 
the possibility of IT Operations (ITOPS) supporting EEKMS and Office of 
Electronic Health Record Modernization (OEHRM) will fund Eagle6 (VistA 
Security Scanning).

    The efficacy of one critical technology demonstrated by the DHP was 
the Application Programming Interface (API). Using the DHP as a 
baseline technology demonstration platform for APIs, VA has delivered a 
developer portal, a Benefits Intake API, a Facilities API and a 
Veterans Health API. VA's Veterans Health API is part of VA's 
commitment to health IT modernization, and contributes to VA's 
electronic health record modernization program since much of the data 
exchanged between Cerner and the VA health data stores will be through 
APIs, rather than complicated custom-built interfaces.

     Purchased Care--The Congressional Project includes the 
Medical Care Collections Fund (MCCF) sub-project that has been ongoing 
for years, which has improved the efficiency and effectiveness of the 
system. As such efficiencies are realized, the project does not require 
as much development funding to move forward.
     Education Benefits--The funding decrease within the 
Congressional Project ``Education Benefits'' from FY 2019 to FY 2020 is 
based on the plan to execute the largest portions of required work in 
FY 2018 and FY 2019, therefore there was a larger request in 2019. In 
addition to this, the FY 2020 request reflects the realignment of a 
sub-project (eFolder enhancements) and its funding into another 
Congressional Project (Benefits Systems), which more appropriately 
aligns to where the work is being performed. Therefore, the FY 2020 
request for Education Benefits was reduced in comparison to FY 2019.
     Human Resources--The Congressional Project Human Resources 
includes the following Human Resources (HR) Smart Phase 4 and Talent 
Management System (TMS) Upgrade sub-projects:

           TMS Upgrade--TMS has closed its Development efforts 
        in 2018 and has transitioned to sustainment funding supported 
        by the Franchise Fund.
           HR Smart Phase 4--During the 2020 budget cycle, it 
        was determined that development work would conclude in 
        August 2019, therefore additional funding was not requested for 
        2020 and beyond. The current system is maintained in the VA 
        Enterprise Cloud (VAEC).

     Data Integration and Management--The FY 2020 budget 
request for this Congressional Project actually increased due to the 
new sub-project Enterprise Cloud Solutions in the amount of $50 million 
in operations and maintenance, which is a high priority modernization 
effort.

    Question 9. At recent congressional staff briefings, VA officials 
have stated that there are 11 different IT projects underway related to 
VA MISSION Act implementation. The Secretary's March 4, 2019, letter to 
Appropriations Committee and Subcommittee leadership--which requests 
authority to transfer $95.94 million to the IT Systems account to 
support the development of these projects in fiscal year 2019--
identifies 9 of those 11 projects. What are the other two projects not 
listed below?

     Decision Support Tool
     HealthShare Referral Manager
     Provider Profile Management System
     Enterprise Program Reporting System
     Integrated Billing and Accounts Receivable
     Community Care Reimbursement System
     Automated solution to query state prescription drug 
monitoring program websites
     Caregiver Application Tracker database
     Customer Relationship Management Platform

    Response. The other two projects are the following:

     Consult Toolbox; and
     Enrollment and Eligibility.

    Question 10. Please provide descriptions of the ``integrated 
billing and accounts receivable'' project, the ``customer relationship 
management platform,'' and the two other projects not listed above, as 
the letter to the Appropriations Committee did not provide adequate 
detail on these projects.
    Response. The Integrated Billing (IB) and Accounts Receivable (AR) 
(IB/AR) module project includes system enhancements to Vista packages 
to implement long-term administration of Urgent Care (UC) Copays and 
provides modifications to billing systems to enhance collections 
capabilities, retrieve the VA Maintaining Internal Systems and 
Strengthening Integrated Outside Networks Act of 2018 (MISSION) Copay 
status, and ensure proper processing and reporting regarding billing.
    The Customer Relationship Management (CRM) module creates a backend 
platform to support stakeholder engagement. This facilitates innovation 
sourcing and engagement at scale leveraging technology instead of 
manual human effort. Implementing the CRM software in VA contact 
centers allows VA to collect and preserve the context of interactions 
and automate processes to enhance performance. The CRM platform 
functionality provides VA employees a consolidated interface and means 
of answering, tracking and reporting calls from Veterans, 
Beneficiaries, and applicable Veteran stakeholders to enhance customer 
service. The platform supports call center performance improvement and 
enhanced service delivery across administrations and business lines.
    Consult Toolbox is a consult management tool that integrates with 
VistA to support Community Care consult creation. Consult Toolbox 
provides additional data fields that standardize consult data and 
provide critical content to the Community Care consult. Consult Toolbox 
is also used to initiate the Decision Support Tool.
    The Eligibility and Enrollment System provides Veteran Community 
Care eligibility information to downstream systems and will be enhanced 
to support MISSION specific eligibility requirements for June 6th, 
2019.

    Question 11. Please provide documentation of the overall timeline 
and expected dates of key milestones related to the delivery of the 
Decision Support Tool (DST) for the Veterans Community Care Program 
(VCCP)--from contract solicitation to release of the final product.
    Response. VA expects between 10,000 and 15,000 clinical consults 
per day, where anywhere from one to three staff members accessing each 
consult. The latest DST statistics show there is an average of 38,000 
technical uses of DST per day, which is in line with expectation of 
high user adoption.

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Question 12. According to the March 1, 2019, U.S. Digital Service 
(USDS) sprint report on VA MISSION Act community care, VA only began 
actively developing the DST about six weeks earlier, and the DST 
project development timeline assumes a May 23, 2019, production 
release. As the USDS report points out, this leaves very little time to 
correct any errors or performance issues before the new Veterans 
Community Care Program (VCCP) must be implemented on June 6, 2019.

    Question 12a. Given that the majority of the eligibility criteria 
for VCCP were set forth in the VA MISSION Act (with the exception of 
the designated access standards that the Secretary recently proposed), 
why did VA wait until January 2019 to begin developing the DST?
    Response. The MISSION Act legislation was signed into law June 6, 
2018, and discussions of implementation plans and related IT solutions 
began immediately. Technical requirements evolved with the development 
of regulation and policy proposals, and solution development was then 
able to begin in January 2019.

    Question 13. This budget reflects a continued, steady increase in 
VA's mental health budget.

    Question 13a. How is VA tracking the effectiveness of its mental 
health and suicide prevention programs?
    Response. The Clay Hunt Suicide Prevention for American Veterans 
(SAV) Act (Public Law No. 114-2) requires an annual, independent 3rd 
party evaluation of VA's mental health care and suicide prevention 
programs. The first report was completed in December 2018. The reports 
are to:

     include evaluations of opioid prescribing/safety and 
services for women Veterans;
     consider effectiveness, cost effectiveness, and Veteran 
satisfaction;
     propose best practices including practices suggested by 
other Federal departments or agencies; and
     use metrics that are common and useful for practitioners.

    Suicide prevention activities span a broad public health approach 
in which implementation factors are measured in the short term, and 
long-term outcomes are tracked over time. Measurement plans for 
interventions, including both performance/implementation metrics, and 
effectiveness/impact outcomes, aimed at the universal, selected, and 
indicated levels are underway.

    Question 13b. How will this increased funding be used to recruit 
and retain more mental health professionals?
    Response. The Office of Mental Health and Suicide Prevention 
(OMHSP) continues to work collaboratively with Workforce Management and 
Consulting (WMC) in enhancing hiring processes and opportunities across 
the enterprise.

     As of January 31, 2019, the Mental Health Hiring 
Initiative (MHHI) resulted in an increase of 1,045 mental health 
providers onboard in VHA with total hires of 3,956.
     Between June 2017 and March 2019, Suicide Prevention 
Coordinators increased from 360 to 444.

    In FY 2018, VHA awarded 253 Mental Health Retention Education Debt 
Reduction Program (EDRP) awards, which was 23 percent of all EDRP 
awards. As a group, psychologists received the third most EDRP awards. 
Recent OMHSP and WMC efforts have included collaboration with the 
Office of Academic Affairs (OAA) establishing recruitment fairs for VHA 
trainees. Initial efforts focused on recruiting psychology trainees, 
and as the academic year progresses, efforts will focus on medical 
residents (psychiatry).

    Question 13c. Is this funding sufficient to provide mental health 
care to newly eligible veterans, such as those with other than 
honorable discharges or those within the first year of transition?
    Response. The overall influx of newly eligible Veterans associated 
with recent eligibility expansion efforts is unfamiliar territory for 
VHA. However, OMHSP has an established population health staffing model 
which allows for near real-time monitoring of staffing needs across 
VHA. Increases in Veteran demand for services will be reflected in 
decreasing Staff-To-Patient (SPR) ratios. VHA anticipates sufficient 
funding mechanisms are in place which allow VACO and individual VISNs 
the flexibility to rapidly address critical staffing shortages due to 
increased demand.

    Question 13d. How will VA fund the President's newly signed 
Executive Order aimed at reducing veteran suicide?
    Response. The Task Force roles and leads for the lines of effort 
(enabling support, state and local action to include grant structure, 
and the research strategy) are in the process of being determined. Role 
determinations and associated kick-off meetings are planned to occur in 
May 2019.

    Question 14. This budget request includes $54 million for 
Comprehensive Addiction and Recovery Act Programs.

    Question 14a. While the budget justification documents provide an 
overview of what VA has done to address opioid addiction, it does not 
include details on how the $54 million will be spent or what outcomes 
VA is attempting to achieve. Please provide clarity on what CARA 
programs will be improved with this funding.
    Response.

    A. Funding

 
------------------------------------------------------------------------
                                                             Dollars in
                          Program                              FY 2020
------------------------------------------------------------------------
Pain and Opioid Management (10P11)........................   $16,405,311
Office of Patient Advocacy, Comprehensive Addiction and       $7,458,689
 Recovery Act (CARA) Section 924 (10H)....................
CARA Section 933:
  Pilot Program on Integration of Complementary and
   Integrative Health and Related Issues for Veterans and
   Family Members of Veterans and CARA Section 931
  Expansion of Research and Education on and Delivery of     $30,190,000
   Complementary and Integrative Health to Veterans,
   ``Creating Options for Veteran's Expedited Recovery''
   or COVER (10NE)........................................
                                                           -------------
    Total.................................................   $54,054,000
------------------------------------------------------------------------

              pain and opioid management cara improvements
     The Pain Management Program in the Office of Specialty 
Care Services (10P11) has historically received a partial allocation of 
the Comprehensive Addiction Recovery Act of 2016 (CARA) budgeted funds. 
If a similar amount is available in FY 2020, Specialty Care Services 
(SCS) anticipates supporting the following CARA and Opioid related 
programs:

          - Expansion of the Opioid Overdose Education and Naloxone 
        Distribution (OEND) program through funding Naloxone free to 
        the field, development and delivery of new educational and 
        training materials, and providing support to the expansion of 
        Naloxone to first responders and in AED kits.
          - Supporting the development and site integration of the 
        CARA-mandated interdisciplinary pain management teams through 
        training, education, and material resources such as equipment, 
        supplies, or personnel time to assist in setting up and 
        managing the teams.
          - Support and strengthen the VA/DOD Joint Pain Management 
        Workgroup through funding personnel time, new training 
        development, and support the JEC in developing, monitoring and 
        tracking a strategic goal related to Opioid awareness between 
        the agencies.
          - Expanding and enhancing the implementation of high-risk 
        patient reviews before prescribing opioids and during and after 
        treatment utilizing tools such as Stratification Tool for 
        Opioid Risk Mitigation (STORM) and Opioid Therapy Risk Report 
        (OTRR).
          - Supporting Federal initiatives to address the Opioid Crisis 
        including the ODNCP National Drug Strategy, the President's 
        Plan to Address the Opioid Crisis, and the Recommendations 
        resulting from the White House Commission on Addressing the 
        Opioid Epidemic.
          - Supporting the expansion of the Stepped Care Opioid Use 
        Disorder Training the Training (SCOUTT) initiative to sites 
        beyond the original pilot sites and increase the number of VA 
        providers with X-waivers to dispense and treat patients with 
        buprenorphine for Opioid Use Disorder (OUD). This will include 
        training material, resource time, and supplies to support the 
        program expansion.
                 whole health system cara improvements
     Section 933 of the CARA legislation requires demonstration 
projects on integrating the delivery of Complementary and Integrative 
Health (CIH) services with other health care services provided by VA 
for Veterans with mental health conditions, chronic pain, and other 
chronic conditions. Rather than just adding these approaches into 
primary care, CIH approaches are delivered through a Whole Health 
System. This approach improves access and reduces the burden on primary 
care. Whole Health is an approach to health care that empowers and 
equips people to take charge of their health, well-being, and to live 
their life to the fullest, and is the primary delivery vehicle through 
which Veterans can access CIH services.
     The Whole Health System includes the following three 
components:

          - Empower: The Pathway--in partnership with peers, empowers 
        Veterans to explore mission, aspiration, and purpose, and begin 
        personal health planning;
          - Equip: Well-being Programs equip Veterans with self-care 
        tools, skill-building, and support. Services may include 
        proactive CIH approaches such as yoga, tai chi, or mindfulness.
          - Treat: Whole Health Clinical Care--in VA, the community, or 
        both, clinicians are trained in Whole Health and incorporate 
        CIH approaches based on the Veteran's personalized health plan.

    VA staff has been working with Veterans around the country to bring 
elements of this Whole Health approach to life. In conjunction with the 
CARA legislation, VA began implementation of the full Whole Health 
System in 18 Flagship Facilities in the beginning of FY 2018, the first 
wave of facilities in the national deployment of Whole Health. Flagship 
facility implementation of the Whole Health System will proceed over a 
3-year period (FY 2018-FY 2020) and is supported by a well-proven 
collaborative model which drives large-scale organizational change.

     In FY 2020, Whole Health System (WHS) implementation and 
deployment will continue to make progress in the following areas:

          - Continue to disseminate a comprehensive standardized Whole 
        Health System model, deployment strategy, implementation guide, 
        and resources for use by all field sites.
          - Provide third year of funds to support the development and 
        deployment across 18 Flagship facilities. Flagship sites were 
        funded at $3.9 million over 4 years.
          - Continue to train Veteran peers in the Introduction to 
        Whole Health sessions for Veterans. Continue to train VA 
        employees in Whole health. Over 10,000 VA employees trained in 
        Whole Health to date; 5,500 more in FY 2019; Building VA's core 
        faculty in Whole Health- 60 faculty trained thus far.
          - Continue over 100 ongoing national Community of Practice 
        Calls focused on learning from the field and sharing lessons 
        learned. This strategy has proven to be a highly effective 
        method of advancing Whole Health across the field.
          - Continue to respond to all facilities requesting Whole 
        Health support, requiring intensive work, onsite consultation, 
        ongoing education, and provision of Whole Health tools and 
        resources.
          - Continue a robust Whole Health research agenda evaluating 
        and addressing: patient outcomes, implementation, cost and 
        utilization, and health care workforce across the 18 Flagship 
        facilities.
          - Continue to lead a robust, intentional effort to increase 
        collaboration and build coalitions both internally and 
        externally. These include strong partnerships with other 
        national program offices, including: Mental Health and Suicide 
        Prevention, Spinal Cord Injury, Women's Health, Primary Care, 
        National Center for Health Promotion and Disease Prevention, 
        Social Work, Patient Care Services, Nutrition and Food 
        Services, Nursing, Chaplaincy, Connected Health, and HSRD.
          - Continue random survey of Veterans with chronic pain at the 
        18 WH Flagship sites (Veterans Health and Life Survey) with a 
        target of 10,000 respondents. Expecting preliminary findings on 
        impact on Veteran quality of life, pain, patient engagement, 
        life meaning, and purpose from this large cohort within the 
        next 6 months.
          - Continue research and dissemination of evidence of 
        effectiveness for Battlefield Acupuncture (BFA), a specific 
        ten-point auricular acupuncture protocol developed in DOD and 
        now being widely used in VA used for pain. Data from a national 
        outcome study on BFA looking at over 11,000 Veterans being 
        treated shows on average a 2-point drop on the 0-10 pain scale 
        from before to immediately after BFA treatment. BFA is also 
        equally effective in patients on opioids as it is on patients 
        not on opioids. To date, 2,400 VHA clinicians have been trained 
        to offer BFA, and demand for this service continues to 
        increase.
             office of patient advocacy (opa) improvements
     As per section 924 of CARA, the new Office of Patient 
Advocacy was established and directly reports to the Under Secretary 
for Health. OPA is tasked with ensuring the following:

          - Patient Advocates truly advocate on behalf of Veterans with 
        respect to health care received and sought when managing 
        complaints;
          - Responsibilities of the Patient Advocate are carried out at 
        VA Medical facilities as per CARA requirements; and
          - Patient Advocates receive consistent training.
               standardized complaint resolution process
     In process of standardizing the complaint resolution 
processes across the system with a goal that complaints will be 
resolved at the lowest level possible, preferably at the point of 
service. If that is not possible, the patient advocate will advocate on 
behalf of the Veteran to come to a resolution.
         patient advocate tracking system--replacement (pats-r)
     Partnered with the VA Veterans Experience Office to 
develop a more user-friendly web-based system to manage Veteran 
complaints.
     Will more efficiently connect service lines to expedite 
resolution of Veteran complaints at the point of service.
     Shifts VHA organizational culture to resolving Veteran 
complaints at the point-of-service, in collaboration with Patient 
Advocates.
     Leverages technology to improve communication between all 
points of service no matter where Veteran is seen, to allow timely and 
efficient resolution.
     Will provide accurate and timely reports communicating 
trends on Veteran complaints at the facility, VISN and national levels.
     Will roll out in May 2019.
                          staffing methodology
     Partnered with the VA Center for Healthcare Organizations 
and Implementation Research (CHOIR) and VHA Workforce Management to 
develop an evidence-based patient advocacy staffing model.
     This model will account for facility size, complexity and 
geographic region.
                          training & education
     Community of Practices Calls are held monthly to provide 
live, consistent information and education to Patient Advocates.
     Continue to provide funding to the field to support VISN-
level meeting/conferences/trainings focused on Patient Advocacy with 
focuses on Opioid Safety; Suicide Prevention; and/or Lesbian, Gay, 
Bisexual, and Transgender (LGBT) Care.
     New educational modules are currently under development in 
partnership with VHA Employee Education Systems (EES) focusing on the 
VHA Directive for Patient Advocacy Programs and New Patient Advocate 
Orientation.

    Question 15. Public Law 115-182, the VA MISSION Act of 2018, 
authorized a higher ceiling for individual loan repayment under the 
Educational Debt Reduction Program.

    Question 15a. Please describe how the Department developed its 
estimate of $5.5 million in increased usage as a result of the law's 
higher reimbursement amount.
    Response. At the end of FY 2018, there were approximately 4,100 
active participants in Educational Debt Reduction Program (EDRP); 
nearly 3,500 of these participants were approved in the last 4 fiscal 
years following the implementation of Choice Act changes. In FY 2018, 
physicians received the most EDRP awards, nurses ranked second, and 
psychologists were third.
    VA projected $5.5 million in FY 2020, in addition to planned 
program growth, for the initial year of the increased award amounts 
based on the number of current program participants with awards 
exceeding $20,000 per year. Preceding MISSION Act 2018, the maximum 
award was $24,000 per year and 10 percent of participants receiving an 
EDRP award exceeded $20,000 per year. Therefore, VA projected 10 -15 
percent (150-200) of applicants would be eligible for an increased 
award of up to $40,000 per year. $5.5 million only includes estimates 
for FY 2020; future year costs will increase to sustain recently 
approved participants and new applicants (The FY 2021 estimate is $7.5 
million).
    As anticipated, implementation of the $200,000 limit in FY 2019 
authorized by MISSION Act is impacting new award costs. Awards for new 
participants under the $200,000 award amount are currently averaging 
$114,000, up from $77,000 under the previous $120,000 limit. VA medical 
centers are actively utilizing EDRP to fill VA's hardest to fill 
physician positions as demonstrated by the significant increase in 
physician awards which are near 50 percent of all EDRP awards received 
thus far for 2019.

    Question 15b. How does VA ensure that funding is available for 
hard-to-fill positions even if a medical center director does not make 
a request for funding such positions?
    Response. VA uses several processes to ensure funding is available 
for hard-to-fill positions identifying top shortage occupations at the 
facility level annually and monitoring each facility's usage of 
recruitment and retention incentives and EDRP awards toward those 
occupations throughout the year, shifting resources as needed.

    Question 16. Section 212 of Public Law 115-46, the VA Choice and 
Quality Employment Act, authorized competitive pay for Physician 
Assistants.

    Question 16a. Please provide the amount of funding in the budget 
request that will allow VA to provide this increased pay to Physician 
Assistants.
    Response. A conversion average based on nine employees being paid 
from three different Physician Assistant (PA) schedules was used to 
arrive at this costing average. To arrive at an average upon 
conversion, the lowest pay schedule (the GS Rest of the US Locality Pay 
schedule) and two special rate schedules (Durham and San Francisco) 
were used. The costing was intended to show an average of the 
conversion costs only. In a sampling, the average PA will receive 
$5,108 upon conversion to the Nurse Locality Pay System. Employees at 
step 1 upon conversion will receive no increase. All other PAs at steps 
2 through 10 will be placed at the first step that equals or exceeds 
their current rate of pay immediately prior to conversation; this will 
normally result in a 1 or 2 step increase. This would be a one-time 
cost of $12.3 million dollars to move all PAs to the Nurse Locality pay 
system. The 12.3 million represents an estimate of obligations and not 
a budget request number. This would increase the pay for all current 
PAs (steps 2-10) and then would revert to normal step increases which 
would be in line with current practices, which is why there is no cost 
for the future.
    The average increase of $5,108 times the number of PAs currently at 
steps 2--10 was used--2,400 Physician Assistants in VHA at steps 2--10 
x $5,108 = 12,259,200.00, or approximately $12 million.
    This costing only provides an average of the initial cost increase 
upon conversion. It does not consider the ability of Medical Center 
Directors to subsequently adjust rates at any time they deem necessary 
post conversation.

    Question 17. Since 2017, Congress has stepped in three times to 
provide additional funding so the Department would not exhaust Veterans 
Choice Program funding. In at least two of the instances, veterans were 
needlessly stressed and inconvenienced while VA sorted out its 
budgeting issues.

    Question 17a. In detail, please provide how VA developed the 
estimate of funds necessary to carry out the Veterans Community Care 
Program.
    Response. The Veterans Community Care Program projection in the 
2020 President's Budget was developed by summing the following 
components:

     A base actuarial model (referred to as the Enrollee Health 
Care Projection Model [EHCPM]). The EHPCM is based on 2017 actuals and 
projects costs from demographic changes, intensity of medical services, 
and unit price changes.
     An incremental EHCPM run for the expanded access standards 
as stated in the Access Regulatory Impact Analysis.
     An incremental EHCPM run for the new Urgent Care benefit 
as stated in the Regulatory Impact Analysis.
     Adjustments for more recent actuals and programs excluded 
from the EHCPM. Programs that are excluded from the EHCPM but added 
after including CHAMPVA and the Long-Term Services and Supports (LTSS) 
State Home programs.

    Additional detailed information on the forecasting of the MISSION 
Act may be found within the Regulatory Impact Analysis documents.

    Question 17b. How has VA improved its process for projecting how 
much it needs for this type of a program since 2017?
    Response. The estimates from the EHCPM supporting the 2020 VA 
health care budget and the MISSION Act are informed by VA's experience 
under Choice. The actual health care utilization experience of the 
Choice enrollees since the onset of the Choice program has provided 
invaluable insight into the reliance changes that are expected to 
continue for this population into the future. This experience also 
informed the expectations for the enrollees that will become eligible 
for similar community care access under the new MISSION Act drive-time 
standards.

    Question 18. At the hearing, Secretary Wilkie briefly discussed the 
market area assessments that VA is currently undertaking, which will 
inform the VA MISSION Act's Asset and Infrastructure Review Commission. 
It is my understanding that through the market area assessment process, 
VA is evaluating its own current and future capacity, and the capacity 
of the community, to deliver health care services that will meet the 
needs of veterans in 96 regional markets nationwide. At a recent staff 
briefing, VA officials provided an overview of the Department's four-
stage market assessment methodology: data collection, data validation, 
site visits, and development of recommendations.

    Question 18a. At the staff briefing, VA officials said that the 
site visits the Department plans to conduct in each market would last 
between one half to one full day, and they would cover interviews with 
VA facility leadership, community providers, and area veterans service 
organizations. So that I can better understand VA's planned approach, 
please provide a sample site visit schedule, to include a list of 
topics that will be addressed during each of the interviews that will 
take place during each half-day to full-day site visit.
    Response. A sample site visit interview schedule and a list of 
topics that will be addressed during each of the interviews are 
attached.

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Question 18a (response continued)
    All site visits to VA Medical Center (VAMC) parent facilities are 
full day visits. The team will also be visiting a limited number of 
Health Care Centers (HCC), VAMC child facilities, and multi-service 
Community-Based Outpatient Clinics (CBOC) that are key points of care 
in certain markets. These visits will be half-day visits consisting of 
facility walk-throughs and conversations with VA staff.
    At each VAMC full day visit, the team will be meeting with each 
member of the executive leadership team, including the Director, Chief 
of Staff, and Associate/Assistant Director. The team will also meet 
with all service line directors, including but not limited to the 
Directors/Chiefs of Education, Research, Primary Care, Mental Health, 
Medicine, Surgery, Extended Care, Rehab Community Managed Care/
Purchased Care, the Nurse Executive, and the Group Practice Manager. In 
addition, the team will be meeting with the facility planner, engineer, 
and any other role that is either recommended to the team or is 
integral to the facilities service offerings or critical support 
service.
    Topics the interview team will address will vary depending on the 
interviewee and market conditions. The focus of the interviews is to 
obtain the interviewees' outlook of the future and to understand the 
local VAMC perspective on the needs of Veterans in their market, both 
now and in the future. In conjunction with collaborative data review 
sessions, these interviews will provide market assessment teams a 
holistic view of the market while developing high-performing networks 
of care.

    Question 18b. Please provide VA's planned schedule of site visits 
for all 96 markets.
    Response. The planned schedule to visit all 96 markets is divided 
into three phases. One-third of all VISNs are evaluated in each phase. 
Phase 1 is ongoing and includes markets in VISNs 2, 4, 5, 6, 16, and 
17. Each VISN has a dedicated market assessment team, and site visits 
occur concurrently among all six VISNs. Ideally, each team will have 
time between visits to collaborate and share notes on previous site 
visits before traveling to the next market.

    Question 18c. Does VA expect that the market area assessments will 
result in any observations or recommendations related to the condition 
of VA facilities or infrastructure (in general or on a facility-by-
facility basis)?
    Response. The purpose of the Market Assessments is to develop high-
performing networks of care that include VA as the primary provider of 
care, supplemented by care in the community. Facility/infrastructure 
conditions will be considered when developing high-performing networks 
but will not be the sole factor under consideration. It is difficult to 
anticipate future opportunities until the process is complete. We 
anticipate the process will yield observations and opportunities in 
facilities and infrastructure, given their role in health care 
delivery.

    Question 18d. If facility/infrastructure conditions will be part of 
the market assessments, what are the qualifications of those personnel 
(be they VA employees or VA contractors) doing the market assessments 
when it comes to evaluating the facilities and infrastructure?
    Response. The purpose of the Market Assessments is to develop high-
performing networks of care that include VA as the primary provider of 
care, supplemented by care in the community. Facility/infrastructure 
conditions will be considered, including building ages, active capital 
projects, and VA-provided Facility Condition Assessments (FCA) when 
developing opportunities.
    The market assessment team, consisting of both VA and contractor 
employees, includes degreed professionals covering the entire range of 
architectural, engineering, health care planning, and construction 
management expertise. Team credentials include professional engineers 
and registered architects. These professionals have significant 
experience in VA, other Federal, and commercial health care facilities 
planning and management.

    Question 18e. What degrees and credentials do they have, what pre-
visit research will they conduct on the facilities' infrastructure, and 
how much time during each visit is allocated to infrastructure review?
    Response. The purpose of the Market Assessments is to develop high-
performing networks of care that include VA as the primary provider of 
care, supplemented by care in the community. Facility/infrastructure 
conditions will be considered when developing high-performing networks 
but will not be the sole factor under consideration. Degrees and 
credentials for market assessment team members are indicated in the 
response to question 18d. The team also includes clinicians and data 
analysts to provide comprehensive analysis of each market.
    Pre-visit research includes a review of VA-provided Facility 
Conditions Assessment (FCA) information, major, minor, and non-
recurring maintenance projects; a review of VA Office of Inspector 
General (OIG) facility-related findings; a review of building 
engineering system studies commissioned by the VAMC or VISN Capital 
Asset Manager where available; a review of campus master planning 
documents; a review of the campus facility inventory, square footage, 
subsequent major capital improvements, historic designation; and a 
site-by-site review of this material with each facility chief health 
care engineer and strategic planner or appropriate designee as well as 
an onsite tour of the facility during the site visit.
    Market assessments are a collaborative process between VISN and 
facility leadership, the Office of Policy and Planning, Office of 
Construction and Facilities Management, and a contractor team. The 
review process for each market spans months, and infrastructure review 
for each facility is integrated into the broader review process to 
develop high-performing networks of care. Facility infrastructure 
review is included in comprehensive data assessments, pre-visit market 
meetings, site visit interviews, and post-visit collaboration sessions 
and out briefs. In addition to a site visit tour, facility and space 
considerations are addressed in each interview.

    Question 18f. To what extent are engineers involved in this aspect 
of the market area assessments?
    Response. Engineers and health care architects from the VAMC, VISN, 
Office of Construction and Facilities Management, and contract team are 
involved in all facility-related aspects of the market assessments as 
the team develops opportunities for high-performing networks of care. 
This includes assessments of existing data, pre-visit market meetings, 
site visit interviews, and post-visit collaboration sessions and out 
briefs. The collective expertise of these professionally-degreed team 
members is used to evaluate the medical functional state for key 
infrastructure elements within each major facility.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
                  U.S. Department of Veterans Affairs
    Question 1. When will the Department decide to act on your 
recommendation not to appeal the Procopio decision?
    Response. Prior to issuance of the court's decision in Procopio, VA 
began researching some of the complexities related to determining the 
Veteran population that served within the 12 nautical miles of the 
Republic of Vietnam and assessing the potential workload. VA spoke with 
members of the U.S. Navy and the National Archives Records 
Administration to determine the available service records, such as deck 
logs. VA provided its regional offices with procedural guidance to 
ensure that claims received for Blue Water Navy (BWN) Veterans are 
properly tracked in its system of records. In addition, VA's internal 
work groups are developing policy guidance, training, and strategic 
outreach materials that will ensure these Veterans are aware of their 
eligibility for benefits and services. VA is also updating its costing 
for mandatory funding to support benefits paid to BWN Veterans as well 
as the additional administrative costs and personnel that are necessary 
to address all Veteran claims. VA anticipates a surge in claims and 
appeals that will result in significant claims Therefore, VA's 
implementation must include plans to maintain an acceptable level of 
claims processing for all Veteran claimants. These ongoing efforts are 
necessary in order to comply with the court's order.

    Question 1a. Please provide me with a detailed breakdown of VA's 
decisionmaking process related to the National Academies 
recommendations regarding bladder cancer, hyperthyroidism, hypertension 
and Parkinson's like symptoms?
    Response. VA uses the process described in the attached directive--
VA Directive 0215. The first step is the formation of a technical 
workgroup comprised of subject matter experts who review the report 
(e.g. Veterans and Agent Orange 2018--Vol. 11) from the National 
Academy of Medicine (NAM, note this used to be called the Institute of 
Medicine) in depth and also consider scientific evidence published 
since the NAM's cutoff date for new literature for that report. This 
technical workgroup then summarizes the findings and makes potential 
recommendations to report them to the NAM Strategic Workgroup (made up 
of Agency leaders and other experts).
    The NAM Strategic Workgroup then makes recommendations on its 
findings to the VA Task Force composed of Agency Leaders, who in turn 
discuss the conclusions and make the final recommendations (including 
any potential presumptions) to the Secretary.

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Question 1b. Please provide me with VA's analysis regarding total 
number of veterans effected, and the cost associated with extending 
service connection to each specific illness.
    Response. VA's estimates for the cost and number of Veterans 
impacted by the Procopio decision are being finalized. Once VA's 
estimates are finalized, estimates will be shared with the Committee.
    VA's estimates for the cost and number of Veterans impacted by 
potential presumptive conditions associated with Agent Orange are being 
finalized. If the Secretary decides to add any presumptive conditions, 
VA's estimates will be shared with the Committee.

    Question 2. Please provide me with the following information for 
all the VAMCs in Ohio:


    Question 2a. The extent to which directors have utilized the direct 
hiring authority provided by OPM?
    Response. On January 24, 2018, VA was granted direct hiring 
authority by the Office of Personnel Management (OPM) for the following 
occupations: accountant, boiler plant operator, general engineer, 
health science specialist (Veterans Crisis Line), health technician, 
histopathology technician, human resource assistant, human resource 
specialist, information technology specialist, personnel security 
specialist, police officer, realty specialist, utility systems 
operator, and utility systems repair. On October 11, 2018, OPM granted 
direct hiring authority for an additional eighteen STEM positions.
    Since January 2018, there have been 74 people hired into Ohio 
medical facilities for the occupations granted direct hiring authority, 
22 percent were hired using the direct hiring authority.

    Question 2b. The extent to which the directors have utilized the 
student loan repayment increase that Congress provided in the MISSION 
Act to incentivize healthcare professionals to work at VA.
    Response. VAMCs are actively utilizing EDRP to fill VA's hardest to 
fill physician positions as demonstrated by the significant increase in 
physician awards which are nearly 50 percent of all EDRP awards 
received thus far for 2019, up from 31 percent overall for FY 2018.

    Question 3. Throughout Ohio, we have heard that staffing shortages 
have cause excessive wait times for vitals, EKG's, blood draws, longer 
stays in the emergency department. We have also heard that VAMC 
director and clinical management decisions meant in-patient units could 
not receive inpatient care. I have several workforce management 
questions and would like information from all the VAMCs in Ohio.

    Question 3a. What is the optimal nursing and ancillary staffing 
model?
    Response.
     Primary Care Teams (PACT) the model is 3:1, 2 
professional/clinical staff (RN and LPN or Health technician) and 1 
clerical/admin support staff for each provider (MD or APRN).
     Inpatient and Long-Term Care units, staffing levels are 
determined based on the type of unit, acuity of care and support 
services available in the facility. The model uses hours per patient 
day (HPPD) for units that provide 24/7 care. The hours are based on the 
clinical skill level of staff required (RN, LPN, and Nursing 
Assistant). Each unit has a staff panel that formally makes 
recommendations to facility executive leadership for staffing every 2 
years or earlier if the patient population, acuity level, or volume 
changes. Facility leadership reviews the recommendations and provides 
concurrence or guidance for adjustments.

    Below are national averages for skill mix percentages across VHA, 
Data source: VSSC national average Feb YTD FY 2019 for Critical Care 
Clusters, Medical, Surgical Clusters and CLC Clusters (excluding Small 
houses).
          - Critical Care Units: 93 percent RN, 7 percent Nursing 
        Assistant or Health Technician.
          - Medical and Surgical Units: 68-70 percent RN, 5 percent LPN 
        and 21-25 percent Nursing Assistant.
          - Long Term Care Units: 34 percent RN, 21 percent LPN and 44 
        percent Nursing Assistant.

    Question 3b. What is the ratio of RNs, LPNs, NAs, Health 
Technicians and ancillary providers to patients in all direct patient 
care areas?
    Response. Ratio models are not used since ratios do not reflect 
patient acuity or support services available within the facility in 
determining appropriate staffing levels.

    Question 3c. What is the call-off rates and injuries rates 
associated with direct patient care and ancillary care?

    Question 3d. Please breakdown the number of many managers and 
clinicians who have been redirected from direct patient care to 
administrative tasks?

    Question 3e. Does this cause a disproportionate manager/supervisor 
ratio to employee?
    Response. Please see table that follows for questions 3c-3e.

 
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                     Chillicothe VAMC      Cincinnati VAMC         Cleveland VAMC         Columbus VAMC              Dayton VAMC
--------------------------------------------------------------------------------------------------------------------------------------------------------
Question 3c        What is the call- I do not have     Direct patient care      Nursing averages 4.7  Our OSHA recordable   FY18 call-off rates
                    off rates and     these             call-off rate for FY     unexpected absences   injury rate for       (measured as a percentage
                    injuries rates    statistics.       18 is: 14% including     per 100 employees     FY18 was 2.07, and    of call-off per FTE of 1664
                    associated with                     RNs, NAs & HTs.          for the past 12       the lost time         direct care hours) for
                    direct patient                                               month in direct       claims rate (call     nursing were as follows:
                    care and                                                     patient care.         off rate) was 0.0.    Acute/Specialty Care--
                    ancillary care?                                                                                          7.62%, Mental Health--
                                                                                                                             6.70%, and CLC--9.46% with
                                                                                                                             an overall nursing rate of
                                                                                                                             8.36%.
                                                                                                                            For FY18, there were 65
                                                                                                                             cases where clinical
                                                                                                                             employees were injured, per
                                                                                                                             the OSHA 300 log. We had
                                                                                                                             217 total injuries (rate of
                                                                                                                             .09 with 2444 FTE) through
                                                                                                                             our current reporting
                                                                                                                             system but are unable to
                                                                                                                             easily separate clinical
                                                                                                                             and administrative staff in
                                                                                                                             this database. We will be
                                                                                                                             able to distinguish this
                                                                                                                             information in the future,
                                                                                                                             as our database has changed
                                                                                                                             and provides for a more
                                                                                                                             robust reporting ability.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Question 3d        Please breakdown  None. The         Inpatient Managers may   No managers have      3, reassignments      For FY18, 3 Nurse Managers
                    the number of     numbers of        be pulled from their     been permanently                            and 4 Registered Nurses
                    many managers     managers and      primary                  redirected from                             within Nursing Service.
                    and clinicians    assistant nurse   responsibilities to      direct patient care
                    who have been     managers are      cover the NOD, HUC,      to administrative
                    redirected from   determined in     Telemonitor, and         tasks. There are
                    direct patient    the Staffing      Virtual Monitor. We do   currently 4 direct
                    care to           Methodology       not currently capture    patient care
                    administrative    calculations.     the hours they are       employees who have
                    tasks?                              staffing HUC,            been temporarily
                                                        Telemonitoring, and      assigned
                                                        Virtual Monitoring.      administrative
                                                       The managers have been    tasks.
                                                        used in the NOD role,
                                                        during their regular
                                                        tour 5% of their
                                                        regularly scheduled
                                                        hours.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Question 3e        Does this cause   No.               When this occurs, it     No.                   No.                   No.
                    a                                   reduces the manager:
                    disproportionat                     employee ratio by 25%
                    e manager/                          resulting in 3
                    supervisor                          managers covering 5
                    ratio to                            units.
                    employee?
--------------------------------------------------------------------------------------------------------------------------------------------------------


    Question 3f. Provide a breakdown of employees disciplined or 
terminated under section 714 of the VA Accountability and Whistle 
Blower Act. Please include by race, grade, discipline, and issue that 
led to termination.
    Response. Please see tables below.

                         Chillicothe 3f Response
------------------------------------------------------------------------
        Grade                Discipline                  Issue
------------------------------------------------------------------------
GS-5.................  Removal                Unexcused absence
GS-11................  Removal                Unexcused absence
GS-6.................  Removal                Unexcused absence
WG-2.................  Removal                Unexcused absence
GS-9.................  Removal                Medical Inability
WG-2.................  Removal                Unexcused absence
------------------------------------------------------------------------


                         Cincinnati 3f Response
------------------------------------------------------------------------
  Grade               Offense                     Action           Cases
------------------------------------------------------------------------
     GS-4 Disrespectful or abusive     Removal................      1
           language/conduct
     GS-4 Drug/Alcohol related         Removal................      1
     GS-5 Conduct Unbecoming a         Probationary                 1
           federal employee             Termination.
     GS-5 Disrespectful or abusive     Probationary                 1
           language/conduct             Termination.
     GS-5 Failure to follow policy     Probationary                 1
                                        Termination.
     GS-5 Failure to properly request  Probationary                 1
           leave                        Termination.
     GS-5 Improper conduct on VA       Probationary                 1
           premisis without VA          Termination.
           endorsement
     GS-5 Unexcused or unauthorized    Probationary                 3
           absence/tardiness            Termination.
     GS-5 Failure to meet a condition  Removal................      1
           of employement
     GS-5 Unexcused or unauthorized    Removal................      7
           absence/tardiness
     GS-6 Performance Issues           Probationary                 1
                                        Termination.
     GS-6 Conduct Unbecoming a         Removal................      1
           federal employee
     GS-6 Unexcused or unauthorized    Removal................      3
           absence/tardiness
     GS-8 Failure to follow policy     Demotion...............      1
 Title 38 Failure to meet a condition  Probationary                 1
           of employement               Termination.
 Title 38 Unexcused or unauthorized    Probationary                 1
           absence/tardiness            Termination.
 Title 38 Conduct Unbecoming a         Removal................      1
           federal employee
 Title 38 Failure to maintain          Removal................      1
           licensure requirements of
           position
 Title 38 Unauthorized delivery of     Removal................      1
           care
 Title 38 Conviction                   Suspension--Indefinite.      1
     WG-1 Failure to maintain a        Probationary                 1
           regular work schedule        Termination.
     WG-1 Unexcused or unauthorized    Probationary                 4
           absence/tardiness            Termination.
     WG-1 Unexcused or unauthorized    Removal................      2
           absence/tardiness
     WG-2 Disrespectful or abusive     Probationary                 1
           language/conduct             Termination.
     WG-2 Unexcused or unauthorized    Probationary                 5
           absence/tardiness            Termination.
     WG-2 Disrespectful or abusive     Removal................      1
           language/conduct
     WG-2 Drug/Alcohol related         Removal................      1
     WG-2 Failure to meet a condition  Removal................      1
           of employement
     WG-2 Unexcused or unauthorized    Removal................      6
           absence/tardiness
     WG-3 Unexcused or unauthorized    Probationary                 1
           absence/tardiness            Termination.
     WG-3 Unexcused or unauthorized    Removal................      2
           absence/tardiness
     WG-5 Conviction                   Suspension--Indefinite.      1
     WG-6 Disrespectful or abusive     Probationary                 1
           language/conduct             Termination.
                                                               ---------
                                                                   57
------------------------------------------------------------------------


                          Cleveland 3f Response
------------------------------------------------------------------------
    Position Title     Grade  Type of Discipline         Charge(s)
------------------------------------------------------------------------
Nursing Assistant....     5   15 Day Suspension.  AWOL, Failure to
                                                   Follow Proper Leave
                                                   Request Procedures &
                                                   Failure to Follow
                                                   Instructions
LPN..................     6   Removal...........  Conduct Unbecoming a
                                                   LPN (7 Spec); Failure
                                                   to Follow Instruction
Nursing Assistant....     3   Last Chance         15 charges AWOL, 5
                               Agreement.          charges failure to
                                                   follow proper leave
                                                   request procedures &
                                                   2 charges failure to
                                                   follow instructions
LPN..................     6   Proposed Removal..  AWOL (15 Specs)
                                                   Failure to Follow
                                                   Leave Procedures (10
                                                   Specs)
Nursing Assistant....     5   Removal...........  Carelessness in the
                                                   Performance of Duties
                                                   (5 Spec); Conduct
                                                   Unbecoming a Federal
                                                   Employee
Health Technician....     7   Notice to Effect    Violation of last
                               Removal.            chance-Inappropriate
                                                   Conduct
Health Technician....     6   15 Day Suspension.  2 charges conduct
                                                   unbecoming & 1 charge
                                                   failure to timely
                                                   transport patient
Health Technician....     6   Removal...........  1 charge inappropriate
                                                   conduct
LPN..................     6   Removal...........  Medical Inability
Nursing Assistant....     5   Last Chance         3 charges AWOL & 2
                               Agreement.          charges failue to
                                                   follow proper leave
                                                   request procedures
Nursing Assistant....     5   Removal...........  Inappropriate
                                                   Interaction with
                                                   Patient (3 specs)
LPN..................     6   Last Chance         3 charges
                               Agreement.          inappropriate conduct
Nursing Assistant....     5   Last Chance         3 charges
                               Agreement.          inappropriate
                                                   conduct, 1 charge
                                                   AWOL & 1 charge
                                                   failure to follow
                                                   proper leave request
                                                   procedures
Nursing Assistant....     5   Removal...........  Failure of critical
                                                   element, 1 charge
                                                   AWOL , 1 charge
                                                   failure to follow
                                                   proper leave request
                                                   procedures, 1 charge
                                                   lack of due care & 1
                                                   charge making
                                                   unfounded statements
Nursing Assistant....     6   Removal...........  Carelessness in the
                                                   Performance of Duties
                                                   (2 Spec); Conduct
                                                   Unbecoming a Federal
                                                   Employee
Health Technician....     6   Removal...........  AWOL (3 Spec); Failure
                                                   to Follow Leave
                                                   Request Procedures (3
                                                   Spec); Inappropriate
                                                   Conduct (4 Spec)
------------------------------------------------------------------------



                                              Columbus 3f Response
----------------------------------------------------------------------------------------------------------------
                                                                714 Disciplinary Proposal and Decision
                           Issue(s)                                            Actions                    Grade
----------------------------------------------------------------------------------------------------------------
Muni-Court Conviction........................................  Proposed Removal/Removal Decision......     GS-5
Off duty misconduct (domestic violence)......................  Proposed Removal/Resignation prior to      GS-11
                                                                issuance of decision.
Unacceptable Conduct (Threatening Behaviors).................  Proposed Removal/Removal Decision......     GS-5
Sleeping on duty/Inappropriate Comments......................  Proposed Demotion/Demotion Decision....     GS-7
Off duty misconduct (domestic violence)......................  Proposed Removal/Resignation prior to       NV-2
                                                                issuance of decision.
AWOL, Lack of Candor.........................................  Proposed Removal/Removal decision......    GS-06
Conduct unbecoming a federal employee........................  Proposed Removal/Resignation prior to       GS-9
                                                                issuance of decision.
Privacy violation............................................  Proposed Removal/(1) day suspension        GS-09
                                                                decision.
Unacceptable Disrespectful Conduct...........................  Proposed Removal/(14) day suspension       GS-06
                                                                decision.
Unacceptable Disrespectful Conduct...........................  Proposed Removal/Employee retired prior    GS-09
                                                                to issuance of decision.
Failure to disclose or provide accurate information..........  Proposed Removal/Removal decision (MSPB     NV-3
                                                                filed--Settlement Agrmt--Employee
                                                                returned to a different vacant
                                                                position).
Conduct unbecoming a federal employee........................  Proposed Removal/DAB held/EE returned      GS-06
                                                                to former position.
Leave and Attendance Issues..................................  Proposed Removal/(5) day suspension        GS-06
                                                                decision.
Insubordination..............................................  Proposed Removal/(7) day suspension        NV-02
                                                                decision.
Unsatisfactory Performance...................................  Proposed Demotion/Demotion Decision to     GS-12
                                                                a different vacant position.
Unprofessional Conduct.......................................  Proposed Removal/Written counseling        GS-06
                                                                decision.
AWOL.........................................................  Proposed Removal/Employee retired prior    GS-09
                                                                to issuance of decision.
Conduct unbecoming a federal employee........................  Proposed Removal/(5) day suspension        GS-06
                                                                decision.
Failure to meet standard of care.............................  Proposed Removal/Demotion Decision to a    GS-05
                                                                different vacant position.
Medical Inability to Perform.................................  Proposed Removal/Removal Decision......    GS-15
Unauthorized possession of firearm on VA property/Unfit for    Proposed Removal/Removal Decision(MSPB     GS-09
 Duty.                                                          filed--Settlement Agreement Employee
                                                                will be returning to a different
                                                                vacant position).
Conduct unbecoming...........................................  Proposed Removal/(5) day suspension        NV-01
                                                                decision.
Failure to Supervise.........................................  Proposed Demotion/Demotion Decision....    GS-06
Sleeping on duty/Conduct unbecoming..........................  Proposed Removal/currently awaiting        NV-03
                                                                Director's decision.
AWOL/Failure to follow leave procedures/Failure to provide     Proposed Removal/ OAWP complaint filed     GS-06
 accurate information.                                          pausing Director's decision.
----------------------------------------------------------------------------------------------------------------



                                               Dayton 3f Response
----------------------------------------------------------------------------------------------------------------
                                                                            Non-
                  Issue                           Grade         Clinical  Clinical       Type of Discipline
----------------------------------------------------------------------------------------------------------------
AWOL, Failure to Follow Leave Requesting   VN-2                     x               Suspension
 Procedures.
HIPAA/Privacy Violations.................  VN- 2                    x               Suspension
Loss of Controlled Substance.............  GS-7                               x     Indefinite Suspension
Untimely Documentation, Failure to Follow  VM-15                    x               Discharge
 Supervisor Instruction, Unethical
 Conduct, Endangering Safety of a Veteran
 Patient.
Failure to follow supervisory              GS-6                               x     Removal
 instructions.
AWOL/Failed Last Chance Agreement........  WG-2                               x     Removal
AWOL.....................................  GS-7                               x     Removal
Inappropriate Conduct....................  VN-2                     x               Discharge
AWOL, Failure to Follow Leave Requesting   WG-3                               x     Removal
 Procedures.
Unauthorized Use of PIV Card; Accessing    WG-2                               x     Removal
 an Unauthorized Area; Unauthorized
 Possession of Govt property.
AWOL; Failure to Follow Leave Requesting   GS-5                     x               Removal
 Procedures.
Negligence; Inappropriate Conduct........  WG-10                              x     Removal
Inappropriate Conduct, Failure to Follow   VM-15                    x               Discharge
 VA Directive.
Failure to Follow Supervisory              WS-3                               x     Removal
 Instructions/Poor Workmanship.
AWOL.....................................  WG-2                               x     21-Day Suspension
Using an Unauthorized Area for Research    WG-8                               x     Removal/Failed Last Chance
 and Breaks; Sleeping on Duty.                                                       Agreement
Using an Unauthorized Area for Research    WG-10                              x     Removal
 and Breaks.
----------------------------------------------------------------------------------------------------------------


    Question 4. Last year's MILCON-VA appropriations bill, Pub. L. 115-
244, direct VA to do a pilot program related to hospice care to develop 
best practices and techniques for Vietnam era veterans.
    It has come to my attention that VA decided to use the $1 million 
of funding associated with this provision on salaries, and not on the 
broad implementation of the pilot program with non-profit hospice and 
palliative care providers with Vietnam veteran centric programs as 
directed in report language.

    Question 4a. How $1 million budget remains?
    Response. The entire $1 million has been obligated to implement a 
strategic plan that has included collaboration with non-profit hospice 
and palliative care providers.

    Question 4b. Does VA plan to reprogram that funding to allow non-
profit hospice and palliative care providers with Vietnam veteran 
centric programs to ramp up its care delivery yet this year and help 
actual Vietnam veterans on the ground?
    Response. VHA implementation of this initiative has included 
collaboration with non-profit hospices. The prolonged government 
contracting process would not have permitted effective implementation 
of identified best practices for this 1-year initiative. If additional 
funding becomes available, competitive bid contracting to engage high 
performing community hospices that have a demonstrated commitment to 
the care of Veterans could significantly expand the dissemination of 
the best practices and techniques identified in this first year of the 
initiative.
Multifaceted Approach to Improve Care
    As outlined in the 180-day report to Congress on this initiative, 
VHA is rapidly moving forward to the following:

     Identify the unique characteristics and quality elements 
at end of life for Vietnam-era Veterans through analysis of medical 
records and bereaved family surveys;
     Develop three ``Train the Trainer'' curricula on 
identifying and addressing Post Traumatic Stress Disorder (PTSD), Moral 
Injury, and Suicide intent specifically for Vietnam-era Veterans on 
hospice; and
     Collaborate with the National Hospice and Palliative Care 
Organization (NHPCO) to conduct semi-structured interviews with 
Vietnam-era Veterans on hospice and their families to learn about 
quality issues directly from hospice users.

    Additionally, VHA has collaborated with NHPCO to survey community 
hospice partners in the We Honor Veterans program 
(www.WeHonorVeterans.org) to learn more about their best practices and 
insights on how to improve the care Vietnam-era Veterans.
Initial Findings
    The initial findings from analysis of qualitative open-ended 
comments from 2,781 inpatient decedent Vietnam-era Veterans' family 
members has identified the following themes as highly valued: 
compassionate staff, ceremonies that honor the life of the Veteran, 
information on VA benefits, accommodations for family, genuine 
expressions of condolence, and attendance at memorial services. Several 
of these themes (e.g., compassionate care) are similar to those desired 
elements voiced by non-Veterans and their families. A small number of 
family members of Vietnam-era Veterans reported war-era specific 
concerns such as the following: the need for greater assistance for 
Veterans' struggles with PTSD, sensitivity to triggers for PTSD, and 
greater recognition of the impact of exposure to Agent Orange. VA will 
further explore these Vietnam-era specific concerns.
    Preliminary analysis of nearly 100,000 VA inpatient decedents 
indicate that there are unique characteristics among Vietnam-era 
Veterans (e.g., increased Agent Orange exposure and higher prevalence 
of substance use disorder) as compared to pre-Vietnam-era Veterans. 
Other notable characteristics among Vietnam-era Veterans (e.g., 
increased prevalence of depression and anxiety), may reflect emerging 
challenges in Veterans of subsequent war eras. For example, unadjusted 
scores on bereaved families' perceptions of end of life care show 
Vietnam-era Veteran families rate care lower in quality than pre-
Vietnam (WWII, Korean and Post-Korean). However, these differences are 
negligible after accounting for differences in Veteran age at death. 
Further analyses are required to determine meaningful trends on quality 
perceptions and elements.
Actions to Improve Care and Next Steps
    Translating the findings from these analyses into actionable 
protocols while empowering community hospices is the next major step 
for this 1-year initiative. For example, VHA has identified high-
performing facility teams to be trained and then disseminate the newly 
developed Train-the-Trainer curricula to community hospices (with a 
projection of more than 1,000 front-line staff to receive these 
trainings by the end of the year) and build collaborative networks of 
care to support enhanced access to telehealth for Veterans receiving 
community hospice care. In collaboration with the National Hospice and 
Palliative Care Organization and the National Partnership for Hospice 
Innovation, VHA will develop best practice hospice protocols based on 
the substantial evidence revealed as part of this initiative and pilot 
these over the final months of this fiscal year to determine 
feasibility for broader dissemination.

    Question 4c. It has also come to my attention that VA decided to 
focus areas of care on suicide prevention, moral injury and PTSD 
therapy. How did VA make that decision, and was it made in consultation 
with the Committees regarding congressional intent of the underlying 
hospice care provision?
    Response. VHA has responded to all Committee inquiries into this 
initiative and has sought to meet or exceed the intent of any guidance 
provided by the Committees. The development and dissemination of 
expertise in the three areas mentioned above is only part of VHA's 
actions for this initiative, however, the decision to develop ``Train 
the Trainer'' curricula on PTSD, Moral Injury, and Suicide Prevention 
specifically for Vietnam-era Veterans in hospice was made in 
collaboration with subject matter experts from the following VHA 
programs: Palliative and Hospice Care, National Center on PTSD and 
Suicide Prevention, Office of Mental Health, Office of Care 
Coordination, Office of Patient Centered Care and Culture 
Transformation, National Chaplaincy Center, and the Office of Nursing 
Service, as well as incorporating guidance from the National Hospice 
and Palliative Care Organization. These offices and community hospice 
partners agreed that reducing the suffering in these three areas was 
and is a top priority for this initiative as outlined ``. . . to 
develop the techniques, best practices and support mechanisms to serve 
these veterans . . . .'' For example, in a survey of community 
hospices, many shared they do not screen for nor have the capacity to 
address the symptoms of PTSD, Moral Injury, and Suicide Intent. Through 
dissemination of expertise in these three areas, community hospices 
will be more empowered to meet the specific needs of Vietnam-era 
Veterans in hospice.

    Question 5. On December 20, 2018, I signed onto a letter led by 
Senator Carper regarding the closure of Education Corporation of 
America schools and its impact on veterans and their families. My 
colleagues and I have not yet received the answer to Questions from 
that letter and have included them here for a thorough response.

    Question 5a. When did ECA notify the VA about the planned closures 
for each campus?
    Response. VA received a letter from Education Corporation of 
America's (ECA) chief executive on December 12, 2018, officially 
advising VA of the closure and the effective date of closure for each 
of its locations.

    Question 5b. When and how did the VA notify GI Bill recipients 
about the closures for each campus?
    Response. Once VA was officially aware of the school's closure 
(December 12, 2018), VA notified affected students within the 5 
business days required by law. All students impacted by the closure 
received a notice at their address of record. VA also posted notices of 
the closure on its Web site and social media pages with the following 
message and active link to more information on December 7th:

          ``VA is aware of the abrupt closure of facilities associated 
        with Education Corporation of America (ECA), which operated 
        several chains of schools, to include Virginia College, 
        Brightwood College, Golf Academy of America, and Ecotech 
        Institute, throughout the Nation. VA is coordinating with the 
        various State Approving Agencies (SAA) and is in the process of 
        gathering the specific details surrounding this closure.''

    Additionally, the assistance provided to students by VA is in the 
form of the links and information contained in the 5-day outreach 
letter to students. A copy of this letter is attached below. Education 
Call Center agents were available to answer questions and provide 
assistance to students with school closure questions. Last, VA 
coordinated with Veterans Service Organizations (VSOs) to notify any 
affected students or provide support services.

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Question 5c. How many Post-9/11 GI Bill recipients were enrolled at 
ECA colleges at the time of the announced closure? Please provide GI 
Bill enrollment data for each campus.
    Response. There were 1,389 students enrolled at ECA colleges who 
were using Post-9/11 GI Bill benefits at the time of closure. Please 
see the enrollment data spreadsheets below.

                            ECA School List

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                    ECA Colleges by Institution Name

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]




                     Brightwood Institutes by State
------------------------------------------------------------------------
 
------------------------------------------------------------------------
Brightwood Career Institute...................    28119823        MN
Virginia College..............................    21004336        OK
Brightwood College............................    24918414        IN
Brightwood College............................    24931614        IN
Brightwood College............................    24986435        OH
Brightwood College............................    24955442        TN
Virginia College..............................    21904042        TN
Golf Academy of America.......................    24201010        FL
Virginia College..............................    249F1410        FL
Virginia College..............................    219B6110        FL
Virginia College..............................    24994410        FL
Golf Academy of America.......................    24113440         SC
Virginia College..............................    21802440         SC
Virginia College..............................    21802640         SC
Virginia College..............................    21802340         SC
Virginia College..............................    21802740         SC
Virginia College..............................    21802840         SC
Golf Academy of America.......................    24929403        AZ
Virginia College..............................    21917211        GA
Virginia College..............................    21917811        GA
Virginia College..............................    21917311        GA
Virginia College..............................    21917611        GA
Virginia College..............................    21001418        LA
Virginia College..............................    21001618        LA
Virginia College..............................    24801424        MS
Virginia College..............................    24801324        MS
Virginia College..............................    21802301        AL
Virginia College..............................    21952301        AL
Virginia College..............................    21953101        AL
Virginia College..............................    21958101        AL
Virginia College..............................    21014146        VA
Brightwood Career Institute...................    24956438        PA
Brightwood Career Institute...................    24939438        PA
Brightwood Career Institute...................    24942438        PA
Brightwood Career Institute...................    24940638        PA
Brightwood Career Institute...................    24961438        PA
Brightwood College............................    24912133         NC
Virginia College..............................    21905133         NC
Brightwood College............................    24801005          CA
Brightwood College............................    24005705          CA
Brightwood College............................    24804405          CA
Brightwood College............................    24008205          CA
Brightwood College............................    24001805          CA
Brightwood College............................    24003305          CA
Brightwood College............................    24936405          CA
Brightwood College............................    24832005          CA
Brightwood College............................    24804605          CA
Brightwood College............................    24831905          CA
Golf Academy of America.......................    24909105          CA
Brightwood College............................    25011906          CO
Ecotech Institute.............................    21014806          CO
Brightwood College............................    25106731        NM
BRIGHTWOOD COLLEGE-ARLINGTON..................    24037343        TX
BRIGHTWOOD COLLEGE-BEAUMONT...................    24036043        TX
BRIGHTWOOD COLLEGE-BROWNSVILLE................    24036243        TX
BRIGHTWOOD COLLEGE-CORPUS CHRISTI.............    24042043        TX
BRIGHTWOOD COLLEGE-DALLAS.....................    249J2143        TX
BRIGHTWOOD COLLEGE-EL PASO....................    24036643        TX
BRIGHTWOOD COLLEGE-FORT WORTH.................    249L8143        TX
BRIGHTWOOD COLLEGE-FRIENDSWOOD................    24036343        TX
BRIGHTWOOD COLLEGE-HOUSTON....................    24042143        TX
BRIGHTWOOD COLLEGE-LAREDO.....................    24037543        TX
BRIGHTWOOD COLLEGE-MCALLEN....................    24035643        TX
BRIGHTWOOD COLLEGE-SAN ANTONIO INGRAM.........    24036443        TX
BRIGHTWOOD COLLEGE-SAN ANTONIO SAN PEDRO......    24036143        TX
Golf Academy of America.......................    24038643        TX
Virginia College..............................    24033943        TX
Virginia College..............................    24039243        TX
Brightwood College............................    24921720        MD
Brightwood College............................    24921520        MD
Brightwood College............................    24921920        MD
------------------------------------------------------------------------


    Question 5d. Please describe the specific steps the VA has taken to 
identify and assist Post-9/11 GI Bill recipients affected by ECA 
closures.
    Response. VA uses the data contained in its VA Online Certification 
of Enrollment (VA-ONCE) system to identify impacted Veterans; this is 
the system the schools used to certify Veteran attendance. The 
assistance provided to students by VA is in the form of the links and 
information contained in the 5-day outreach letter to students. A copy 
of this letter is attached to this reply. Education Call Center agents 
were available to answer questions and provide assistance to students 
with school closure questions. Last, VA coordinated with Veterans 
Service Organizations (VSOs) to notify any affected students or provide 
support services.

    Question 5e. Under the Forever GI Bill, will ECA veterans be 
eligible for an additional housing allowance, and, if so, what is the 
duration of that relief?
    Response. Students attending ECA locations that terminated their 
operations during the term will be eligible to receive their housing 
allowance until what would have been the conclusion of the term in 
which they were enrolled, or for 120 days, whichever comes first.

    Question 5f. Please describe how the VA is coordinating with SAAs, 
the U.S. Department of Education, or ECA to provide information to GI 
Bill recipients on their transfer options.
    Response. VA works closely with State Approving Agencies (SAA) to 
ensure that VA was aware of the ECA closure and allow for prompt 
notification to students regarding entitlement restoration; in ECA's 
case, VA also received a letter from the institution, which was helpful 
as ECA had numerous campuses in many states. VA does not work directly 
with Department of Education (ED) but is aware that ED posted 
information for students to notify them of options and VA monitors EDs 
activities. Please see https://studentaid.ed.gov/sa/sites/default/
files/education-corporation-america.pdf.
    Individual SAAs may post information directly on their Web site to 
assist students but often rely on their Higher Education Departments to 
post information for students. For an example, please see https://
osar.bppe.ca.gov/closures/brightwood.shtml.

    Question 5g. Please describe how the VA is ensuring that transfer 
options do not put student veterans at risk of further harm--such as 
providing guidance regarding institutions that have active caution 
flags on the GI Bill Comparison Tool.
    Response. The 5-day letter VA sends to students upon notice that an 
institution has closed directs students to VA's Comparison Tool where 
caution flags can be found when researching prospective new 
institutions.

    Question 5h. How much funding from the VA did each of ECA's schools 
receive in academic years 2014-2015, 2015-2016, 2016-2017, and 2017-
2018?
    Response.

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

Please refer to the chart above for a summary total of payments paid to 
ECA schools for each academic year from 2014-2018. The latest available 
data to date for academic year 2018 is only available through 01-31-19. 
The accompanying pdf document below further expands payments by 
individual training institution, facility code, and academic year. Only 
school payment data (tuition and fees and Yellow Ribbon) is presented 
in the dataset.

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



    Question 5i. Post-9/11 GI Bill beneficiaries have recently 
experienced delays and underpayments in housing benefits this year. How 
many students impacted by the ECA closures were also affected by delays 
in housing payments, and will ECA students who may have received 
incorrect housing allowances be retroactively reimbursed?
    Response. VA is unable to tell how many ECA student were impacted 
by the fall 2018 delays in housing payments; however, ECA's closure did 
not impact VA's ability to correct those payments by January 1, 2019, 
in the event they were incorrectly paid. However, in the event an ECA 
student was attending a campus under section 107, ECA would need to 
report this information to VA for VA to re-adjudicate the claim to 
determine if additional funds should be issued to a student. VA will 
work individually with those ECA students who report an improper 
housing payment under section 107 in the event ECA in unwilling or 
unable to report due to their closure.

    Question 5j. Please provide information on any efforts by the VA to 
limit, suspend, or withdraw ECA's participation in the Post-9/11 GI 
Bill program prior to their announced closure and within the last five 
years.
    Response. There was no effort by VA to limit, suspend, or withdraw 
ECA's participation in the Post-9/11 GI Bill program prior to their 
announced closure or within the last 5 years; however, VA may not be 
aware of efforts on the part of individual SAAs in this regard. VA was 
not aware of any issues that would have impacted its approval status, 
financial stability is not a requirement for the approval of accredited 
programs, and VA has no statutory authority to limit, suspend, or 
withdraw a school's GI Bill approval because the school closes some of 
its campuses.

    Question 5k. Please provide information on the overall number of 
student veteran complaints to the GI Bill Feedback System about schools 
owned by ECA and the VA's efforts to address them since 2014.
    Response. Since 2014, Education Service (EDU) received a total of 
28 complaints from students within the GI Bill Feedback System about 
schools owned by ECA. VA addressed each of the 28 complaints through 
initial contact with the student to gain additional details of the 
issue. VA then contacted the appropriate ECA institution with the 
issues and requested they respond within 45 days. Of the 28 complaints, 
22 were resolved in a timely manner and six cases were identified as 
information only. Each of the cases are stored electronically and 
available to establish trends in support of the overall EDU strategy to 
safeguard the integrity of the GI Bill. Furthermore, the EDU Oversight 
and Accountability division has completed 128 compliance survey visits 
at the ECA institutions since 2014.

    Question 6. In the last year, there have been two waves of school 
closures and the practical collapse of a most of the Dream Center 
Education Holdings (DCEH) campuses, affecting thousands of students 
across the country.

    Question 6a. How many Post-9/11 GI Bill recipients were enrolled at 
DCEH schools at the time of the July 2018 reports that DCEH would stop 
enrolling students at 30 campuses and shut down those locations? Please 
provide GI Bill enrollment data for each campus. How many, if any, 
Post-9/11 GI Bill recipients transferred to online-only offerings when 
those 30 campuses ceased on campus offerings?
    Response. Please see the excel spreadsheet for Dream Center 
Education Holdings (DCEH) student count by school at the time of the 
July 2018 reports that DCEH would stop enrolling students at 30 
campuses and shut down those locations. Additionally, VA determined 
that 20 Chapter 33 education beneficiaries have transferred to online-
only training.

 
------------------------------------------------------------------------
                                                              Distinct
                       Facility Name                           Student
                                                                Count
------------------------------------------------------------------------
ARGOSY UNIVERSITY.........................................         1
Argosy University Atlanta.................................         2
Argosy University San Francisco Bay Area--Alameda CA......         9
Argosy University--American Samoa.........................         5
ARGOSY UNIVERSITY--CHICAGO................................         1
ARGOSY UNIVERSITY--DENVER.................................         9
Argosy University--Honolulu HI............................        24
ARGOSY UNIVERSITY--INLAND EMPIRE..........................        20
Argosy University--Los Angeles CA.........................         7
ARGOSY UNIVERSITY--NASHVILLE..............................        11
Argosy University--Organe CA..............................         8
ARGOSY UNIVERSITY--SAN DIEGO..............................        17
ARGOSY UNIVERSITY--SARASOTA...............................         1
Argosy University--Tampa FL...............................        14
ARGOSY UNIVERSITY--TWIN CITIES............................         2
The Art Inst of Atlanta...................................         3
The Art Inst of Austin....................................        25
The Art Inst of California San Diego......................        15
The Art Inst of Dallas....................................        24
The Art Inst of Houston...................................        12
The Art Inst of Pittsburgh................................         1
The Art Inst of Pittsburgh Online.........................        20
The Art Inst of Virginia Beach............................         6
The Art Inst San Antonio..................................        28
The Art Inst Tampa........................................         5
THE ART INSTITUTE OF CALIFORNIA--INLAND EMPIRE--A CAMPUS           4
 OF ARGOSY UNIV...........................................
THE ART INSTITUTE OF LAS VEGAS............................         9
THE ART INSTITUTE OF SEATTLE..............................        17
                                                           -------------
    Distinct Grand Total..................................       298
------------------------------------------------------------------------


    Question 6b. What communication did VA have with Post-9/11 GI Bill 
recipients enrolled in DCEH schools after the July 2018 reports of 
campus closures?
    Response. VA did not provide any specific communications for DCEH's 
announcement in July 2018 that it would be closing some of its campuses 
as part of strategy to reduce its physical footprint. DCEH announced 
that it was suspending the enrollment of new students, and existing 
students were allowed to complete their classes, switch to another 
campus, or continue pursuing their programs online. This was a 
different scenario than the abrupt, mid-term closure in March 2019 
which also included the online campuses of Argosy University and the 
Art Institutes.

    Question 6c. How many Post-9/11 GI Bill recipients were enrolled at 
Argosy University and Art Institutes campuses that closed on March 8, 
2019? Please provide the GI Bill enrollment data for each campus.
    Response. VA's official count stands at 1,782 students who were 
using Post-9/11 GI Bill benefits, after a review of all received 
enrollment certifications from the associated schools. Please see 
accompanying pdf document with enrollment data for each campus.

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Question 6d. When and how did VA notify GI Bill recipients about 
the closure for each DCEH campuses?
    Response. VA informed GI Bill beneficiaries of actions taken by the 
Department of Education on three occasions through email and social 
media accounts (Facebook):

     March 1--Notified students of Department of Education's 
termination letter of Title IV funding to Argosy University (Facebook 
posted on February 28).
     March 8--Notified students of Dream Center Education 
Holdings motion with the court requesting permission for emergency sale 
or closure of its Argosy and Art Institute campuses on March 8.
     March 13--Notified beneficiaries of the closure of 25 
Dream Center Education Holdings campuses and that VA was coordinating 
with the various State Approving Agencies (SAA) and gathering the 
specific details surrounding the closures. Also, informed students VA 
would contact current students attending institutions that closed 
advising them of their options and the possibility of having benefits 
restored within 5 days of official notification from its SAA partners.
    The GI Bill restoration team completed all 5-day closure 
notification letters by March 21, 2019.

    Question 6e. Describe the steps VA has taken to identify and assist 
Post-9/11 GI Bill recipients affected by the DCEH closures.
    Response. VA reviewed its enrollment and payment records to 
identify students who were attending one of the impacted schools during 
the month of March 2019. They were then notified on three occasions 
through email and social media accounts. VA's notifications contained 
links to potential resources that could be of assistance to impacted 
students as shown below. Below, we have included copies of the original 
and updated notification letter being used as of May 20, 2019.

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Question 6f. How much VA funding did each DCEH campus (including 
those that have no yet closed) received in the past five academic 
years?
    Response. Please see the excel spreadsheet below for DCEH school 
payments for chapter 33 benefits as of April 12, 2019. Please note the 
information provided is by fiscal year and not academic year.

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Question 6g. Describe how VA coordinated with SAAs, the U.S. 
Department of Education, or the DCEH to inform GI Bill recipients of 
their transfer and/or discharge options.
    Response. VA informed GI Bill beneficiaries of actions taken by the 
Department of Education and DCEH on three occasions through email and 
social media accounts. The GI Bill Restoration Team has reached out to 
impacted individuals by letter to notify them and provide information 
on their options moving forward.
    Additionally, VA coordinated with SAAs by supplying all relevant 
information received from the accreditor, the Department of Education, 
and the school itself within three business days of receipt.

    Question 7. In November 2016, the Consumer Financial Protection 
Bureau (CFPB) issued ``A snapshot of servicemember complaints'' noting 
that veterans had reported ``being targeted with aggressive 
solicitations by lenders to refinance'' their home loan using a 
Department of Veterans Affairs (VA) product. Veterans also reported 
that solicitations were ``potentially misleading.'' One year later, the 
CFPB and VA issued a joint Warning Order about aggressive and 
potentially misleading advertising of VA home loan refinances.
    Most recently, the VA published an advanced notice of proposed 
rulemaking (ANPR) and a subsequent interim final rule on cash-out 
refinances on VA loans, in compliance with Section 309 of Public Law 
115-174, the Economic Growth, Regulatory Relief, and Consumer 
Protection Act. Both documents indicated that potential lender abuses 
remain a substantial problem. That ANPR stated that ``perhaps more than 
50 percent of [VA] cash-out refinances remain vulnerable to predatory 
terms and conditions'' and that ``some lenders are pressuring veterans 
to increase artificially their home loan amounts when refinancing, 
without regard to the long-term costs to the veteran and without 
adequately advising the veteran of the veteran's loss of home equity.''

    Question 7a. What tools does VA currently have to ensure that all 
VA lenders are in compliance with VA regulations and policies?
    Response. VA conducts post audits of closed loans to ensure that 
lenders comply with regulations and policies. VA's loan system 
automatically identifies and selects loans to review based on specific 
selection criteria and/or on a random sample basis. If a loan goes into 
default within the first 6 months after loan closing, VA reviews 100 
percent of these cases to ensure that the lender followed VA policies 
and procedures. VA field staff can also request loans to review from 
lenders if there is an identified issue to examine based on data or 
findings from previous loan reviews. VACO staff also analyze program 
data for anomalies to identify which lenders to review to ensure 
compliance with program requirements.
    Additionally, VA conducts onsite operational audits of lenders to 
test compliance with applicable laws, regulations, policies, and 
procedures that have direct material impact on the VA home loan 
benefit. These operational audits consist of: Quality Control of loan 
underwriting and closing; the Lender Appraisal Processing Program; 
Early Claims Loans; and Declined Loan reviews.

    Question 7b. Does the VA have the oversight and enforcement 
authorities and resources it needs to hold lenders accountable and 
ensure that veteran homeowners aren't subject to predatory refinances?
    Response. VA's oversight and enforcement authority are limited. For 
example, 38 United States Code (U.S.C.) Sec. 3702 provides that certain 
lenders have authority to close loans on an automatic basis. It also 
provides that VA may, with 30-days' notice, require such lenders to 
begin submitting their loan packages for prior approval. The authority 
does not, however, expressly provide VA's authority to establish 
consequences, such as suspension from the program, for lenders, 
holders, or servicers who engage in predatory lending practices or 
dubious marketing practices.
    Section 3710(g) provides a framework for establishing civil 
penalties against lenders who violate VA's underwriting rules and loan 
processing standards. Yet the authority is not necessarily broad enough 
to include conduct that falls outside the analysis of individual loan 
packages. By taking an expansive approach to address ``novel lending 
products'' and misleading solicitations, VA is at risk of facing legal 
challenges that could easily be avoided with additional statutory 
clarification. Another example is 38 U.S.C. Sec. 3703(c)(1), a 
provision on which VA relies heavily to regulate the guaranteed loan 
program. This provision requires that VA-guaranteed loans be payable 
upon such terms and conditions as may be agreed upon by the parties 
(i.e., the Veteran and the lender), subject to the provisions of 
chapter 37 of title 38, U.S.C., and regulations issued by the 
Secretary. Although the provision can be given a broad interpretation, 
VA believes that more affirmative authority to promulgate rules could 
be extremely helpful when facing litigation challenges.
    Please note that most lenders and loan servicers complete VA 
mortgage transactions in a responsible manner and VA does not want to 
impede benefits delivery to Veterans. VA generally guarantees 25 
percent of the loan to help entice lenders to offer Veterans favorable 
loan terms (including a no down-payment mortgage and low interest 
rates), as part of Veterans' earned benefit entitlement. VA relies on 
private sector lenders to provide the earned benefit to Veterans 
through delegated authority and want to ensure that Veterans can 
continue to enjoy access to mortgage credit, while also holding 
unscrupulous lenders and servicers accountable.

    Question 8. In April 2017, VA issued guidance for affordable loan 
modifications for VA-guaranteed loans in Circular 26-17-10. The 
guidance in this circular replaced options available under the VA Home 
Affordable Modification Program with the VA Affordable Modification 
Program (VAAM). But the circular also rescinded the guidance effective 
April 1, 2019, and, to date, VA has not issued an updated circular 
regarding the rescission date, putting affordable modifications for 
veterans at risk.
    Other Federal mortgage insuring and guaranteeing agencies have 
adopted similar loan modification programs that have been or are 
proposed to be made permanent. The Federal Housing Administration has 
created a permanent FHA Home Affordable Modification Program (FHA-HAMP) 
to provide affordable modifications, while the United States Department 
of Agriculture (USDA) has proposed a new modification program for 
single-family loans.

    Question 8a. Does VA intend to continue VAAM on a temporary or 
permanent basis? If not, why not?
    Response. Circular 26-17-10 will expire, but the VA Affordable 
Modification (VAAM) will continue as is. VA will continue VAAM on a 
permanent basis. VAAM has now been included as a loss mitigation option 
in the VA Servicer's Handbook (VA Manual 26-4, Chapter 5: https://
www.benefits.va.gov/WARMS/M26-4.asp).

    Question 8b. If VA does not intend to renew VAAM, will VA create a 
new modification program to prevent avoidable and costly foreclosures?
    Response. Please see response to question 8a.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal 
                 to U.S. Department of Veterans Affairs
    Question 1. In December 2018, the OIG published an audit to 
determine if VA and State Approving Agencies (SAAs) were effective in 
their review of education programs where Post-9/11 GI Bill 
beneficiaries were enrolled.

    Question 1a. What actions has VBA taken, in coordination with the 
SAAs, to implement the OIG's recommendations?
    Response. VA implemented a workgroup consisting of VA and SAA 
staff. The workgroup has met in-person and by teleconference numerous 
times to develop draft recommendations that will allow for 
implementation of the recommendations. VA worked closely with SAAs and 
schools to ensure Recommendation 3 was remedied, and it has been 
closed.

    Question 1b. Please provide an update on the status of 
implementation of each of the OIG's recommendations
    Response. Please see the attached most recent VBA update memo.

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    Question 2. Do you agree that VBA has an administrative and 
financial responsibility to protect students' and taxpayers' interests 
by monitoring the SAA's performance effectively?
    Response. Yes, VA agrees it has an administrative and financial 
responsibility to protect students' and taxpayers' interests by 
monitoring the SAA's performance effectively. Additionally, VA has a 
statutory responsibility, per 38 U.S.C. Sec. 3674A to monitor SAA 
performance. VA does so by ensuring the terms of the annual cooperative 
agreement are met through review of SAA approval packages, compliance 
survey findings, and other deliverables. Once reviewed, VA will assign 
an annual rating and ensure that any deficiencies are mitigated. If 
deficiencies are not adequately addressed, VA may decide not to enter 
into a future agreement with the SAA to perform the work outlined in 
chapter 36 of title 38, U.S.C.

    Question 3. What steps has VBA taken to improve their quality 
reviews of SAA program and modification approvals, as well as their 
evaluation of SAA decisions regarding a programs' eligibility and 
compliance with Federal laws?
    Response. VA formed a workgroup consisting of VA and SAA staff that 
is drafting recommendations to ensure that quality reviews are 
performed on program approvals and compliance surveys. The compliance 
survey quality reviews are set to begin this month (April 2019). 
Additionally, VA is reviewing approval data to develop requirements of 
the documentation that SAAs will need to provide VA to substantiate 
that all approval requirements are met. This will be negotiated for 
inclusion in the FY 2020 SAA/VA agreement.

    Question 4. What changes has VBA made to its compliance survey 
process since December 2018 to ensure programs are meeting the 
conditions necessary for approval?
    Response. VA is in the final stages of revising compliance surveys 
to strengthen and improve assessment of program approval requirements. 
The revisions cannot be fully implemented until modifications to the 
VA/SAA cooperative agreement are negotiated. The target date for 
completion is October 1, 2019.

    Question 5. Does the VA's budget request for FY 2020 account for 
improving VBA's oversight of SAA reviews of Post-9/11 GI Bill benefits?
    Response. VA is working to improve and increase oversight of SAAs 
utilizing existing resources in the FY 2020 budget.

    Question 6. Has VA awarded a Software Development and System 
Integration (SISD) contract?
    Response. VA is committed to implementing sections 107 and 501 of 
the Colmery Act by December 2019. To that end, VA awarded a Software 
Development and Systems Integration contract to Accenture Federal 
Services (AFS) February 15, 2019. AFS will be responsible for 
delivering a complete IT solution to support sections 107 and 501.

    Question 7. How can you ensure that IT modernization efforts in 
Education Services won't be sidelined by other IT projects, such as the 
Electronic Health Records Modernization?
    Response. Modernization of Education Services efforts have their 
own dedicated resources and funding. IT architecture of Education 
systems is segmented and separate from the other IT efforts to minimize 
impact by other IT priorities. The efforts supporting modernization of 
Education IT solutions have regular and direct engagement with OIT 
senior leadership to ensure any conflicts are resolved.

    Question 8. Is it correct to assume that all veterans who were 
underpaid have now been reimbursed? If not, about how many veterans are 
awaiting reimbursement?
    Response. On December 8, 2018, VA installed the 2018 uncapped 
monthly housing allowance rates. All impacted students were updated to 
the correct MHA rate and if underpaid received a payment for the 
difference. Veterans who were overpaid were not held liable for any 
debts. Until the IT solution is in place on December 1, 2019, VA will 
pay students the current year uncapped rate. Upon implementation the IT 
solution will allow schools to accurately report all campus locations s 
where their students are attending the majority of their classes, so VA 
can process housing payments in accordance with sections 107 and 501

    Question 9. Is VA on track to meet the May 31, 2019 deadline?
    Response. VA is on track to meet the December 2019 deadline set by 
the Secretary in his November 29, 2018, announcement resetting the 
implementation of sections 107 and 501 of the Colmery Act.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to 
                  U.S. Department of Veterans Affairs
    Question 1. The Maui Minor Replacement CBOC project has been in 
progress for several years. The State Department of Education has 
offered land for the project and the Department of Veterans Affairs 
(VA) Central Office approved the land. My office was notified that a 
Memorandum of Understanding (MOU) would be executed in the second 
quarter of Fiscal Year 2019.

    Question 1a. Has this MOU been completed?
    Response. The draft Memorandum of Agreement (MOA) between the 
Veterans Affairs Pacific Island Health Care System (VAPIHCS) and the 
State of Hawaii Department of Education (HIDOE) was drafted and 
published for review by each of these agencies on August 30, 2018. 
There have been several reviews with key staff at various levels and 
with corporation consuls requesting clarifying points of interests that 
have been responded to over the course of the last 7 months. In the 
last month, HIDOE completed a final review with the State Attorney 
General's office in preparation for the final MOA sign off and to 
present to the State Board of Land and Natural Resources to consummate 
the property extended land lease.

    Question 1b. If not, can you please explain the delay?
    Response. Part of this delay can be attributed to the fact that 
this extended property land lease between the State and VAPIHCS is 
precedent setting. Dubbed ``the Maui Doctrine,'' Federal funds and 
ultimately a permanent Federal facility will be designed, planned, 
constructed, and operated on State land and not Federal or purchased 
land owned by VAPIHCS. Legal sufficiency has been provided by VACO 
along with the State of Hawaii's respective legal counsels since both 
Federal (Maui Community Outpatient Clinic and Maui Vets Center) and 
state entities (Maui Office of Veterans Services) will be operating 
under the same roof. This MOA sets forth a structure in which both 
parties will work in a mutually beneficial manner to advance an 
educational and academic program with the purpose of providing 
voluntary internships and training primarily in health care disciplines 
to students at Maui High School. HIDOE, Maui High School, and VAPIHCS 
will have a shared responsibility for the academic enterprise.

    Question 2. Compared to their nonveteran peers, women veterans have 
a higher rate of suicide than men. This difference in suicide rates 
suggests that strategies for preventing suicide among women veterans 
need to include consideration of gender-based risk factors.

    Question 2a. Do you think that VA's suicide prevention and mental 
health efforts are adequately tailored to reach and treat women 
veterans?
    Response. VA recognizes the urgent need to address the increasing 
rates of suicide among women Veterans and is committed to ensuring that 
appropriate services are available to meet the treatment needs of women 
Veterans who may be at risk for suicide. The Office of Mental Health 
and Suicide Prevention (OMHSP) has focused on developing trainings in 
gender-sensitive mental health approaches and implemented multiple 
initiatives to bolster mental health services for women Veterans, 
including those at risk for suicide.
    Examples of innovative clinical training initiatives:

     The Women's Mental Health Mini-Residency is a 3-day 
training that covers a broad range of topics related to the treatment 
of women Veterans, such as understanding suicide risks in female 
patients and working with women whose mental health problems are 
influenced by hormonal changes.
     The STAIR (Skills Training in Affective and Interpersonal 
Regulation) training teaches clinicians to deliver a trauma treatment 
that focuses on strengthening emotion regulation and relationship 
skills. These areas of functioning are often disrupted in women who 
have experienced severe interpersonal traumas, such as sexual assault. 
Research suggests that emotion dysregulation is associated with 
suicidal ideation and behaviors.
     Parenting STAIR training teaches therapists to deliver a 
component of the STAIR treatment that is designed to help Veterans who 
have persistent trauma-related reactions that negatively impact their 
parenting and parent-child relationships.
     The Multidisciplinary Eating Disorder Treatment Team 
training aligns with the Joint Commission's rigorous standards for the 
outpatient treatment of eating disorders. Eating disorders are 
associated with increased risk for suicide attempts and death by 
suicide.
     The National Women's Mental Health Monthly Teleconference 
Series is a monthly clinical training designed to enhance knowledge of 
gender-tailored treatment approaches, including prescribing practices. 
Physiological changes across women's reproductive lifecycles can affect 
her mental health and suicide risk. For example, women who have 
premenstrual dysphoric disorder (PMDD) have a greater likelihood of 
having suicidal thoughts, plans, and attempts. Treating PMDD is 
different than treating depression. Only some antidepressants are 
effective for PMDD, and dosing only during the luteal phase (2nd half, 
after ovulation) of the menstrual cycle is effective. Proper 
recognition, diagnosis, and treatment of PMDD can substantially reduce 
suicide risk for this subset of women Veterans.

    Examples of clinical programs and resources to enhance services for 
women Veterans:

     Studies have shown links between MST (Military Sexual 
Trauma) and suicidal ideation, suicide attempts, and death by suicide. 
VA's universal screening program, in which every Veteran seen for 
health care is asked about experiences of MST, is an important way of 
identifying individuals potentially at increased risk for suicide. VA's 
specialized MST-related services are key means of preventing suicide 
among at-risk women Veterans who have experienced MST.
     VA offers a continuum of care and a national network of 
Women's Mental Health Champions who disseminate information, facilitate 
consultations, and develop local resources.
     Specialty care programs target problems such as PTSD, 
substance use, depression, and MST--each of which has been associated 
with heightened suicide risk. Evidence-based therapies for conditions 
such as PTSD, including Prolonged Exposure and Cognitive Processing 
Therapy, have been shown to decrease suicidal ideation and are 
available at every VAMC.
     Additional VA suicide prevention and mental health 
resources for women Veterans include 24/7/365 immediate crisis 
intervention and support through the Veterans Crisis Line and Suicide 
Prevention Coordinators located at every VA facility and large 
community-based outpatient clinics.

    Question 2b. Are you at all concerned the reported harassment and a 
sexist culture at VA is indirectly contributing to the elevated suicide 
risk by discouraging women veterans from seeking care?
    Response. VA strives to create an environment in which all Veterans 
feel welcome and safe. VA also recognizes that harassment and sexism 
occur and can be disruptive to Veterans' access to care and overall 
patient experience.
    As VA continues to promote respect for women Veterans, it has 
expanded efforts to address forms of harassment, including sexual 
harassment (e.g., lewd comments or gestures) and gender harassment 
(e.g., sexist remarks, being dismissive of a woman's military service). 
VA launched an End Harassment program at every medical center in the 
summer of 2017. This large-scale effort is designed to increased 
awareness, disseminate education, improve reporting, and promote a 
culture of accountability throughout VA. As part of this campaign, VA 
have launched messaging such as ``it's not a compliment, it's 
harassment'' directed primarily at educating male Veterans that these 
actions are harmful and unacceptable. Employees have received training 
to increase sensitivity to this issue and to ensure that any VA 
employee who witnesses harassment knows how to effectively intervene 
and respond. Culture change efforts continue as VA develops updated 
resources, training, and associated messaging.
    VA also continues to develop initiatives and strategies to 
facilitate women Veterans' access to gender-sensitive mental health 
care. Resources are now in place to improve women Veterans' ease and 
comfort navigating the health care system, and confidence in the 
competency of VA providers to address their specific needs. For 
example, VA has recently established a national infrastructure of 
Women's Mental Health Champions who serve as a local point of contact 
for Women's Mental Health within each VA health care system. Champions 
disseminate information, facilitate consultations, and develop local 
resources in support of gender-sensitive mental health care. Every VA 
health care system also has a designated MST Coordinator who serves as 
the local point person for MST-related issues. Additionally, as 
detailed in response to Question 2a, extensive clinical training 
initiatives are in place to ensure that VA mental health providers have 
the expertise and specific competencies to address women Veterans' 
treatment needs.

    Question 3. VA's Medical and Prosthetic Research helps improve 
veterans' health care by focusing on veteran-unique conditions. This 
research is especially vital to understand new and emerging issues and 
to assess how to care for a diversifying veteran population. Due to 
inflation, funding for VA research would need to be increased by $22 
million over the 2019 baseline just to maintain current research 
levels. However, instead of investing in VA's research capacity, the 
President's Budget proposes a $17 million decrease in funding.

    What areas of research is VA going to scale back to accommodate 
this decrease in funding? Please provide a justification for those 
decisions.
    Response. The FY 2019 appropriation included a one-time addition of 
$27 million for collaboration with DOE on a big data science initiative 
and high capability computing. The $27 million provided for the DOE 
collaboration was provided to cover a 5-year period of availability 
through FY 2023. The remainder of the request for research in FY 2019 
was $752 million (total $779 million). For FY 2020, VA requests to grow 
support for all other initiatives from $752 million to $762 million. 
That $10 million growth represents an overall program growth of 2 
percent.

    Question 4. Over three weeks ago I signed a letter with twelve of 
my colleagues to the Department of Education regarding the sudden 
closure of Argosy University that has affected an estimated 18,000 
students nationwide--including 800 students in Hawaii, some of whom are 
veterans. In the letter we urged the Department of Education to work 
with the VA ``to ensure that accurate information is being provided to 
GI Bill beneficiaries regarding students' remaining benefits, including 
housing, and their options to have their benefits restored'' before the 
school closed.

    Question 4a. In the wake of Argosy's collapse, has the Department 
of Education taken any steps to coordinate with the VA on this issue?
    Response. The Department of Education has coordinated with VA on 
its actions via teleconference, as well as updates to its Federal 
Student Aid (FSA) Web site located here: https://studentaid.ed.gov/sa/
about/announcements/dream-center#motion-for-closure.

    Question 4b. If so, then can you elaborate on how the Departments 
have coordinated?
    Response. VA was invited to multiple teleconferences and received 
numerous emails outlining the steps that the Department of Education 
has and is taking regarding Argosy University. VA has taken steps to 
inform students via social media and through the GI Bill Comparison 
Tool as new information has been shared.

    Question 4c. If not, how does VA plan to make sure that student 
veterans affected by Argosy's closure in Hawaii and elsewhere have the 
resources they need?
    Response. As stated in the previous responses, VA is working 
closely with the Department of Education to provide information and 
assistance to GI Bill beneficiaries. In addition, the 5-day letter that 
VA sent to students upon notice that an institution has closed also 
provides contact information and resources.

    Question 5. Generally speaking what resources does the VA make 
available for student veterans affected by school closures?
    Response. VA has the authority, provided by section 109 of the 
Harry W. Colmery Veterans Educational Assistance Act of 2017, to 
restore entitlement to qualifying beneficiaries. The specific details 
and process for entitlement restoration due to school closures can be 
found online at https://www.benefits.va.gov/gibill/fgib/
restoration.asp.
    VA provides the following information in its letters to students:

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    Question 6. I have received information that the VA has updated its 
online tools and resources and notified student veterans who were 
affected.

    Question 6a. Can you provide further information about what steps 
the Department has taken?
    Response. VA has ensured restoration information on the GI Bill Web 
site was up to date: https://www.benefits.va.gov/gibill/fgib/
restoration.asp. Additionally, VA posted announcements and regular 
updates to the GI Bill Web site--https://www.benefits.va.gov/GIBILL/
news.asp--and the GI Bill Facebook page--https://www.facebook.com/
gibillEducation/.

    Question 7. I have also received information that the VA has 
identified 716 GI Bill beneficiaries who were attending schools that 
closed.

    Question 7a. Is this number still accurate, or have more 
beneficiaries been identified?
    Response. The identification of ``716 students'' corresponds to the 
Department of Education's notification revoking Argosy University's 
approval for Federal Student Aid, on February 27, 2019, and that number 
did not include VA students enrolled at the Art Institute campuses that 
also subsequently closed. The number of impacted students identified 
following the closure of the Argosy University and Art Institute 
campuses, on March 8, 2019, is 1,782, which includes the 716 
individuals identified previously.

    Question 7b. If more have been identified, which campuses did they 
attend and in which states?
    Response. As indicated in our previous response, 1,782 students 
were identified after the schools closed. Please see accompanying pdf 
document below for campus and state information.

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    Question 8. I have received information that the VA has been 
coordinating with state approving agencies. What kind of coordination, 
if any, has there been with the state approving agency in Hawaii?
    Response. VA does not have a signed cooperative agreement with the 
state of Hawaii and, therefore, VA is acting as the SAA for that state. 
VA has taken withdrawal actions as necessary for the state of Hawaii 
and Veterans in that state have been provided all relevant information.

    Question 9. Last Congress this Committee worked to pass the Forever 
GI Bill, which expanded access to educational opportunities for student 
veterans, servicemembers, families, and survivors, and changed how 
housing allowances are calculated for these students. However, we have 
seen challenges to implementation, which have resulted in students 
receiving inaccurate or delayed payments. The Department's Inspector 
General recently concluded that even as VA missed implementation 
deadlines there was no accountable official overseeing these changes.

    Question 9a. Since these challenges have been identified, what 
steps has the VA taken to notify students who were affected, and what 
resources has VA provided for these students?
    Response. Immediately following the Secretary's November 2018 
announcement on resetting implementation, VA notified schools, Veterans 
Service Organizations, and other stakeholders on its efforts moving 
forward. This included an email notification to almost one million GI 
Bill beneficiaries on November 28, 2018 and December 4, 2018 and 
multiple social media posts. VA also held seven online webinars for 
Veterans throughout December 2018 and January 2019 to provide 
additional details and resources.

    Question 9b. What more does VA plan to do to address this issue for 
students going forward?
    Response. VA will continue to regularly update students through 
social media, targeted email notifications, and webinars regarding the 
implementation of sections 107 and 501. In April 2019, VA began to host 
a series of Roundtable Discussions with schools and stakeholders on 
implementation and will follow these sessions with updates on its Web 
site and social media.

    Question 10. The VA Office of Health Equity was established in 2012 
to advance health equity and reduce health disparities for 
disadvantaged veterans. Part of the goal when establishing the office 
was to conceptualize and release a blueprint for achieving these ends, 
which it did with the March 2016 release of the VHA Health Equity 
Action Plan (HEAP).

    Question 10a. Since the introduction of HEAP, has the VA achieved 
any of the deliverables outlined in the plan?
    Response. The HEAP describes many activities that the Office of 
Health Equity should do on an ongoing basis and a few activities that 
have discrete deliverables. In general, the Office of Health Equity is 
involved with most of the indicated ongoing activities and has produced 
many of the specific deliverables.

    Question 10b. If so, which?
    Response. The HEAP is organized around 5 focus areas: Awareness, 
Leadership, Health system and life experience, Cultural and linguistic 
competency, and Data, research, and evaluation.
    Awareness: As planned in the HEAP, the Office of Health Equity 
leads a Health Equity Coalition, has developed many partnerships for 
implementing the HEAP, and presents data on disparities (monthly fact 
sheets and quarterly cyber seminars). Specific goals to develop a 
communication plan and initiate 5 partnerships and 2 projects have been 
completed.
    Leadership: As planned in the HEAP, the Office of Health Equity 
reviews all VHA policies and directives, promotes a culture of dialog 
about equity, coordinates resources to support the HEAP, and directly 
funds health equity projects. Specific goals to include Health Equity 
Coalition members on the National Leadership Council and support VAMCs 
to participate in Health Equity Impact assessments have been achieved.
    Health system and life experience: As planned in the HEAP, the 
Office of Health Equity tracks many measures of access and quality, 
identifies disparities, supports interventions to reduce disparities, 
and promotes understanding of Veterans' life experiences, 
decisionmaking, and social determinants of health. Specific goals to 
report on and disseminate findings on disparities have been completed.
    Cultural and linguistic competency: As planned in the HEAP, the 
Office of Health Equity shares information and supports training on 
cultural competency, unconscious bias, and Culturally and 
Linguistically Appropriate Services (CLAS). Specific goals to support 
rollout of the VA Talent Management System's Cultural Competency Module 
and Clinical Look at Unconscious Bias training have been completed.
    Data, research, and evaluation: As planned in the HEAP, the Office 
of Health Equity monitors and tracks disparities, fills information 
gaps on disparities, promotes data sharing, and develops tools and 
dashboards to increase equity. Specific goals to develop standards for 
disparities reporting and to report on disparities among Veterans have 
been achieved in the first National Veteran Health Equity Report.

    Question 11. The majority of the deliverables in HEAP rely on an 
understanding of what populations are experiencing disparities, yet the 
most recently available data outlining race/ethnicity, gender, age, 
geography, and mental health status among veterans receiving care is 
from 2013.
    Response. The 2013 data are the most recent VHA data that the 
Office of Health Equity has reported to the public. Within VHA, working 
with VHA Central Office, VISN, and VAMC partners to reduce disparities, 
much more recent data are used. A second National Veteran Health Equity 
Report is planned for release in 2019 and will report on 2017 data.

    Question 11a. How does the Department intend to address disparities 
in health care provision and outcomes without understanding what 
disparities actually exist?
    Response. Identifying disparities in health care provision and 
outcomes is at the core of efficient quality improvement. The Office of 
Health Equity is working with VHA Central Office, VISN, and VAMC 
partners to develop an Equity Guided Improvement Strategy (EGIS) that 
identifies measures and populations with the largest quality deficits 
and thereby allows facilities to target quality improvement toward 
these specific Veteran groups with specific conditions. EGIS also 
allows the application of optimal interventions for these specific 
Veteran groups with specific conditions.

    Question 11b. Do you believe that the Office of Health Equity can 
credibly fulfill their mission without updated, relevant data?
    Response. Yes, the Office of Health Equity is fulfilling its 
mission because we currently have access to updated, relevant data that 
allows identification of disparities in health care processes and 
outcomes for many Veteran groups. For some Veteran groups, such as 
Lesbian, Gay, Bisexual and Transgender (LGBT) and disabled Veterans, 
systematic identification is limited in VHA data. The Office of Health 
Equity is involved in activities to improve data on these groups 
through use of and data linkage with non-VHA data.

    Question 11c. If not, please provide a plan for updating the data.
    Response. As VHA modernizes to the new EHR system, the Office of 
Health Equity will work to ensure that data needed to identify 
disparities for different Veteran groups is available.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Joe Manchin III to 
                  U.S. Department of Veterans Affairs
    Question 1. Secretary Wilkie, in your testimony we discussed my 
concern with investment in infrastructure and construction projects, 
especially in rural States like West Virginia. I used the Rural Mobile 
Unit (RMU) in Clarksburg as an example. According to our recent RFI, a 
replacement RMU is the only true long term solution costing $600k.

    Question 1a. This RMU is the only VA facility for many of our rural 
Veterans. Will you make this RMU replacement a priority in your 2020 
budget?
    Response. The Office of Rural Health (ORH) does not currently have 
an enterprise wide funding program for Rural Mobile Units (RMU). ORH 
ceased funding RMUs in 2014 after VHA suspended mobile medical unit 
acquisitions in the wake of an unfavorable audit by the VA Office of 
the Inspector General (VAOIG-13-03213-152). Although the suspension has 
since been lifted, ORH's FY 2020 funding is completely committed to 
other programs. However, we will revisit the funding opportunities for 
RMUs in FY 2021.

    Question 2. I'm concerned that as we are investing in community 
care, we will leave rural facilities in WV behind.

    Question 2a. What are you doing to decrease the project backlog and 
making sure that our VA facilities in rural communities are not waiting 
in a never-ending list of projects?
    Response. In order to be fair, equitable, and transparent, VISN 5 
takes a multifaceted approach to the distribution of construction 
funding each fiscal year:

     High Cost High Tech (HCHT) equipment funding and 
procurement are often on rigid timelines. This equipment has a direct 
impact on patient care and access. As such, the HCHT equipment site 
prep projects are funded off the top of the VISN construction 
allocation.
     Each facility in VISN 5 submits business cases for their 
top five projects each fiscal year. Each facility then scores the other 
facility business cases against a list of criteria. This yields a 
prioritized list of all the VISN-5 projects submitted. Those projects 
that fall above the cumulative budget line get funded that fiscal year; 
the others are subject to the availability of funding. This process is 
transparent and gains the consensus of all the facilities.
     A portion of the overall construction appropriation is 
distributed to each facility for station level projects. The 
distribution is prorated, based on each facility's Facility Condition 
Assessment (FCA) backlog. Each facility determines how the station 
level funds are spent, based on locally identified priorities.

    Each facility in VISN 5 gets their HCHT site prep funded, each 
facility gets a fair shot at getting their top 5 projects funded, and 
each facility receives an allowance to spend at their discretion on 
local priorities.

    Question 3. As of today, there were 138 open positions posted on 
USAJOBS for the VA in West Virginia. Our CBOC in Petersburg especially 
is having a hard time recruiting and retaining staff.

    Question 3a. Do you have some type of vacancy action plan for rural 
communities who have a hard time competing with neighboring States?
    Response. VA implements targeted solution-driven approaches to 
increase the overall care to 2.8 million Veterans living in rural 
communities who rely on VA health care. VA remains fully engaged in a 
fiercely competitive clinical recruitment market and has employed a 
multi-faceted strategy to attract qualified candidates for rural 
facilities including the following:

     Expanding the ability of all clinicians to practice at the 
full extent of their licenses;
     Increased maximum physician salaries;
     Utilization of recruitment/relocation and retention (3R) 
incentives and the Education Debt Reduction Program (EDRP);
     Targeted Nation-wide recruitment advertising and 
marketing;
     Expanding opportunities for telemedicine providers;
     DOD/VA effort to recruit transitioning Servicemembers; and
     Exhibiting regularly at key health care conference and job 
fairs.

    Question 4. Mr. Secretary, you know that the opioid epidemic is my 
number one issue. The VHA in WV is treating over 1,300 Veterans for 
opioid use disorder I want assurances that when Veterans go outside of 
the VA under these new access standards, we have rock-solid agreements 
and oversight with non-VA care providers that ensures over-prescription 
of opioids will not occur. I know we have the formulary and other 
safeguards to prevent against abuse now.

    Are there ways that we can improve these safeguards and 
coordination given your commitment to increased access to care in the 
community?
    Response. Section 131 of the VA MISSION Act requires VA to ensure 
that all community providers are furnished a copy of and certify that 
they have reviewed the evidence-based guidelines for prescribing 
opioids set forth by VA's Opioid Safety Initiative. It further requires 
VA to implement a process to ensure that VA submits to community 
providers the available and relevant medical history of the Veteran and 
a list of all medications prescribed to the Veteran as known by VA. 
Community providers must submit medical records, including records of 
any opioid prescriptions to VA in the timeframe and format specified by 
VA. VA must report annually on the compliance of covered health care 
providers with the requirements of this section. If VA determines that 
the opioid prescribing practices of a community provider, when treating 
covered Veterans, meet certain conditions, VA must take appropriate 
action to ensure the safety of all Veterans receiving care from the 
provider. Finally, VA must ensure any network contracts include 
language authorizing the contractors to take similarly appropriate 
action. All Community care providers will follow the same opioid 
prescribing practices as VA providers.

    Question 5. With respect to the access standards and community 
care. My biggest concern is that the VA is not adequately preparing 
communities for these new access standards.

    Question 5a. What are you doing to investigate whether communities, 
especially rural communities like in my State, are prepared for more 
Veterans coming to them from the VA?
    Response. Providers joining the Community Care Network (CCN) are 
required to take training in the unique needs and cultural aspects of 
the Veteran population. Additionally, VHA works closely with CCN Third 
Party Administrators (TPA) to assist them in understanding the network 
adequacy requirements and how that applies to the Veteran population. 
Part of evaluating network adequacy includes factoring in an equitable 
allotment of Veteran patients into the community provider's practice. 
This is done through close collaboration with the TPA and utilizing 
both internal metrics as well as industry standard calculations.
    For both Primary Care and Mental Health there are many sites that 
are presently meeting wait time standards. These sites will be able to 
retain Veterans and not need to send them to the community for care. 
VA's goal is to achieve and sustain 100 percent in both categories.
    See data summary below.

 
------------------------------------------------------------------------
                                               % of sites with less than
                As of 4/23/19                  20 days avg. wait for new
                                                       patients
------------------------------------------------------------------------
MH..........................................             98.58%
PC..........................................             57.5%
------------------------------------------------------------------------

    VA continues to work to strengthen direct care delivery. The Office 
of Veterans Access to Care is partnering with several VHA program 
offices to lead the ICEP initiative. This includes facilities in rural 
sites. The main goals of ICEP are the following:

     Ensure accuracy of labor mapping, person class code, and 
Primary Care Management Module data;
     Ensure sustainment plan for maintaining continued accuracy 
for the data in sub-bullet one;
     Balance supply and demand by using present resources and 
full care teams more efficiently by maximizing individual providers 
capacity for direct patient care; and
     Partner with workforce development to hire additional 
staff where applicable.

    MISSION Act section 401 also helps to prepare facilities for access 
standards:

     Section 401 of the MISSION Act requires VA to identify and 
develop plans to address underserved facilities. Some of the facilities 
VA identified as underserved are rural facilities. In collaboration 
with VISN Directors, VA is developing a program leveraging system-wide 
resources to support improvement in facilities designated as 
underserved.
     Some of these resources particularly used in rural 
facilities include maximizing hiring incentives to attract and retain 
providers to these areas by offering the following:

          - Recruitment, Retention, and Relocation awards;
          - Education Debt Reduction Program offering student loan 
        reimbursement to employees with qualifying loans;
          - Compressed/flexible work schedules; and
          - Retirement waivers that offset the required salary offset 
        to reemploy retired staff members on a temporary basis.

     Difficulties hiring providers in rural areas are also 
addressed by the following:

          - Maximizing current resources and capacity;
          - Leveraging interagency relationships;
          - Using Mobile Medical Units;
          - Offering training opportunities such as the national 
        consultative program, academic detailing programs, as well as 
        continuing education opportunities and scholarship programs; 
        and
          - Using direct hiring authority.

     Additionally, many rural facilities identified as 
underserved leverage technology and telehealth strategies such as the 
following:

          - Increasing the use of VA Video Connect;
          - Establishing/expanding Clinical Resource Hubs;
          - Using Store and Forward Telehealth where clinical health 
        data is retrieved by a VA provider at another VA location for 
        clinical evaluation and follow up; and
          - Establishing/expanding ATLAS (Advancing Telehealth through 
        Local Access Stations).

    Additionally, VA is enhancing Same Day Primary Care and Mental 
Health services and leveraging virtual care modalities to provide 
Veterans convenience while increasing access. Proposed budgets in FY 
2020 and FY 2021 further support the Clinical Contact Centers for 
virtual care. Currently, nearly half of all VISNs have licensed 
independent practitioners, expanding access to care by addressing 
patient needs via telephone or video appointment. These services are 
especially useful for Veterans in rural communities.

    Question 5b. Will you be communicating to Veterans if you deem 
certain communities unprepared to accept Veterans as patients?
    Response. At the time of scheduling, if a community provider is 
unable to accept Veterans within the metrics defined by the CCN 
contract, the Veteran is given the opportunity to select another 
provider. The inability for a provider to accept a patient within the 
metrics negatively impacts the third-party administrator's (TPA) 
performance and is reflected in a percentage decrease in payment to the 
TPA. Network adequacy is monitored monthly to identify gaps. When gaps 
are identified, the TPA is required to submit a plan outlining how they 
intend to resolve the issue and bring the network into compliance.

    Question 6. I applaud the VA for investing in alternative pain 
management prevention programs, such as acupuncture, chiropractic 
services, Tai Chi, and Yoga. In West Virginia, these programs are 
growing in demand but don't seem to be widely implemented at all the 
VAMCs.

    Question 6a. What are your plans for growing these potentially 
life-saving programs so all Veterans have access to them?
    Response. As a preliminary point of clarification, we generally now 
use the terms ``complementary'' or ``integrative'' to describe this 
category of therapies rather than ``alternative.'' This is to make 
completely clear that we do not endorse using these therapies to the 
exclusion of evidence-based conventional approaches, but rather in 
addition to and in support of these.\1\
---------------------------------------------------------------------------
    \1\ For the same reason, the National Center for Complementary and 
Alternative Medicine at NIH has now changed its name to ``National 
Center for Complementary and Integrative Health.''
---------------------------------------------------------------------------
    VHA requires that all VA facilities have at least one evidence-
based psychological/behavioral therapy available at the facility as 
part of the integrated and interdisciplinary pain management teams at 
each facility. This mandate was established as part of VA's 
implementation of CARA. The teams also include access to physical 
medicine and rehabilitation providers and integrated access to 
assessment of opioid use disorder, if clinically indicated with access 
to providers skilled in addiction medicine who provide evidence-based 
treatment.
    Substantial progress has been made in building infrastructure to 
support increased access to Complementary and Integrative Health (CIH) 
services for Veterans with pain and other conditions. On May 19, 2017, 
VHA Directive 1137 ``Provision of Complementary and Integrative 
Health'' was approved, establishing internal policy regarding the 
provision of CIH approaches. The current list of approved CIH 
approaches covered by the Veterans Medical Benefits package includes 
acupuncture, meditation, yoga, tai chi/qi gong, biofeedback, hypnosis, 
guided imagery, and massage as covered benefits if appropriate as part 
of the Veterans care plan. Chiropractic care was previously approved 
for use at VA in 2004 so was not included in this list but its use 
across VA continues to increase. Chiropractic care has been shown to 
correlate with decreased opioid use in Veteran and general populations, 
and currently over 110 VA facilities operate on-station chiropractic 
clinics.
    The availability of CIH approaches in VA has also continued to grow 
as the infrastructure (including policy, qualifications standards, 
tracking/coding/billing mechanisms, position descriptions, etc.) has 
been developed to support the ability to deliver, manage, and track 
these services. Most notable is the recently approved qualification 
standard for massage therapists, which will allow licensed and 
certified massage therapists to be hired across VHA for the first time, 
and a qualification standard for licensed acupuncturist which was 
approved in February 2018 and which will greatly improve in-house 
delivery of acupuncture. In FY 2018 there were 181,961 total 
acupuncture encounters (a 20 percent increase from FY 2017) and 131,547 
unique Veterans receiving acupuncture (a 60 percent increase from FY 
2017) across the enterprise.
    In addition, VHA has trained over 2,400 battlefield acupuncture 
(BFA) providers and has 78 active BFA instructors. BFA is a limited 
acupuncture protocol applied just to the ears designed to relieve acute 
and chronic pain. Standards have also been developed for facilities to 
use in identifying staff properly trained to deliver each of the CIH 
approaches, and CIH Skills Training programs are being developed to 
increase capacity of VA staff to deliver these in the future.
    Additionally, CIH champions from facilities across the country have 
been identified and included on VISN Pain Management Committees to 
support inclusion of CIH approaches as a routine part of pain 
management. This group meets monthly with the Office of Patient 
Centered Care and Cultural Transformation/10NE (OPCC&CT) Integrative 
Health Coordinating Center to discuss VISN level best practices and 
concerns and to gain new information related to CIH to take back to 
their VISNs. The Integrative Health Coordinating Center is also working 
closely with VHA Office of Community Care to develop standards and 
protocols for the delivery of CIH services in the community where 
necessary.
    Section 933 of the CARA legislation requires demonstration projects 
on integrating the delivery of CIH services with other health care 
services provided by VA for Veterans with mental health conditions, 
chronic pain, and other chronic conditions. Rather than just adding 
these approaches into primary care, CIH approaches are delivered 
through a Whole Health System. This approach improves access and 
reduces the burden on primary care. Whole Health is an approach to 
health care that empowers and equips people to take charge of their 
health, well-being, and to live their life to the fullest, and is the 
primary delivery vehicle through which Veterans can access CIH 
services.
    The Whole Health System includes three components: 1) Empower: The 
Pathway--in partnership with peers, empowers Veterans to explore 
mission, aspiration, and purpose and begin personal health planning; 2) 
Equip: Well-being Programs equip Veterans with self-care tools, skill-
building, and support. Services may include proactive CIH approaches 
such as yoga, tai chi, or mindfulness; and 3) Treat: Whole Health 
Clinical Care--in VA, the community, or both, clinicians are trained in 
Whole Health and incorporate CIH approaches based on the Veteran's 
personalized health plan. VA staff has been working with Veterans 
around the country to bring elements of this Whole Health approach to 
life. In conjunction with the CARA legislation, VA began implementation 
of the full Whole Health System in 18 Flagship Facilities in the 
beginning of FY 2018, the first wave of facilities in the national 
deployment of Whole Health. Flagship facility implementation of the 
Whole Health System will proceed over a 3-year period (FY 2018-FY 2020) 
and is supported by a well-proven collaborative model which drives 
large scale organizational change.
    The Whole Health approach is well-integrated with the VA Opioid 
Safety Initiative (OSI) and the National Pain Program's Stepped Care 
Model, both of which emphasize redesigning pain care with a focus on 
non-pharmacological approaches, self-care, skill building, and support. 
Preliminary data shows a decrease in opioid prescription costs among 
Veterans with two or more Whole Health encounters; we continue to focus 
on the mitigation of opioid overuse as a priority goal for the Whole 
health initiative.
    An important delivery strategy is making Whole Health and CIH for 
pain and other conditions available via telehealth, and we have made 
significant progress in this area. In FY 2017, 770 Whole Health/CIH 
Encounters were offered to 160 unique Veterans at 9 VAMCs across VHA; 
In FY 2018, 4,354 Whole Health/CIH encounters have been offered to 
1,004 unique Veterans via Telehealth at approximately 26 VAMCs across 
VHA. We continue to see significant growth in utilization of Whole 
Health via telehealth in FY 2019 to date as well.
    In addition, the VA Whole Health Education Program provides 
education and skills-based practice on Whole Health and CIH approaches; 
to date over 20,000 VA staff have participated in one or more Whole 
Health education offerings. One example of the many educational 
opportunities is Whole Health for Pain and Suffering: this 2-day course 
teaches evidence-informed, safe, and effective non-pharmaceutical 
approaches to pain care. Participants learn how mind-body approaches 
and self-management can support coping and wellbeing for people with 
pain, including acupuncture, dietary supplements, and manual therapies. 
Clinician self-care, burnout prevention, and enhancing resilience are 
also emphasized. To date 1,274 VA staff have completed the Whole Health 
for Pain and Suffering course, with an additional 704 projected to 
attend through the end of FY 2019.
    Along with identifying the challenges and successes of CIH 
implementation at VA facilities, our research partners from VA HSR&D 
continue to examine many patient-reported health outcomes, clinical 
outcomes, and Veteran satisfaction measures in their comprehensive 
study of the flagship sites. We will be able to better understand the 
health outcomes as well as cost impact upon conclusion of their 
evaluation efforts. VA plans to continue to expand Veteran access to 
complementary and integrative approaches for pain through all our 
successful strategies to date, including infrastructure development, 
hiring of CIH providers, telehealth, community care coordination, 
education, and research.
    One specific example, in 2018, the Office of Patient Centered Care 
& Cultural Transformation adopted the Institute for Healthcare 
Improvement (IHI) Learning Collaborative model and launched the first 
Learning Collaborative for the 18 Whole Health flagship facilities to 
support the delivery and implementation of the Whole Health System. To 
further support national deployment, The Whole Health Learning 
Collaborative Two: Driving Cultural Transformation begins in the spring 
of 2019 and will support 36 more facilities in continuing to accelerate 
Whole Health delivery and innovation across VA. On March 12, 2019, 
guidance via the Office of the Deputy Under Secretary for Health for 
Operations and Management was distributed requesting that each VISN 
identify two additional sites to help further Whole Health deployment 
in their VISN. Teams from each of the participating sites will join 
three face-to-face meetings during the 18-month collaborative, as well 
as monthly calls and virtual meetings as part of this Learning 
Collaborative process.
    Telehealth modalities are continuing to grow to facilitate a 
smoother Provider and Veteran experience of Whole Health and CIH. The 
most recent innovation is the VA Video Connect modality which is 
popular among both group and one-on-one TeleWholeHealth encounters such 
as Tele-Coaching, Tele-Facilitated Groups, and TeleWholeHealth Clinical 
Care encounters. With this modality, Veterans can access their Health 
Coach or Provider from anywhere they have an internet connection. The 
provider and Veteran enter a virtual medical room where they can 
complete the encounter.
    We are also planning for continued growth in our education program, 
which is critical to expanding access to CIH services for pain. We have 
trained 60 VA clinical faculty across the country to date to teach the 
Whole Health curriculum as a means to scale implementation. This coming 
year, we will train an additional 40 field-based faculty to continue 
this expansion. In addition, we anticipate continued increase in the 
hiring of CIH providers across VA to provide pain treatment options. 
For example, we expect on-station chiropractic clinics at a minimum of 
50 percent of all VAMCs in each VISN by December 2021.
    VA is also committed to expanding its research efforts in the area 
of CIH and Whole Health for pain. In 2016, VA HSR&D held a state-of-
the-art Conference on non-pharmacological approaches to chronic pain. 
This conference convened VA researchers and clinical experts to 
identify which CIH and other non-pharmacological approaches had 
sufficient evidence to be provided across the system and which require 
further research. Based on the findings of this conference, the VA 
Office and Research and Development will continue to support research 
on the use of this type of approaches for the management of pain 
conditions.

    Question 6b. What other alternative pain-treatments do you think 
could be effective in preventing opioid addiction?
    Response. VA's approach to preventing opioid addiction in patients 
with chronic pain has been to promote safer, more effective pain care 
that minimizes reliance on opioid medication for treatment of both 
acute and chronic, non-end-of-life pain conditions. Instead, VA's 
approach relies on non-opioid pharmacological and non-pharmacological 
pain treatment modalities that have greater safety and long-term 
benefits than opioid pain medication.
    The VA/DOD Clinical Practice Guideline on Opioid Therapy for 
Chronic Pain, updated in 2017, makes the following recommendations to 
prevent opioid addiction for patients with chronic non-end-of-life 
pain:

     ``We recommend against initiation of long-term opioid 
therapy for chronic pain.
     We recommend alternatives to opioid therapy such as self-
management strategies and other non-pharmacological treatments.
     When pharmacologic therapies are used, we recommend non-
opioids over opioids.
     We recommend alternatives to opioids for mild-to-moderate 
acute pain.
     We suggest use of multimodal pain care including non-
opioid medications as indicated when opioids are used for acute pain.
     If take-home opioids are prescribed, we recommend that 
immediate-release opioids are used at the lowest effective dose with 
opioid therapy reassessment no later than 3-5 days to determine if 
adjustments or continuing opioid therapy is indicated.''

    The full clinical practice guideline is available at this Web site: 
https://www.healthquality.va.gov/guidelines/Pain/cot/.
    In November 2016, VA held a state-of-the-art conference titled 
``Non-Pharmacological Approaches to Chronic Musculoskeletal Pain 
Management'' to obtain expert consensus on evidence-based treatment 
modalities to guide policy recommendations. The attached summary report 
was published in the Journal of General Internal Medicine in 2018, by 
Kligler et al. Categorized under the three groups of psychological/
behavioral therapies, exercise/movement therapies, and manual 
therapies, the following recommendations were made to be implemented 
across the VHA system as part of pain care:

     Cognitive behavioral therapy;
     Acceptance and commitment therapy;
     Mindfulness-based stress reduction;
     Exercise therapy;
     Tai Chi;
     Yoga;
     Acupuncture;
     Manipulation; and
     Massage.

    The complementary and integrative health modalities are outlined 
above in the response to Question 6a. Regarding behavioral/
psychological therapies, VHA has rolled out a national treatment manual 
to administer cognitive behavioral therapy for chronic pain (CBT-CP) 
with 12 standardized session modules. This was then adapted to a brief 
CBT-CP protocol suitable for mental health providers embedded within 
Primary Care, with 30-minute sessions for 4-6 appointments.

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



    Question 7. How will the initiatives in the President's new 
Executive Order creating a roadmap for suicide prevention, issuing 
community grants, and increasing mental health research be funded?
    Response. Task Force roles and leads for the lines of effort 
(enabling support, state and local action to include grant structure, 
and the research strategy) and grant structure are in the process of 
being determined. Role determinations and associated kick-off meetings 
will occur in May 2019.

    Question 7a. We're all waiting on the FCC to issue a report on the 
feasibility of a 3-digit ``N11'' number from legislation we passed last 
year. Have you been given any update from the FCC on the status of 
creating a 3-digit suicide hotline number for Veterans?
    Response. Per the timeline included in the signed legislation, the 
Federal Communications Commission (FCC) has until August 2019 to submit 
the final report to Congress. This report will include responses by the 
Veterans Crisis Line (VCL), the Substance Abuse and Mental Health 
Services Administration (SAMHSA), and requested organizations such as 
the North American Numbering Council (NANC). VCL has submitted the 
original report to FCC on January 28, 2019, and the secondary NANC 
request on March 22, 2019. James Wright, VCL Chief of Staff, presented 
to NANC at FCC on March 28, 2019, to share a summary of both responses 
by VCL. Upon completion of the meeting, NANC requested additional 
information (3 points of interest) that VCL is currently completing. 
After receiving all requested information, NANC will submit their 
technical report to FCC for inclusion in the final report. The National 
Suicide Hotline Improvement Act of 2018 does not mandate the creation 
of a 3-digit code for Veterans or community services. The Act 
specifically calls for FCC to study the feasibility of designating a 3-
digit dialing code, including recommendations on the number, costs 
associated with designation, and logistics to include infrastructure 
and operation needs.

    Question 7b. How quickly can this be implemented?
    Response. VCL does not have information regarding the actual 
creation of a 3-digit code, as the legislation does not mandate that 
outcome. Depending on the FCC final report, recommendations will be 
included on potential impact of such a designation. Additional steps 
post report would need to be taken to move toward implementation if a 
3-digit code expansion was feasible, including expansion requirement 
with state vs. national guidelines, along with financial, marketing, 
training, and infrastructure needs.

    Question 8. The Vocational Rehabilitation and Employment (VR&E) 
program is a good news story that a lot of folks do not hear about 
often. A key focus of mine in the Senate has been working to reduce the 
Veterans unemployment rate has and the VR&E program is a big player in 
our successes. The latest VA data shows that from 2016 to 2018, the 
number of VRE participants fell from 173,000 to 164,000 a decrease of 
more than 5%.

    Question 8a. Given how important this program is to disabled 
Veterans, why are fewer using this service?
    Response. In 2018, Vocational Rehabilitation and Employment (VR&E) 
program participants achieved over 15,000 positive outcomes while 
participants decreased by 5 percent. VR&E Service attributes the 
decrease to due to a combination of the following factors:

     Applicants found eligible for the VR&E program are not 
reporting to their initial orientation and, therefore, not entering a 
plan of services; and
     The number of Veterans successfully exiting the program 
have increased each year (positive outcomes). Positive Outcomes were 
introduced as a performance measure fourth quarter FY 2015 (July 1, 
2015), and were fully implemented effective FY 2016 (October 1, 2015). 
Year-over-year results and increases are as follows:

 
------------------------------------------------------------------------
                                                Positive           %
                    FY                          Outcomes      
------------------------------------------------------------------------
2016......................................           14,351          NA
2017......................................           15,528      +8.20%
2018......................................           15,998      +3.03%
------------------------------------------------------------------------

    With the number of new plans remaining stagnant and despite the 
steady mix of eligible and entitled applicants, more Veterans are 
exiting the program than entering. However, VR&E continues to work on 
plans to hire to additional Vocational Rehabilitation Counselors (VRC) 
to reach a Veteran-to-Counselor ratio of 125 to 1 or below, implement a 
new case management system, and use other technological solutions to 
keep Veterans engaged throughout the lifecycle of their program 
participation (remote entitlement, VA Video Connect (tele-counseling), 
appointment reminders, etc.). These changes are expected to increase 
the number of participants. With the number of new plans remaining 
stagnant and despite the steady mix of eligible and entitled 
applicants, more Veterans are exiting the program than entering. VR&E 
is embarking on a multiyear modernization effort that will serve as the 
solution to improve participation of Veterans in the program. These 
efforts will address Veteran's understanding of the program through 
outreach and the administrative burden counselors have in the field.
    VR&E will expand outreach through social media, engagement with 
VSOs at conferences, expanding briefings at TAP, and through Vet 
Success on Campus Counselors at Institutes of Higher Learning. This 
will aid in decreasing the 66% of discontinuances the Service has due 
to Veteran's misunderstanding of what the VR&E program does. As for 
administrative burden, VR&E Service research discovered over 60 percent 
of a counselor's day is spent in administrative tasks and functions. 
Modernization initiatives such as the new case management system, an 
electronic virtual assistant that will provide 24/7 scheduling and 
administrative support to counselors and Veterans, and e-invoicing will 
dramatically decrease that administrative burden. This will increase 
the ability of counselors to have direct-facing veteran services and 
increased capability to follow up with Veteran clients. Those services 
are essential to Veterans persistently participating in the program.

    Question 8b. Have you instituted new policies or taken any actions 
that would have led to decreased usage?
    Response. No, VA's VR&E program has not instituted any new policies 
or taken any actions that would have led to decreased usage. To the 
contrary, over the past several years VR&E has taken several actions to 
meet Servicemembers and Veterans where they are and in the manner they 
wish to be met. These actions, coupled with legislative changes, were 
expected to increase participation in the VR&E program. These actions 
include the following:

     In accordance with Public Law 114-223, section 254, 
Veteran-to-Counselor ratio should not exceed 125 to 1. VA's VR&E 
Program began the process of reducing the average Veteran-to-Counselor 
ratio to 125 to 1 or below through the hiring of 169 VRCs. This will 
help improve service to Veterans with service-connected disabilities 
and employment barriers, as well as help provide them with expanded 
services to improve their ability to transition to the civilian 
workforce.
     The placement of 145 VRCs on 71 military installations 
across the Nation provides outreach and rehabilitation services to 
Servicemembers and their families prior to discharge from active duty 
service.
     The placement of 87 VRCs on 104 college campuses across 
the Nation provides outreach and rehabilitation services to 
Servicemembers, Veterans, and their dependents.
     On September 29, 2018, the VA Expiring Authorities Act of 
2018, Public Law 115-251, section 126, made permanent the authority to 
provide VR&E benefits and services to Servicemembers who are awaiting 
discharge due to a severe illness or injury incurred during active duty 
service.
     VR&E expanded its Tele-counseling policy to allow its use 
during all aspects of the rehabilitation process. This practice allows 
VR&E VRCs to meet virtually with a VR&E participant via an application 
that can be used on a computer or smart device. This practice saves 
travel time for the participant and allows for greater access to the 
program.

    VR&E continues to increase awareness and share information on VR&E 
benefits and services. VR&E reviews and updates all VR&E fact sheets 
and Web sites each year as needed as well as promotes, monthly, all the 
marketing material that is available online. VR&E promotes the online 
marketing materials in a variety of ways, including by email, social 
media, outreach events, and conference calls with VR&E's field staff. 
They have developed an overview whiteboard video which was distributed 
to the field offices. The video provides an overview of VR&E's benefits 
and the types of assistance available and is a tool for the VRCs to 
promote the VR&E program. VR&E has also provided numerous trainings on 
how to promote early intervention into VR&E to active duty members on 
the military installations. Last, VR&E is changing the performance 
standards for the VRCs on military installations to focus more on 
ensuring Servicemembers are entering the VR&E program.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Kyrsten Sinema to 
                  U.S. Department of Veterans Affairs
    Question 1. Can I count on your support to ensure the VA takes 
steps to make family members aware of benefits available to their loved 
ones?
    Response. Yes. VA continues to proactively conduct outreach to the 
families of Servicemembers and Veterans through face-to-face 
interactions, social media, and email correspondence. VA's outreach 
services include attendance at various types of national and local 
events, stakeholder presentations, and collaboration efforts with other 
Federal and state agencies, Veterans Service Organizations, private 
partners, and non-profit organizations such as the Tragedy Assistance 
Program for Survivors. VA works to promote information on benefits and 
services available to family members and proactively disseminates 
information in the same manner as its recent VA Benefits Bulletin 
newsletter sent on April 5, 2019, to over 5.5 million recipients with 
specific information pertaining to a VA Survivors and Burial Benefits 
Kit.

    Question 2. What is your long term plan to be able to fully staff 
the VA with the adequate number of medical professionals and retain 
them long term to serve those that served us?
    Response. VHA's workforce challenges mirror those of the health 
care industry as a whole. There is a national shortage of health care 
professionals, especially for physicians and nurses. The American 
Association of Colleges of Nursing, Association of American Medical 
Colleges, and other national health care organizations have written 
about this workforce shortage at length. VHA remains fully engaged in a 
fiercely competitive clinical recruitment market. VHA has been 
successful in increasing the number of clinical providers including 
hard-to-recruit-and-retain physicians such as psychiatrists.
    While there are many approaches to projecting staffing of medical 
professionals and support staff across large health care systems at the 
national level, forecasting at the local level remains challenging due 
a multitude of factors. Nationally, Veteran enrollment is projected to 
grow by 1.6 percent from 2017 to 2026 even though the Veteran 
population is declining. The VHA workforce has consistently grown by 
approximately 3 percent annually over the last 5 years. Integration of 
existing resources with community care as well as the expansion of 
telehealth capabilities will be a critical driver in assessing future 
resource requirements.
    In FY 2018, VHA formally stood-up the VHA Manpower Management 
Office (MMO). VHA has an aggressive schedule for establishing manpower 
capabilities, which includes establishing staffing models for all 
functional areas; benchmarking staffing, quality, and access at similar 
health care systems; developing predictive recruitment models; and 
identifying facilities in danger of low staffing levels.
    VHA staffing plans account for normal rates of workforce turnover, 
retirement, and growth, and the expectation that there will always be 
vacant positions. VHA is taking several key steps to attract qualified 
candidates, including the following:

     Mental Health and other targeted hiring initiatives;
     increased maximum physician salaries;
     utilization of 3R incentives and the Education Debt 
Reduction Program (EDRP);
     targeted Nation-wide recruitment advertising and 
marketing;
     ``Take A Closer Look at VA'' trainee outreach recruitment 
program;
     expanding opportunities for telemedicine providers;
     DOD/VA effort to recruit transitioning Servicemembers; and
     exhibiting regularly at key health care conferences and 
job fairs.

    The MISSION Act also provides additional authority that VA will 
leverage for recruitment and retention of medical professionals, 
including the following:

     Awarding 50 scholarships per year for people enrolled in a 
medical or dental school;
     increasing the maximum award amount for the Education Debt 
Reduction Program (EDRP),
     expanding program eligibility to additional mental health 
providers;
     offering recent medical school graduates loan repayment 
opportunities in exchange for service in VAMCs through the Specialty 
Education Loan Repayment Program (SELRP);
     initiating a pilot scholarship program targeted toward 
Veterans for medical school education; and
     increased the overall sums authorized for VA bonus awards 
and funding 3Rs.

    VA recently achieved our goal of adding 1,000 more mental health 
providers to serve Veterans, adding 1,045 more mental health providers 
as of January 31, 2019. VA made this commitment in June 2017 as part of 
VA's #1 clinical priority to eliminate Veteran suicide and used a wide 
variety of strategies to recruit and retain the mental health 
workforce. This included VA's first-ever virtual trainee hiring fair, 
which resulted in 74 mental health trainees accepting job offers. The 
second trainee hiring event is currently underway and will connect 
current VA psychology trainees with available positions at VHA 
facilities using the non-competitive hiring process. Building a 
clinical trainee pipeline of qualified health care professionals is 
crucial to future VA recruitment and sustainment efforts.
    Each year, VHA hires more employees than it loses to replace 
turnover and keep up with the growth in demand for services. VHA 
turnover rates compare favorably with the health care industry, 
including for those occupations identified as mission critical. In FY 
2018, VHA's annual turnover rate for full-time and part-time employees 
was 9.5 percent, which compares well to the health care industry 
turnover rate of 20-30 percent.
    The best indicators of adequate staffing levels are Veteran access 
to care and health care outcomes, and VHA continues to make substantial 
progress on these measures. As identified by external research and 
studies, in general, Veterans are receiving the same or better care at 
VAMCs as patients at non-VA hospitals.

    Question 3. Mr. Secretary, are you aware of the recent United 
States Digital Service findings on the issues surrounding the new 
software to determine eligibility under the MISSION Act?
    Response. Yes.

    Question 3a. What steps is the VA taking in response to the USDS 
study?
    Response. The United States Digital Service (USDS) identified 
several key points and recommendations that OIT could use to enable a 
better product development effort for MISSION Act and more specifically 
for the Decision Support Tool (DST). OIT and VHA are using USDS's 
recommendations to improve DST and other MISSION Act IT needs.

                            A P P E N D I X

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              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

      Joint Statement of The Co-Authors of the Independent Budget
    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee, The co-authors of The Independent Budget (IB)--DAV (Disabled 
American Veterans), Paralyzed Veterans of America (PVA), and Veterans 
of Foreign Wars (VFW)--are pleased to present our views regarding the 
President's funding request for the Department of Veterans Affairs (VA) 
for Fiscal Year (FY) 2020, including advance appropriations for FY 
2021.
    Last month, prior to the Administration's budget request, the IB 
released our comprehensive VA budget recommendations for all 
discretionary programs for FY 2020, as well as advance appropriations 
recommendations for medical care accounts for FY 2021.\1\ The 
recommendations also include funding to implement the VA MISSION Act of 
2018 (P.L. 115-182) and other reform efforts. The IB believes that 
Congress must continue vigorous oversight of VA to ensure an accurate 
assessment of its true needs. Our own FY 2020 estimates affirm that 
these needs continue to grow.
---------------------------------------------------------------------------
    \1\ The full IB budget report addressing all aspects of 
discretionary funding for VA can be downloaded at 
www.independentbudget.org.
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    After reviewing the Administration's budget request for VA and 
comparing it to the IB recommendations, particularly in light of the 
requirements of the VA MISSION Act, we believe that the request falls 
short of meeting the needs of veterans seeking care through VA. 
Although the budget request provides a seven percent increase in the 
level of discretionary funding, when factoring in VA's own estimates of 
the cost of implementing the VA MISSION Act, the shift of $5.5 billion 
from mandatory to discretionary funding from the Choice program, and 
the increased cost for providing medical care due to inflation and 
other factors, VA will not have sufficient resources to meet the health 
care needs of America's veterans.
    The Administration's request of $84 billion for Medical Care is $4 
billion less than the IB estimates is necessary to fully meet the 
demand by veterans for health care during the fiscal year. For FY 2020, 
the IB recommends approximately $88.1 billion in total medical care 
funding and approximately $90.8 billion for FY 2021. This 
recommendation reflects the necessary adjustments to the baseline for 
all Medical Care program funding in the preceding fiscal year, and 
assumes the Choice program is fully replaced at the beginning of FY 
2020 by the Veterans Community Care Program (VCCP).
    For FY 2020, the IB recommends $56.1 billion for VA Medical 
Services. This recommendation is a reflection of multiple components 
including the current services estimate, the increase in patient 
workload, and additional medical care program costs. The current 
services estimate reflects the impact of projected uncontrollable 
inflation on the cost to provide services to veterans currently using 
the system. This estimate also assumes a 2.1 percent increase for pay 
and benefits across the board for all VA employees in FY 2020.
    Our estimate of growth in patient workload is based on a projected 
increase of approximately 90,000 new unique patients. These patients 
include priority group 1-8 veterans and covered non-veterans. We 
estimate the cost of these new unique patients to be approximately $1.3 
billion.
    The IB believes that there are additional projected medical program 
funding needs for VA. Those costs total over $1.2 billion. 
Specifically, we believe there is a real need for funding to address an 
array of issues in VA's Long-Term Services and Supports (LTSS) program, 
including the shortfall in non-institutional services due to the 
unremitting waitlist for home and community-based services; to provide 
additional centralized prosthetics funding (based on actual 
expenditures and projections from the VA's Prosthetics and Sensory Aids 
Service); funding to expand and improve services for women veterans; 
funding to support the recently approved authority for reproductive 
services, to include in vitro fertilization (IVF); and initial funding 
to implement extending comprehensive caregiver support services to 
severely injured veterans of all eras.
    The Administration's request for VA Medical Services of $51.4 
billion is approximately $4.7 billion below the IB recommendation. To 
better understand the shortfall, it should be noted that the IB does 
not include anticipated receipts from VA's Medical Care Collections 
Fund in its recommendation. Although the Administration's request 
reflects an apparent increase of three percent, the IB believes that 
when taking into account the increased cost to maintain current 
services and anticipated increases in workload, as well as increased 
costs inside VA due to the VA MISSION Act that apparent increase will 
ultimately result in a shortfall.
    Of great concern to our organizations and members, the 
Administration's budget request makes clear that VA will fail to meet 
the VA MISSION Act's very clear timetable for expanding its 
comprehensive caregiver support program to severely injured WWII, 
Korean, and Vietnam War veterans and their family caregivers. These men 
and women have waited nearly a decade for equal treatment and it is 
simply unacceptable to ask them to wait longer.
    The VA Caregiver Support Program currently uses the IT system known 
as the Caregiver Application Tracker (CAT), which was rapidly developed 
due to time constraints on implementing the program and was not 
designed to manage a high volume of information as is required today. 
We are aware VA has requested a reprogramming of nearly $96 million in 
Medical Care funding to the IT Systems account, which includes just 
over $4 million to continue development and stabilization of CAT, while 
in its FY 2020 budget submission, VA is requesting $2.6 million to 
update the Caregivers Tool (CareT) to support the first phase of 
expansion. As this Committee is aware, VA notified Congress in 
April 2017 that CareT, which at that time was expected to fully 
automate the application and stipend delivery process for the program, 
experienced significant delays associated with external dependencies 
and lost prioritization among competing projects. As a result, a new 
contract had to be drafted to continue work pushing the delivery of 
CareT out one year to June 2018.
    We are deeply troubled at VA's apparent lack of commitment to 
accomplish this IT task correctly and on time and that these funding 
requests appear to uncaringly prioritize caregiver expansion behind 
that of the VCCP. Moreover, the delay in certifying the IT 
infrastructure for expansion of the caregiver program until at least 
2020 raises troubling concerns about VA's ability to fully deploy the 
significant IT infrastructure needed to properly implement the more 
expansive VCCP in a shorter timeframe.
    In terms of funding, the Administration included $150 million to 
expand VA's comprehensive caregiver program. This figure is over $100 
million less than the IB recommendation of $253 million to fully 
implement phase one of the caregiver expansion in FY 2020. The IB's 
recommendation is based on the Congressional Budget Office estimate for 
preparing the program, including increased staffing and IT needs, and 
the beginning of the first phase of expansion.
    For Medical Community Care, the IB recommends $18.1 billion for FY 
2020, which includes the growth in current services, estimated spending 
under the Choice program, and additional obligations under the VA 
MISSION Act of $3.7 billion. The Administration's FY 2020 request for 
$15.3 billion in discretionary funding appears to be a $5.9 billion 
increase in funding for Community Care. However, VA has indicated that 
$5.5 billion of that increase merely represents shifting $5.5 billion 
that would otherwise be necessary to pay for the Choice program, from 
mandatory funding. Considering that VA estimated the VA MISSION Act 
will require $2.6 billion in new funding for expanded access based on 
new access standards, expanded transplant care, and $271 million for 
urgent care, there appears to be a significant shortfall for VA 
community care programs.
    Furthermore, during VA's budget briefing on March 11, VHA officials 
stated that there would be no Medical Community Care funding required 
to implement the new wait time access standards, that VA would be able 
to fully meet those standards within VA facilities; therefore, not one 
veteran would get VCCP eligibility due solely to the wait time 
standard. However, VA has also stated that the current median wait time 
for primary care is 21 days, which would mean that approximately half 
of all veterans seeking primary care appointments today have a greater 
than 20 day wait time. Yet, VA's budget request assumes that they would 
achieve 100 percent compliance with the wait time standard through 
greater efficiency and an approximate 30 percent increase in VA primary 
care providers. We have serious doubts about whether this is realistic 
given the national shortage of primary care providers and the time 
needed to recruit, hire, and onboard new employees; and certainly, 
whether it is achievable by the first day of the next fiscal year, just 
over six months from today.
    The Administration's FY 2020 request for VA's construction programs 
of $1.8 billion dollars is a 44 percent reduction from FY 2019 funding 
levels, and a disappointing retreat in funding to maintain VA's aging 
infrastructure. For major construction in FY 2019, VA requested and 
Congress appropriated a significant increase in funding for major 
construction projects--an approximate $700 million increase. While 
these funds will allow VA to begin construction on key projects, many 
other previously funded sites still lack the funding for completion. 
Some of these projects have been on hold or in the design and 
development phase for years. Additionally, there are outstanding 
seismic corrections that must be addressed. Thus, the IB recommended 
$2.78 billion in major construction, nearly $1 billion more than VA's 
total construction request.
    To ensure that VA funding keeps pace with all current and future 
minor construction needs, the IB recommends that Congress appropriate 
an additional $761 million for minor construction projects. It is 
important to invest heavily in minor construction because these are the 
types of projects that can be completed faster and have a more 
immediate impact on services for veterans. Previously, these changes 
fell under facilities similar to Non-Recurring Maintenance (NRM), but 
the IB recommends these specific modifications be under a different 
authority to ensure their priority.
    In addition, the Administration's FY 2020 Medical Facilities 
request of $6.1 billion, which includes critical NRM to ensure VA 
facilities have the space to provide care, is a $660 million cut 
compared to FY 2019 levels. The IB recommends $6.6 billion for FY 2020. 
This includes nearly $400 million for NRM and leases, which provides 
funding to address VA research NRM needs. VA uses major and minor 
leases in lieu of facility construction to address access needs and 
space gaps to quickly respond to health care advances, and adopt 
changing technology in order to provide state-of-the-art health care to 
veterans when a lease is better aligned with the Department's overall 
capital strategy.
    The Administration's request of $762 million for Medical and 
Prosthetic Research is nearly $80 million below the IB recommendation 
of $840 million. The request represents a 2 percent cut, at a time when 
medical research inflation is estimated to be 2.8 percent. The VA 
Medical and Prosthetic Research program is widely acknowledged as a 
success, with direct and significant contributions to improved care for 
veterans and an elevated standard of care for all Americans. This 
research program is also an important tool in VA's recruitment and 
retention of health care professionals and clinician-scientists to 
serve our Nation's veterans. This reduction would diminish VA's ability 
to provide the most advance treatments available to injured and ill 
veterans in the future, one of VA's core missions.
    Overall, the IB believes that the Administration's FY 2020 budget 
request for VA will neither allow the Department to fully and 
faithfully implement the VA MISSION Act, nor will it fully meet the 
rising demand by veterans for care within VA hospitals and clinics. The 
IB veterans services organizations (IBVSOs) are left with significant 
questions regarding both the assumptions on which the request was made 
and how the VA intends to meet the requirements of not only the VA 
MISSION Act, but also other requirements to provide the health care, 
benefits, and services that veterans have earned. Below are some of the 
questions about VA's budget request that have not been answered.

     At its March 11 budget briefing, VA officials stated that 
the FY 2020 budget request was predicated on a carryover of 
approximately $3 billion from FY 2019 appropriations, but offered no 
details or further explanation. Exactly, how much ``carryover'' is 
assumed in the FY 2020 budget request and how did VA determine less 
than halfway through FY 2019 that such a large amount of funding could 
not be used to meet veterans' health care needs? What are the specific 
dollar amounts being carried over and from what specific accounts, and 
into what accounts and for what purposes will this carryover funding be 
used in FY 2020?
     As discussed above, VA officials indicated that there 
would be zero new dollars necessary for the Medical Community Care 
account as a result of the new wait time access standards proposed 
because VA assumes it will be able to meet those standards 100 percent 
of the time within VA facilities. VA indicated it will do this through 
workload recapture, greater efficiency, and a 30 percent increase in 
the total number of VA primary care providers. What new initiatives 
will VA undertake and what are the specific increases in productivity 
that each will achieve? What are VA's detailed plans and projections 
for increasing primary care providers by 30 percent, and how will these 
new providers be in place at the beginning of FY 2020?
     What factors did VA consider in reaching its decision to 
cut research spending for the emerging field of genomics research in FY 
2020 by 2 percent at a time when medical research inflation is 
estimated to be 2.8 percent?
     In the full budget documents made available on March 18, 
the Veterans Benefits Administration budget request seeks 
appropriations to support the exact same level of FTE for FY 2020 as it 
does in FY 2019. However, the Direct Labor estimate for the Disability 
Compensation program shows a decrease of 51 FTE in FY 2020. This small 
decrease in claims processors occurs at a time that the VA budget is 
projecting that number of pending claims for disability compensation 
will rise to over 450,000 by the end of FY 2020, almost a 50 percent 
increase in just the past three years. Why is VA requesting fewer 
claims processing staff in FY 2020 when its own data shows that the 
number of pending claims is rising dramatically?
     VA budget documents state that the Vocational 
Rehabilitation and Employment (VRE) program will meet and sustain the 
congressionally-mandated goal of 1:125 counselor-to-client ratio. 
However, the latest data in the VA budget document also shows that from 
2016 to 2018, the number of VRE participants fell from 173,606 to 
164,355, more than a five percent decrease. During that same period, 
VRE's caseload also dropped from 137,097 to 125,513, an 8.4 percent 
decline. It would appear that VRE is able to meet the 1:125 goal by 
serving fewer veterans. Given how important and beneficial the VRE 
program is to disabled veterans--providing many of them with the 
ability to increase their economic independence--why are fewer veterans 
taking advantage of this program? Has VRE instituted any new policies 
or practices that have deterred disabled veterans from seeking VRE 
services and what actions is VRE taking to increase awareness about the 
availability and benefits of VRE services?

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

1. Round-Down of the Computation of the Cost of Living Adjustment 
        (COLA) for Service-Connected Compensation and Dependency and 
        Indemnity Compensation (DIC) for Five Years:
          In 1990, Congress, in an omnibus reconciliation act, mandated 
        veterans' and survivors' benefit payments be rounded down to 
        the next lower whole dollar. While this policy was initially 
        limited to a few years, Congress continued it until 2014. While 
        not significant at the onset, the overwhelming effect of 
        twenty-four years of round-down resulted in veterans and their 
        beneficiaries losing billions of dollars.
          In the Administration's proposed budget for FY 2019, the 
        Administration sought legislation to round-down the computation 
        of COLA for ten years. This would have cost beneficiaries $34.1 
        million in 2019, $749.2 million for five years, and $3.11 
        billion over ten years.
          The Administration's proposed budget for FY 2020, is seeking 
        to round-down COLA computations from 2020 to 2024. The 
        cumulative effect of this proposal levies a tax on disabled 
        veterans and their survivors, costing them money each year. 
        When multiplied by the number of disabled veterans and DIC 
        recipients, millions of dollars are siphoned from these 
        deserving individuals annually. All told, the government 
        estimates that it would cost beneficiaries $34 million in 2020 
        and $637 million for five years and $2 billion over ten years.
          Veterans and their survivors rely on their compensation for 
        essential purchases such as food, transportation, rent, and 
        utilities. Any COLA round-down will negatively impact the 
        quality of life for our Nation's disabled veterans and their 
        families, and we oppose this and any similar effort. The 
        Federal budget should not seek financial savings at the expense 
        of benefits earned by disabled veterans and their families.
2. Clarify Evidentiary Threshold for Ordering VA Examinations:
          This proposal would increase the evidentiary threshold at 
        which VA, under its duty to assist obligation in 38 U.S.C. 
        Sec. 5103A, is required to request a medical examination for 
        compensation claims. Section 5103A(d)(2) requires VA to ``treat 
        an examination or opinion as being necessary to make a decision 
        on a claim'' if the evidence of record, ``taking into 
        consideration all information and lay or medical evidence . . . 
         (A) contains competent evidence that the claimant has a 
        current disability, or persistent or recurrent symptoms of 
        disability; and (B) indicates that the disability or symptoms 
        may be associated with the claimant's active military, naval, 
        or air service; but (C) does not contain sufficient medical 
        evidence for the Secretary to make a decision on the claim.''
          The Court of Appeals for Veterans Claims (CAVC), in McLendon 
        v. Nicholson, 20 Vet. App. 79 (2006), determined that in 
        disability compensation claims, VA must provide a VA medical 
        examination when there is:

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

          We oppose this proposal as it would be inherently detrimental 
        to the VA claims process for all veterans. The Administration 
        asserts the holdings by the CAVC, specifically in McLendon v. 
        Nicholson, are inconsistent and too low a bar when compared to 
        38 U.S.C. Sec. 5103A(d)(2). However, that is not correct. As 
        noted above, the statutory requirements for a VA examination 
        are consistent with the CAVC's holding. The Administration's 
        proposed legislation would intentionally raise the bar of the 
        VA's Duty to Assist and allow the VA to hold veterans to a much 
        higher threshold and result in fewer examinations with more 
        claim denials. This would lead to more Higher Level Review 
        requests, supplemental claims, and appeals directly to the 
        Board of Veterans' Appeals. Ultimately, this will result in an 
        increased number of veterans never receiving the benefits they 
        earned.
          The Administration's proposal would reduce anticipated 
        disability compensation to veterans by $233 million in 2020, 
        $1.3 billion over five years, and $2.8 billion over ten years. 
        We strongly oppose this attempt to limit the due process rights 
        of veterans, particularly when the result will be billions of 
        dollars in lost disability compensation for those who were 
        injured or made ill in service.
3. VA Schedule for Rating Disability (VASRD) Effective Dates:
          VA seeks to amend 38 U.S.C. Sec. 1155 so that when VASRD is 
        readjusted, such changes would apply to any new or pending 
        claims and may include action to decrease an existing 
        evaluation. Under section 1155, ``The Secretary shall from time 
        to time readjust this schedule of ratings in accordance with 
        experience. However, in no event shall such a readjustment in 
        the rating schedule cause a veteran's disability rating in 
        effect on the effective date of the readjustment to be reduced 
        unless an improvement in the veteran's disability is shown to 
        have occurred.''
          Currently, if a diagnostic code rating criteria changes, the 
        veteran can only be granted an increased evaluation under the 
        old rating criteria up to the date of the change to the new 
        rating criteria. The new rating criteria must be applied from 
        the date of the change. The Administration's proposal would 
        eliminate a veteran's ability to receive an increased 
        evaluation up to the date of the change and only apply the new 
        criteria.
          This proposal would have a negative impact on veterans and 
        would clearly be in contrast to 38 CFR Sec. 3.103, which 
        states, ``Proceedings before VA are ex parte in nature, and it 
        is the obligation of VA to assist a claimant in developing the 
        facts pertinent to the claim and to render a decision which 
        grants every benefit that can be supported in law while 
        protecting the interests of the Government.''
          The Administration's proposed budget does not show any 
        estimate of budgetary savings based on this legislative 
        proposal and mentions only that it would make it easier for VA 
        rating personnel to make decisions on veterans' claims. 
        However, this proposal will eliminate any potential increased 
        evaluations prior to the change of the rating criteria; 
        thereby, lowering the earned benefit for affected disabled 
        veterans. We oppose this proposal as it will have negative 
        consequences on veterans.
4. Elimination of Payment of Benefits to the Estates of Deceased Nehmer 
        Class Members and to the Survivors of Certain Class Members:
          VA seeks to amend 38 U.S.C. Sec. 1116 to eliminate payment of 
        benefits to survivors and estates of deceased Nehmer class 
        members. If a Nehmer class member, per 38 CFR Sec. 3.816, 
        entitled to retroactive benefits dies prior to receiving such 
        payment, VA is required to pay any unpaid retroactive benefits 
        to the surviving spouse or subsequent family members. This 
        proposed legislation would deny veterans' survivors and 
        families' benefits that would have otherwise been due to their 
        deceased veteran family member as a result of exposure to these 
        toxic chemicals while in service. It is outrageous that the 
        Administration would deny compensation payments due to a 
        surviving spouse. We adamantly oppose this or any similar 
        proposal that may be offered.

    The IBVSOs do support one of VA's legislative proposals regarding 
VA approved Medical Foster Homes (MFH). This proposal would require the 
VA to pay for service-connected veterans to reside in VA approved MFHs.
    MFHs provide an alternative to long-stay nursing home (NH) care at 
a much lower cost. The program has already proven to be safe, 
preferable to veterans, highly veteran-centric, and half the cost to VA 
compared to NH care. Aligning patient choice with optimal locus of care 
results in more veterans receiving long-term care in a preferred 
setting, with substantial reductions in costs to VA. This proposal 
would require VA to include MFH in the program of extended care 
services for the provision of care in MFHs for veterans who would 
otherwise encumber VA with the higher cost of care in NHs.
    Many more service-connected veterans referred to or residing in NHs 
would choose MFH if VA paid the costs for MFH. Instead, they presently 
defer to NH care due to VA having payment authority to cover NH, while 
not having payment authority for MFH. As a result of this gap in 
authority, VA pays more than twice as much for the long-term NH care 
for many veterans than it would if VA was granted the proposed 
authority to pay for MFH. This proposal would give veterans in need of 
NH level care greater choice and ability to reside in a more home-like, 
safe environment, continue to have VA oversight and monitoring of their 
care, and preferably age in place in a VA-approved MFH rather than a 
NH. The proposal does not create authority to cover veterans who reside 
in assisted living facilities.
    MFH promotes veteran-centered care for those service-connected 
veterans who would otherwise be in a nursing home at VA expense, by 
honoring their choice of setting without financial penalty for choosing 
MFH.
    Thank you for the opportunity to submit our views on the 
Administration's budget request for VA. We firmly believe that unless 
Congress acts to substantially increase VA's funding for FY 2020, 
veterans will be forced to wait longer for care, whether they seek care 
at VA or in the community, leaving unfulfilled the promises made to 
veterans in the VA MISSION Act.

      

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