    [House Hearing, 119 Congress]
    [From the U.S. Government Publishing Office]

                       RESTORING FOCUS: PUTTING VETERANS
                            FIRST IN COMMUNITY CARE

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED NINETEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                          WEDNESDAY, JANUARY 22, 2025

                                   __________

                                Serial No. 119-1

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                        Available via http://govinfo.gov

                                    __________

                       U.S. GOVERNMENT PUBLISHING OFFICE
    59-611                     WASHINGTON : 2025

    -----------------------------------------------------------------------------------

                         COMMITTEE ON VETERANS' AFFAIRS

                         MIKE BOST, Illinois, Chairman

    AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking
        American Samoa, Vice-Chairwoman      Member
    JACK BERGMAN, Michigan               JULIA BROWNLEY, California
    NANCY MACE, South Carolina           CHRIS PAPPAS, New Hampshire
    MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK,
    GREGORY F. MURPHY, North Carolina        Florida
    DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky
    MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois
    JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois
    KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York
    JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon
    ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey
    KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota
        Mariana Islands
    TOM BARRETT, Michigan

                           Jon Clark, Staff Director
                      Matt Reel, Democratic Staff Director

    Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
    hearing records of the Committee on Veterans' Affairs are also
    published in electronic form. The printed hearing record remains the
    official version. Because electronic submissions are used to prepare
    both printed and electronic versions of the hearing record, the process
    of converting between various electronic formats may introduce
    unintentional errors or omissions. Such occurrences are inherent in the
    current publication process and should diminish as the process is
    further refined.

                             C  O  N  T  E  N  T  S

                                  ----------

                          WEDNESDAY, JANUARY 22, 2025

                                                                       Page

                               OPENING STATEMENTS

    The Honorable Mike Bost, Chairman................................     1
    The Honorable Mark Takano, Ranking Member........................     2

                                   WITNESSES

    Mr. Paul McKenna, Sergeant Major (Ret.), United States Marine
      Corps..........................................................     6

    Mr. William Dooley, Master Sergeant (Ret.), United States Army...     6

    Ms. Lori Willis Locklear, Mother of Navy Veteran Logan Willis....     9

    Ms. Brittany Dymond Murray, Associate Director, Veterans of
      Foreign Wars...................................................    11

    Dr. Kelley Saindon, DNP, RN, CHPN, Secretary/Treasurer, Nurses
      Organization of Veterans Affairs...............................    12

                                    APPENDIX
                        Prepared Statements Of Witnesses

    Mr. Paul McKenna Prepared Statement..............................    41
    Mr. William Dooley Prepared Statement............................    42
    Ms. Lori Willis Locklear Prepared Statement......................    46
    Ms. Brittany Dymond Murray Prepared Statement....................    49
    Dr. Kelley Saindon, DNP, RN, CHPN Prepared Statement.............    52

                           Statements For The Record

    Alzheimer's Association and Alzheimer's Impact Movement Prepared
      Statement......................................................    55
    Mission Roll Call Prepared Statement.............................    58
    American Psychological Association, Association of VA
      Psychologist Leaders, Association of VA Social Workers,
      National Association of Veterans Affairs Physicians and
      Dentists, National Association of Veterans' Research and
      Educational Foundations, Veterans Affairs PA Association,
      Veterans Healthcare Policy Institute Prepared Statement........    62
    The American Legion Prepared Statement...........................    67
    American Association of Nurse Anesthesiology Prepared Statement..    70

                       RESTORING FOCUS: PUTTING VETERANS
                            FIRST IN COMMUNITY CARE

                                  ----------

                          WEDNESDAY, JANUARY 22, 2025

                        Committee on Veterans' Affairs,
                                 U.S. House of Representatives,
                                                       Washington, D.C.
        The committee met, pursuant to notice, at 1:02 p.m., in
    room 360, Cannon House Office Building, Hon. Mike Bost
    (chairman of the committee) presiding.
        Present: Representatives Bost, Bergman, Mace, Miller-Meeks,
    Murphy, Van Orden, Luttrell, Self, Kiggans, Hamadeh, King-
    Hinds, Barrett, Takano, Brownley, Pappas, Cherfilus-McCormick,
    McGarvey, Ramirez, Kennedy, Dexter, Conaway, and Morrison.

                OPENING STATEMENT OF MIKE BOST, CHAIRMAN

        The Chairman. The committee will come to order. Good
    afternoon, everyone. I want to thank you for being here.
    Welcome to the House Committee on Veterans' Affairs' first
    oversight hearing for the 119th Congress.
        Now, before we start, I wanted to recognize and thank my
    colleague and friend Chairwoman Miller-Meeks for her
    leadership. Chairwoman Miller-Meeks originally proposed this
    hearing topic to be held in a subcommittee, but ultimately, I
    decided this is an important enough issue to discuss that
    requires full committee attention. As chairman, I am deeply
    committed to our shared mission of improving the delivery of
    care and services to our Nation's veterans. I look forward to
    working alongside my colleagues on both sides of the aisle to
    fulfill this mission.
        Last Congress, this committee did meaningful work toward
    the mission by passing the Senator Elizabeth Dole 21st Century
    Veterans Healthcare and Benefits Improvement Act. The committee
    also performed critical oversight of the Biden administration
    VA to find where the shortfalls were. Today we turn our focus
    on VA's Community Care Program, which, as we know today, was
    enacted in the VA Maintaining Internal Systems and
    Strengthening Integrated Outside Networks (MISSION) Act. The VA
    MISSION Act passed in 2018 with overwhelming bipartisan
    support. It was a promise to veterans, a promise to ensure they
    would never again face delays and access to the healthcare they
    have earned. It was a solution born from necessity and on the
    shoulders of what was the Veterans Access, Choice and
    Accountability (Choice) Act. It was designed to eliminate
    barriers to care and expand access for veterans nationwide.
        It is not a solution to private--and it is not a solution
    to privatize VA healthcare. Let me say it again, not to
    privatize healthcare, the VA healthcare, anyone who suggests
    otherwise should step outside the Beltway and talk to the
    veterans who live 3 hours from a VA medical center. Community
    care is that veteran's lifeline.
        Healthcare decisions are deeply personal and they should be
    made by veterans themselves. They know where and when and they
    need care to fix their needs. However, under the Biden-Harris
    administration, the program has been hijacked. Biden-Harris
    administration has prioritized bureaucratic limitations and
    control of a community care over veterans' needs. Scheduling
    practices have been manipulated to distort wait times.
    Appointments have been canceled or rescheduled without
    veterans' consent. Internal VA guidance has actively
    discouraged veterans from seeking care outside the VA system.
    That is dead wrong and likely, like everywhere--and like every
    other law that that is enacted, it is not optional and it is
    not a suggestion, it is the law.
        When VA inserts itself as the sole decision-maker and plays
    politics with veterans' health, people get hurt. These actions
    have real-life consequences, and we are going to hear some of
    those consequences today from actual veterans, not bureaucrats.
        Make no mistake, community care is VA care. It is not a
    substitute, but an essential extension of VA's mission to serve
    veterans where and when they need it without delay. With the
    Trump administration in place, we have the opportunity to
    ensure VA adheres to the MISSION Act and returns healthcare
    decisions to the hands of the only authority that matters, the
    veteran.
        Today we will hear from witnesses who have experienced
    these barriers firsthand. Their stories will remind us that the
    decisions made here in Washington have a far-reaching impact on
    the lives of veterans and their families.
        To our veteran--or to our witnesses, first off, thank you
    for the courage and sharing your experiences. Your experiences
    matter and we are here to listen.
        Now with that, I now recognize Ranking Member Takano for
    his opening comments.

            OPENING STATEMENT OF MARK TAKANO, RANKING MEMBER

        Mr. Takano. Well, thank you, Mr. Chairman. Today we will
    hear perspectives from several veterans who have faced barriers
    in trying to access timely and high-quality healthcare from the
    Department of Veterans Affairs.
        I want to say to our witnesses that I am truly anguished by
    the unacceptable delays to you and your veteran loved ones. I
    am anguished by what they have faced and what you have faced in
    getting the care that you and they need. Your experiences are
    deeply troubling and I have many questions about how things
    went wrong. Unfortunately, I am afraid that today's hearing
    will not help the committee get sufficient answers to those
    questions and it will not enable us to hold those responsible
    accountable. That is because the majority has opted not to
    invite any witnesses from VA or the two third-party
    administrators of its Community Care Program.
        They also opted not to include witnesses from agencies like
    VA's Office of Inspector General or the U.S. Government
    Accountability Office, who could provide us with objective,
    fact-based information about how and why veterans experience
    delays in accessing healthcare. This hearing was hastily
    organized just hours after our committee organizing meeting
    last Thursday. We have six members who are new to this
    committee, to Congress, three of whom are physicians and
    understand better than anyone the importance of proper care
    coordination and the risks of delayed care.
        Mr. Chairman, today's VA community care oversight hearing
    is the first, the first, that you have convened since becoming
    chairman more than 2 years ago. More than 40 percent of
    veterans' care is now being delivered in the community and VA
    is on track to spend more than $42 billion on private sector
    care this fiscal year. When I was chair of this committee from
    2019 to 2022, the full committee and the Health Subcommittee
    collectively convened six oversight hearings that examined the
    timeliness of veterans' access to healthcare and payments to
    community providers, as well as VA's initial implementation of
    the MISSION Act.
        I am explaining all this because what I am about to say may
    shock members, veterans, and other stakeholders watching today.
    Last Thursday, we were informed that this one panel hearing
    will be the only full committee oversight hearing on community
    care before we advance major legislation on the subject and
    that we had to content ourselves with two closed-door committee
    staff-only meetings with stakeholders.
        However, since the committee had not formally organized at
    the time these meetings occurred, no members of their staff
    were present. Moreover, because these meetings were held behind
    closed doors, there is no public record of what was discussed.
        The minority is only permitted to invite one witness to a
    hearing and given that the current transition in Presidential
    administration presents challenges with inviting government
    officials to testify, so I asked the majority to invite Optum
    Serve Federal Health Services, one of the third-party
    administrators for VA's Community Care Program. Optum is a
    subsidiary of UnitedHealth Group and has contracted with VA
    since 2019 to establish networks of community providers and
    process payments to those providers. UnitedHealthcare also
    holds a contract with VA to conduct medical disability
    examinations, the exams veterans receive when they are applying
    for VA disability benefits.
        Today, UnitedHealthcare's VA contracts are worth more than
    $72 billion. That is billion with a B. Worse, that money is not
    all spent on providing care to veterans. A considerable amount
    is going to administrative overhead. Imagine how many new
    hospitals and clinics VA could build and how many clinical
    staff that VA could hire with that amount of money. However,
    UnitedHealthcare declined the invitation declined the
    invitation to testify, citing the lack of sufficient time to
    prepare for the hearing. Now, I do not know about you, but I do
    not have much sympathy for a company that is receiving tens of
    billions of taxpayer dollars complaining that they need more
    advance notice to appear at a hearing. The chairman's staff,
    however, apparently do sympathize because they accepted
    UnitedHealthcare's excuse.
        Now that brings me to Dr. Saindon, who is appearing today
    as the minority's witness. She serves on the Board of Directors
    of the Nurses Organization of Veterans Affairs, otherwise known
    as NOVA. NOVA is a nonprofit professional association whose
    mission is to educate, communicate, and advocate for VA nurses.
    NOVA is not a part of VA nor is a union. NOVA managed to do
    what UnitedHealthcare could not: arrange to get Dr. Saindon to
    D.C. to testify with less than 2 business days' notice. I want
    to thank Dr. Saindon for being here today.
        Now, I know we will not get answers to all our questions in
    this single hearing. Veteran stories are an important part of
    oversight and I thank our witnesses again for their bravery and
    candor in participating in today's hearing. However, oversight
    is not complete without accountability, and there are no
    accountable individuals here today. No accountable individuals
    are appearing before us today.
        I want to be clear that I recognize the importance of
    community care. However, I also do believe any further
    expansion of community care must be met with similar
    investments in VA direct care. The two systems should be
    complementary, in balance with one another to ensure veterans
    can access the best, most timely, culturally competent care.
        That is what is not happening right now. Community care has
    expanded at the expense of VA direct care. If we continue down
    this path, VA will crumble. This is where I draw the hard line.
    Our veterans cannot afford for us to dismantle VA direct care
    in favor of shifting more care to the community nor, by all
    accounts, do they want us to. Rushing to pass this legislation
    without sufficient oversight and diligent efforts to uncover
    the root cause of problems is a recipe for disaster.
        For example, in 2014, after news of ``secret VA waiting
    lists'' broke, Congress acted quickly to create the Veterans
    Choice Program, a temporary program that allowed veterans to
    receive community care when they faced long wait times or
    lengthy travel distances. We went from bill to law in the
    course of 3 months. As we found out over nearly 4 years, over
    the 3 or 4 years that followed, the Choice Program actually
    resulted in longer wait times, confusion about payments, and
    administrative headaches for veterans and staff at VA.
        Then in 2018, Congress passed the MISSION Act, further
    expanding community care eligibility. Yet here we are today,
    with veterans and VA staff facing many of those same issues
    with access, care coordination, and transparency. All the
    while, VA has been rolling out more policies and contract
    modifications altering the administration of the Community Care
    Program. How can we address the effect of these administrative
    changes if we are not conducting proper oversight?
        This committee also needs to conduct more oversight of the
    quality of care veterans are receiving in the community. As we
    will hear from many of the witnesses today, simply getting a
    referral to the community is only the first step. We must also
    ensure that these referrals are actually leading to veterans
    receiving high-quality care.
        Furthermore, we need to ensure that we are being good
    stewards of taxpayer dollars, as our majority so often reminds
    us. Care provided in the community is often--often comes at a
    higher price tag and can be less efficient and less effective
    than care that VA can provide directly.
        We must also consider the long-term future of VA, which
    serves not only our veterans, but all Americans, through its
    role in providing world-class and groundbreaking medical
    research, its Fourth Mission emergency preparedness mandate, as
    well as providing residency and fellowship training for more
    than 70 percent of all U.S. healthcare providers at some point
    in their careers. As a committee, we must candidly assess the
    long-term and far-reaching consequences of undermining the VA
    direct care system in favor of prioritizing private healthcare
    profits.
        With that, I yield back.
        The Chairman. I thank the ranking member for his testimony.
    Let me tell you that this is the first of many hearings focused
    on community care. We are in our very first hearing. That gives
    us a golden opportunity for a lot of them. This hearing is
    solely focused on the hearing the veterans stories so that we
    can work on this.
        Let me explain this to you. The VA, and I have said it so
    many times, the VA was created not for the VA, not for the
    bureaucracy, but providing for the veterans. In this hearing,
    we decided we want to hear from the veterans.
        As my position as chair, let me say this again, it is not
    the majority's position to privatize the VA, but to make sure
    the VA delivers to our veterans at the level that they need to
    have their care given to them when and where they need it, with
    less bureaucracy and given in a way so that incident after
    incident after incident does not occur where someone falls
    through the crack for whatever reason, whether it is in the
    community or at the VA.
        With that, we will turn to our witnesses. Testifying before
    us today is Paul McKenna. Say that correctly for me there,
    Sergeant Major.
        Mr. McKenna. Good afternoon, Chairman Bost.
        The Chairman. I am just introducing. I was just trying to
    pronounce it correctly.
        Mr. McKenna. Paul McKenna.
        The Chairman. McKenna, thank you. Now, he is a sergeant
    major of the Marines, traveled from Representative Murphy's
    district in North Carolina. We also have William Dooley, a 20-
    year Army veteran, traveling away from Congressman Self's
    district in Texas; Ms. Lori Willis Locklear, a former VA
    employee and mother of a Navy veteran, Logan Willis, traveling
    from Representative Harris' district in North Carolina; Ms.
    Brittany ``Demond,'' ``Diamond''? Just Dymond, there you go. I
    always wonder why they put that out whenever it was just pretty
    well that way. Associated director of Veterans of Foreign Wars
    (VFW); and Dr. Kelley Saindon, secretary/treasurer of the
    Nurses Organization of Veterans Affairs.
        Will the witnesses please stand and raise their right hand?
        [Witnesses sworn.]
        The Chairman. Thank you and let the record reflect--you may
    say thank you and let the record reflect that the witnesses
    answered in the affirmative.
        I now recognize Sergeant Major McKenna for the 5 minutes to
    deliver your testimony. Sergeant Major.

                       STATEMENT OF PAUL MCKENNA

        Mr. McKenna. Good afternoon, Chairman Bost. For the record,
    I am retired. Chairman Bost, Ranking Member Takano, and members
    of the House Committee on Veterans' Affairs, thank you for
    inviting me to testify for the record of today's hearing on
    veterans' experiences using the Department of Veterans Affairs'
    Community Care Network. I am here today as a voice for
    countless veterans in Eastern North Carolina who continue to
    struggle to effectively and efficiently utilize the critical
    part of the VA's healthcare system.
        As the committee is aware, the VA MISSION Act became law in
    2018 and was intended to improve access to healthcare for
    veterans. My aim today is to illustrate the gaps and seams
    within the pillars of this legislation that are present in
    Eastern North Carolina, with specific attention on access to
    care, the Community Care Network, and the education and
    training of the VA workforce that coordinates access to care in
    the community. My hope is that my testimony will offer the
    committee some insight to the real challenges that veterans
    face when using the Community Care Network in Eastern North
    Carolina.
        Additionally, and what may sound anecdotal, is to share
    with you my experiences with using the services of the VA
    Community Care Network in two different geographical locations,
    and the experiences of many veterans I have talked to who must
    utilize community-based services.
        My name is Paul McKenna. I retired in 2021 after 36 years
    of active duty service in the United States Marine Corps. I
    have learned many lessons, life lessons, from my nearly four
    decades of service as a U.S. Marine, and at the very top of
    that list is that no American can afford to be disinterested in
    any part of their government: county, city, state or nation.
        One of the great lessons the Marine Corps taught me was to
    never take for granted of being in the presence of other
    Marines and their greatness. For 36 years I walked amongst
    giants. I will forever cherish those relationships, especially
    the relationships of those American heroes that never came
    home. I truly hope that my actions and words today bring honor
    to their memory and their sacrifice.

        [The Prepared Statement Of Paul McKenna Appears In The
    Appendix]

        The Chairman. Thank you, Mr. McKenna.
        Mr. Dooley, you are recognized for 5 minutes.

                      STATEMENT OF WILLIAM DOOLEY

        Mr. Dooley. Thank you, Chairman Bost, Ranking Member
    Takano, for inviting me to testify on my frustrating experience
    with VA Community Care, specifically Dallas, Texas Veterans
    Affairs Medical Center. I sit here today as a veteran, father,
    husband, and cancer patient. I apologize for my appearance, any
    speech deficiencies that I may have while reading my statement.
    I finished my final chemo treatment a week ago and I am still
    having several single--several side effects.
        I will start from the beginning of my cancer journey. In
    September 2023, I voiced my concerns for symptoms while at a
    regular scheduled doctor's appointment. In November 2023, I
    voiced my concerns again by scheduling a doctor's appointment
    for these same symptoms in Bonham, Texas. I completed a sample
    submission for the doctor and he ordered a colonoscopy. I was
    told by the scheduling that they were backlogged and community
    care would be my best route to get care.
        I was referred to Community Care in December 2023. I was
    matched with the Community Care provider, Jenny Sang, at the
    time. My Community Care provider informed me that May 20th,
    2024, was her first available for the colonoscopy. I was
    scheduled for a colonoscopy 9 months after I voiced my concerns
    with my primary physician and 5 months after being referred to
    Community Care program.
        On May 20th, I received the colonoscopy and woke up with
    the dreaded words: you have cancer and need surgery
    immediately. Multiple phone calls from myself and my wife to
    the Veterans Affairs resulted in almost no movement forward. I
    was told it will be September before I would receive the cancer
    testing required prior to surgery. I was told I had cancer and
    the best they could do was get me tested in 4 months. This was
    not acceptable. Community Care was my best option to survive.
        We scheduled my first appointment with University of Texas
    (UT) Southwestern Oncology. With assistance from UT
    Southwestern, we were able to get scheduling for all required
    tests set up the following week, not 4 months. Community Care
    was no assistance and we used our personal insurance for the
    doctor visit. We eventually received referral and approval from
    the required testing and received approval for cancer treatment
    at UT Southwestern. This was only after reaching out for
    assistance from Representative Self's office.
        Unfortunately, after the testing was conducted, it was
    revealed that I did not have stage 1 cancer and, due to too
    many--too much time passing for the original colonoscopy, I was
    currently stage 3 cancer and my lymph node system had been
    compromised. At this point I was informed by the oncologist
    that surgery first was not an option and that a very aggressive
    chemotherapy and radiation treatment was my best option for
    survivability. The treatment would consist of eight rounds and
    two types of chemotherapy and five rounds of concentrated
    radiation. Followed by successful treatment, I would be
    evaluated to determine the level of surgery required.
        I was informed in August after receiving several bills that
    the treatment I received was not covered. This was due to the
    referral for cancer treatment not including chemotherapy or
    radiation. I was informed that of this unit because the billing
    was rejected only. Once again, we reached out to Representative
    Self's office for assistance. I do not believe we would have
    received this approval without the assistance from his office.
        Three major problems I encountered during this process.
    First, the Community Care Program does not communicate directly
    with the provider other than the original scheduling. This
    leads to confusion for the veteran, Adds possibility of poor
    case management and the treatment for the veteran. In my case,
    the Community Care worker could have assisted by contacting me
    and letting me know if 5 months wait was the only option or if
    other care providers had availability sooner.
        Second, the approval of one of the procedures but not the
    others that is known to be required together. Cancer treatments
    for us nondoctors usually comes in three forms and in most
    times all three are used: surgery, chemotherapy, and radiation.
    Why is it standard procedure to approve surgery but not the
    other two? It is very confusing to need three separate
    referrals for the same treatment plan. It adds to the confusion
    for billing and for referral management, especially when all
    three have different expiration dates. At no point did my
    caseworker have direct contact with the provider to discuss the
    issue and how to resolve it. Any attempt to call my caseworker
    and facilitate a three-way call resulted in leaving a message
    and waiting for a call back. This was due to my caseworker
    being a remote employee and not being provided a direct phone
    number to her.
        Third is a lack of professionalism and compassion from the
    VA employees. From the beginning of this journey we have been
    sighed at, told to wait, told to be--treated with disdain by
    the employees we encountered. I was treated like I was asking
    for charity and not treated as a disabled veteran that was
    trying to receive life-saving treatment. Case management
    displays some of the worst incompetence I have seen in decades.
    One of the most--on one of the occasions the response that I
    received from the VA was intertwined with mistruths and blatant
    lies about timeline and what happened. This was very
    concerning.
        At no point has anyone taken ownership or conducted an
    assessment of what could have done differently. The response
    was deny, deny, and counter accuse. Accountability for poor
    performance and low proficiency is not a strong point of
    Veterans Affairs.
        All these problems were shown last Friday after my
    submission of my written testimony. On Friday, I received a
    phone call from the Veterans Affairs. It was my primary
    healthcare provider. The message was primary healthcare
    provider asking if I had been scheduled for treatment for the
    two referrals for chemotherapy and radiation. I just found
    finished eight rounds of chemotherapy and five rounds of
    radiation. They would been scheduled over a 5-month period and
    paid for by the VA. My primary care provider had no idea if I
    would even started chemo or radiation, and still does not
    today. This shows the direct breakdown in any communication
    between Community Care, my primary doctor, and a Community Care
    provider.
        A lot of these questions and concerns could easily be fixed
    if someone cared enough to do their job as a case manager. The
    upper level bureaucracy and lack of accountability for poor
    performance in the Veterans Affairs has become just as much as
    a cancer as what courses through my body today. I can work on
    fixing my personal health, but I am asking you to work on
    fixing the Veterans Affairs because it is unhealthy and full of
    cancer.
        I appreciate the time and opportunity to share my story.
    More detailed information with names and dates has been
    provided in my official written statement. I look forward to
    any questions you may have at this time.

        [The Prepared Statement Of William Dooley Appears In The
    Appendix]

        The Chairman. Thank you, Mr. Dooley.
        Ms. Willis Locklear, you are recognized for 5 minutes.

                   STATEMENT OF LORI WILLIS LOCKLEAR

        Ms. Locklear. Hello, Chairman Bost and Ranking Member
    Takano and the House of Representatives' Committee on Veterans
    Affairs. My name is Lori Willis Locklear.
        First, I want to thank God for getting us here. Thank you
    for the opportunity to speak on behalf of my son, Logan F.
    Willis, who served in the United States Navy from August 2017
    until December 2018. Logan was our only child and his dad,
    Raymond F. Willis, was an Army veteran. I was a VA employee for
    12 years. Logan spent his summers volunteering at the VA. His
    father passed away in 2015 from lung cancer. It was very
    difficult on us both. He graduated from high school in 2014 and
    the University of North Carolina at Pembroke in 2016.
        Logan wanted to further his education, so he enlisted. His
    first duty station was Sasebo, Japan, aboard the United States
    Ship (USS) Wasp. It was during that time that Logan's mental
    health began to decline and he attempted suicide multiple times
    on the ship and later in San Diego.
        Logan received an honorable discharge on December 31, 2018,
    and returned home. I noticed many changes in Logan's demeanor
    and behavior. He was not the same person. As a VA employee, I
    directed Logan to seek help from the VA, but was told, we
    cannot help you. At this point, he developed a distrust for the
    VA system. Logan was so distraught with the lack of support he
    had received at the VA one day I came home and Logan had packed
    up all his belongings and left. Later, he stated he could no
    longer live in a place where he felt unsupported. The saddest
    part for me as a mother is that Logan saw me as the VA.
    Unfortunately, Logan could not see that I was working as hard
    as possible to help him. I was the mother of a veteran and an
    employee, but the mother always came first.
        In the fall of 2019, he entered the master's program at
    Wake Forest University. He was still struggling with depression
    and anxiety, but he was focused on earning his degree. He was
    receiving counseling that he paid for himself and his
    medications. As we all know, 2020 was the year of COVID and
    everything shut down. His classes were all online. There were
    times when Logan would not leave his home for weeks. I checked
    on Logan, visited, encouraged him constantly. He became more
    isolated. As a VA employee, I saw a veteran who was in trouble
    and needed help. With no trust in the system, he would rather
    suffer than seek help. Sadly, we see this so much with too many
    of our veterans who have served their country.
        Logan graduated on May 14, 2022, with a master's degree in
    divinity. After graduation, he was unable to find a job and had
    to move back home. As his mother, I encouraged him to seek the
    services he was eligible for, but, once again, he was
    skeptical, but decided to reach out to the local veterans
    service center for help in June. At the meeting with the
    veterans service officer, he seemed encouraged.
        As a pharmacy technician, I feared that Logan was over
    medicated. On September 1, 2022, I requested a session for
    Logan to speak with our pharmacist so he could ask questions
    about his meds and their side effects. Afterwards, I sent Logan
    to check in and request a mental health provider. He said later
    that he had been given an appointment. However, I learned after
    Logan's death that his appointment was not until 5 months
    later, for February 2023. Logan's mental health issues needed
    immediate help and again was not met. He was met with a broken
    system.
        The Community Care Act, to my knowledge, was not offered.
    Protocol at that time was a veteran request--if a veteran
    requested a mental health provider, they were to be seen or
    sent to Community Care within 20 days. Logan died 63 days
    later. He was never contacted. November came and there was
    still no action in regards to the services Logan had requested,
    to my knowledge. Again, he was disappointed in the VA and, as a
    result, his anxiety and depression increased. As his mother I
    was still working to help find help for my son.
        On November 4th, 2022, my worst nightmare occurred. Logan
    was found in the bathtub at my home by his stepfather with a
    plastic bag over his head and a helium tank with a hose beside
    him. I returned 2 weeks after Logan's burial. I was very
    unstable and not well, but I knew I had to go back to work and
    report a suicide. After doing so, I waited for weeks and I was
    never contacted as an employee or a veteran's family member. It
    was not until February 23rd, I contacted the director to make
    sure she was aware. She stated she did not have knowledge of
    said death.
        I continued to work for as long as I could. I missed most
    of `23 from my job. I was not able to function. I took an early
    retirement. I had to go home. The next year I contacted
    everybody and anybody that would honestly would speak to me. No
    one wanted to talk to me and I was treated like a
    whistleblower. Today I feel like a whistleblower. That is all I
    have to say.

        [The Prepared Statement Of Lori Willis Locklear Appears In
    The Appendix]

        The Chairman. First off, thank you for your testimony.
    Thank you for the three of you. We are going to come back. A
    vote has been called in the House. The committee will stand--
    and I hate to do this right in the middle of this, but it is
    what happens here. Okay? This is a very serious subject.
        If the members would please go to the floor, we have two
    votes, and then return as quick as possible. The committee will
    stand in recess at the subject of the call to chair. We expect
    to reconvene about 10 minutes after the last vote has been
    called. Thank you.
        [Recess.]
        The Chairman. The committee will come to order. I do want
    to apologize to our witnesses. It is part of what we do around
    here. The timing was not--well, anyway.
        Ms. Dymond, you are recognized for 5 minutes to provide
    your testimony.

                  STATEMENT OF BRITTANY DYMOND MURRAY

        Ms. Murray. Chairman Bost, Ranking Member Takano, and
    members of the committee, on behalf of the men and women of the
    VFW and its auxiliary, thank you for the opportunity to provide
    our remarks on this critical topic.
        The VFW believes the VA Community Care Program and its
    network of providers are a vital component of VA healthcare.
    However, it does not always work as Congress intended. My story
    is just one example of a negative experience that could have
    been avoided. For 10 years, I exclusively received Department
    of Defense (DOD) and VA-provided mental healthcare. Not only
    did DOD not diagnose me with Post-Traumatic Stress Disorder
    (PTSD), the VA did, but VA providers also failed to identify
    the complexity of my PTSD diagnosis, resulting in treatments
    that did not fully help. Despite consistent care, I battled
    crippling emotional numbness and had come to blame myself for
    being defective. I also started experiencing passive suicidal
    ideations.
        In late fall 2021, I was referred to a civilian therapist
    through VA Community Care, and she diagnosed me with complex
    PTSD, the first time I recall a mental health professional
    using that term. In May 2022, based on my trauma history,
    symptoms, and her clinical expertise, she recommended a PTSD
    inpatient program with very specific treatment criteria.
    However, D.C. VA staff would not authorize a referral to the
    program because it was in Utah and its physical location was in
    Community Care Network 4. We were told to choose a local
    program instead.
        Following a service-connected surgery, I revisited the
    inpatient treatment discussion with my therapist. This time
    around, however, I had done extensive personal research which
    indicated that in addition to a method called Eye Movement
    Desensitization ad Reprocessing (EMDR), a relatively rare
    therapy called Internal Family Systems (IFS) was effective in
    treating complex PTSD. My therapist and I decided to try to get
    approval for an Arizona program that was also in Community Care
    Network 4 on the West Coast, but offered both EMDR and IFS.
        In July 2023, frustrated with the seeming lack of urgency
    on VA's part, I physically went to the Washington D.C. VA and
    spoke with a social worker, who promised to advocate for a
    referral on my behalf. Again, the referral was denied due to
    its geographic location, but the social worker promised that he
    would keep trying. Unfortunately, he went on emergency medical
    leave and my request for inpatient treatment fell through the
    cracks for over a month.
        In September 2024, VA staff tried helping me find East
    Coast treatment options. However, so much time had passed since
    my initial request in July, I would have to wait until January
    2024 for my next opportunity to enter treatment. I tried
    finding Utah and Arizona comparable programs while the VA
    employees offered in-network options on the East Coast. It felt
    like trying to find a needle in a haystack and VA's suggestions
    generally fell short. Some programs were too long while others
    were only part time. Some had poor reputations while others did
    not offer the correct treatments or they were primarily focused
    on mental health conditions I did not have, like eating or
    substance use disorders. One facility was for patients who were
    dangerous to themselves or others, which was inappropriate for
    me, while another was coed and did not understand why I would
    want to go to a women-only treatment program.
        After weeks of searching, we found a comprehensive
    program--or sorry, a compromise program in Pennsylvania that
    met some of my criteria, but did not offer the EMDR or IFS
    treatment modalities that I needed. I agreed to go there and,
    fortunately, my assigned therapist was able to help me
    understand my complex PTSD symptoms and she ensured my follow-
    on care was with a qualified professional, who did provide
    those needed treatments. I am lucky to have landed with the
    civilian therapist that I did and for the resources family,
    friends, coworkers and accommodating employer that I have. Not
    all veterans can say the same.
        However, getting the right mental healthcare should never
    hinge on luck. I have since learned that suicidal ideations are
    actually a product of the fight element in one's fight or
    flight response essentially giving out. Had I not been
    knowledgeable and advocated for my treatment needs and as a
    result been sent to a treatment program that could not truly
    help me, it could have been my last attempt at getting better.
        VA must stop its practice of rationing inpatient mental
    healthcare based on arbitrary, seemingly thoughtless
    guidelines. Arbitrary location rules should never be the only
    factor in determining which veterans have access to life-saving
    care. Providing veterans with the correct mental healthcare the
    first time means saving lives.
        Chairman Bost, Ranking Member Takano, this concludes my
    testimony. Again, the VFW thanks you for the opportunity to
    testify on this critical issue. I am prepared to take any
    questions you or members of the committee may have.

        [The Prepared Statement Of Brittany Dymond Murray Appears
    In The Appendix]

        The Chairman. Thank you, Ms. Dymond.
        Dr. Saindon, you are recognized for 5 minutes to provide
    your testimony.

                      STATEMENT OF KELLEY SAINDON

        Dr. Saindon. Chairman Bost, Ranking Member Takano,
    distinguished members of the committee, on behalf of the
    members of Nurses Organization of Veteran Affairs, or NOVA,
    thank you for allowing us an opportunity to present our views
    on the topic, ``Restoring Focus: Putting Veterans first in
    Community Care.''
        As a VA nurse, I want to begin by expressing my sincere
    sorrow hearing the stories from these witnesses at this table.
    It is important that we learn from these cases to improve care
    in the veteran experience throughout the VA. NOVA understands
    and supports community care when access to VA is not readily
    available, the distance is too far, or the VA does not provide
    the needed care. We recognize and acknowledge that we cannot
    serve everyone everywhere. Our priority is to ensure veterans
    receive the highest level of care within the VA and utilize
    community care as needed to enhance the healthcare experience.
        Since the passage of Choice and MISSION Acts, community
    care has rapidly expanded. Community care referrals have risen
    by approximately 20 percent annually and 44 percent of Veterans
    Health Administration (VHA) healthcare funds are spent on
    community care. While the MISSION Act expanded community care,
    it was not meant to replace VA's integrated health care system.
    The legislation was meant to provide a balance between non-VA
    care when necessary while bolstering VA direct care.
        We are beginning to see shifts in care and staffing that
    risk diminishing the superior care that VA provides veterans.
    Provider shortages and budgetary constraints continue to affect
    VA care and community care. The constriction and closure of
    community healthcare systems have raised concerns about how and
    when veterans can be referred to the community. The community
    healthcare systems are saturated and cannot absorb the
    continued increased demand for veteran care in the community.
        Despite innovation and improvement focused on efficiency
    for community care coordination, the policy-driven steps remain
    laborious. Inconsistency in scheduling and authorizations
    across the system create confusion for veterans and for our
    community partners. A public-facing site that provides detailed
    information about community wait times, quality metrics,
    provider credentials, and provider training is imperative for
    veterans to make informed decisions about their healthcare.
        VA clinicians are more likely to have experience and
    specialized training in recognizing, diagnosing, and treating
    conditions often encountered by veterans. They are uniquely
    trained not only on military culture, but on veteran-specific
    exposures. The standards for our community providers should be
    no different.
        The oversight of care in the community is inadequate at
    best. We recommend Congress implement strong action and
    enforcement of mechanisms to increase quality and oversight of
    community care. Failure to meet quality expectations should
    result in removal from the network.
        It is vital that VA facilities have more control over
    services provided in the community. Records must be received
    promptly so the VA can direct further care, including any
    necessary diagnostic testing. Without proper coordination
    between VA and community providers regarding the timely return
    of medical records, veterans may not receive the necessary
    information to make informed healthcare decisions.
        For example, this vulnerability is especially important
    with lung cancer screening, lung nodule, follow-up mammograms,
    and colonoscopies. Stories from our membership include VA
    Community Care staff requesting records three or four times to
    the community provider with no response. This leaves the
    veteran at risk for serious and, in some cases, life-
    threatening poor outcomes.
        We recommend the Community Care Network have prescriptive
    guidelines for record sharing. Current practice leaves much
    risk for healthcare decision delays. We encourage Congress to
    implement business rules that permit payment upon receipt of
    medical records. Studies have consistently shown that VA care
    equals or exceeds the quality care provided by the private
    sector. Recent star rating reviews demonstrate that VA
    hospitals score higher than non-VA facilities in both patient
    satisfaction and quality of care.
        My hospital, White River Junction, Vermont, received a
    five-star overall hospital and five-star quality rating in
    September 2024. It was the only facility in Vermont and New
    Hampshire to earn the top rating.
        A 2024 VFW survey showed overwhelming support for VA to
    remain the primary deliverer of care for veterans, with most of
    them saying they prefer using VA medical facilities for their
    healthcare needs. The VA must remain the primary provider and
    coordinator of veterans' healthcare, using community care as a
    supplement when VA services are unavailable. Authorizations and
    referrals should follow access and eligibility standards.
    Requirement for both VA and Community Care should include
    consistent quality and training standards.
        Listening to veterans stories helps us understand their
    needs. NOVA is committed to working with Congress, community
    partners, and VA leaders to ensure veterans receive timely
    access to the highest level of care.
        Thank you again for this invitation to testify. I am happy
    to answer any questions many may have.

        [The Prepared Statement Of Kelley Saindon Appears In The
    Appendix]

        The Chairman. Thank you. Before we get started, I would
    like to thank Representative Harris, who represents Ms.
    Locklear in Congress. He will be joining us later on, but we
    need to make sure that in accordance with committee rule number
    5(e), unanimous consent that Representative Harris from North
    Carolina be permitted to participate in today's committee
    hearing.
        Without objection, so ordered.
        I recognize myself for 5 minutes of questions. Ms.
    Locklear, you shared how your son struggled to access mental
    healthcare. If VA had told Logan about his community care
    eligibility early on, do you think it would have made a
    difference?
        Ms. Locklear. Logan died and I got some bank statements,
    his last bank statements. I have bank statements that shows he
    spent $800-and-some in like 2 months for his mental healthcare.
    He called me one day at work frantic, saying, Mom, I am out of
    my medications. What am I going to do? What am I going to do? I
    said, Logan, you. I directed him to go to his local pharmacy. I
    said, no pharmacist is going to withhold your mental health
    meds from you till you can get a new prescription.
        He did so, he came home, he had bought $288 worth of
    medication that day. I looked at the receipt and I was like,
    Logan. He said, Mama, that is what they said it was, so I just
    paid it. I was like--and that is one of the reasons why I
    brought him into our facility, set him down with their
    pharmacist, and because they--I--they knew the meds he was on
    and they said, Lori, these drugs he is on are dangerous.
        That is the reason after we had that discussion, I said,
    check into the--check in. I told him, I said, if I could get
    you into my facility, I can help manage and take care of your
    mental health--with your mental health needs and his
    medications; $288 that he paid for out of his pocket. My son
    was going into a hole trying to take care of his mental health.
        The Chairman. He did not know that it was available to him.
        Ms. Locklear. He knew it was available, but, I mean, he had
    no faith in the VA. Then when I finally talked him into it,
    there was error after error after error that was done in
    paperwork. He checked in, he got a 5-month appointment, mental
    health. If he had came home and told me that they had given him
    a 5-month appointment, I would have said, you come right back
    to the VA tomorrow, I am going to go down there with you. I
    would have questioned them. Why are you giving a mental
    health--a young man, if you looked at his record, he had tried
    to attempt suicide multiple times in the military. I do not
    understand why he did not have an appointment when they allowed
    him to--an honorable discharge in December. Why would not he
    give him a mental health appointment right then? Why was not he
    locked into a facility right then for from the military?
        The Chairman. Mr. McKenna, you testified the VA counselors
    and parents advocate in your written testimony were unable to
    provide clear guidance on your care options. How do you think
    VA needs to fix this?
        Mr. McKenna. Chairman, if I understand the question
    correctly, it talks about the dichotomy of the two experiences
    I have had. First, when my wife and I retired, we moved to
    northwest Florida, specifically in the Pensacola region. Very
    similar with respect to services as it is in eastern North
    Carolina, meaning the main VA hospital center for northwest
    Florida is located in Biloxi, Mississippi. That is about 2-1/2
    hours from our home.
        Same situation, when I went to the VA clinic in
    Jacksonville after relocating a year later in eastern North
    Carolina, the main VA clinic is in Fayetteville, North
    Carolina. That is again 2-1/2 hours from my residence in
    Richlands, North Carolina.
        These two VA clinics, both in Pensacola and Jacksonville,
    North Carolina, are completely different in the fact that, one,
    the process in Pensacola, Florida, was seamless. The quality of
    care I received from that VA clinic, from meeting with Dr.
    Sandoval and his team, to talking to VA counselors in the
    network, Community Care Network, to actually seeing providers
    out in the community, that entire process from flash to bang
    was about 10 to 15 days depending on what that specialty care
    was.
        Conversely, in eastern North Carolina, same specialist care
    I need, one, I cannot be seen at that VA clinic by either a
    doctor or a nurse because they do not have that capability or
    capacity there. Additionally, they are not taking any new
    patients. They, in turn, set me up with care in the community,
    to a clinic, a Med First clinic. It is a primary and an urgent
    care clinic. Only thing on staff there are nurse practitioners.
    No doctors, no nurses. Good people, but probably from drawing
    your blood to basic medical care like a flu shot, it is beyond
    the scope of their capability.
        They, in turn, will put a referral in. Now, unfortunately,
    they have to use a third-party vendor to do this. The third-
    party vendor puts that referral into the VA, again delaying the
    process.
        I think to answer your question more directly, the friction
    point in eastern North Carolina lies with the third-party
    vendor. There appears to be no oversight either from the VA or
    from Med. First. When I tried to advocate for my own healthcare
    by saying, hey, can I get an email or a phone number to talk to
    this third-party vendor, I was told both by the VA and Med
    First that they are not authorized to provide me that
    information to be able to communicate, to understand why this
    process is taking so long.
        Then finally, when you do try to, or at least when I try
    to, understand what is causing these delays and when you talk
    to the VA counselors either on the telephone or through
    MyHealtheVet online, I get responses like that is just the way
    it is here, or we did not receive the required paperwork from
    your primary care provider out in town.
        Now, to the latter statement, I personally watched that
    nurse practitioner at Med First in Richlands, North Carolina,
    fax that form to the VA. Then when I followed up the next day
    having a fax receipt of that, I was basically told, ``I do not
    know what to tell you.''
        Again, sir, to answer your question more directly, more
    oversight on that third-party vendor and then better training
    and education to the VA workforce that works the Community Care
    Network.
        The Chairman. Thank you. I am way over time, but Ranking
    Member, you are recognized.
        Mr. Takano. Well, with that, Mr. Chairman, I am very glad
    to hear that you intend to hold more oversight hearings and I
    hope you do that before we rush a bill to the floor that
    purports to be a solution. Who is precisely missing this panel
    is the third-party administrator and anyone from VA.
        I want to change my question to Ms. Saindon. You know, I
    find it curious that my majority counterparts want to see VA
    function more like a private sector actor. They force VA to
    abide by standards that no one in the private sector would ever
    accept. For example, can you imagine that UnitedHealthcare
    would pay claims without receiving a patient's health record or
    any proof of medical necessity? Medical necessity. Yet through
    the third-party administrator, in this case Optum, which is in
    reality UnitedHealthcare, renders payment on behalf of VA
    without requiring their providers to transmit veterans' medical
    records back to VA.
        Now, Dr. Saindon, do you think that VA's contracts should
    require network providers to submit medical records as a
    condition of payment?
        Dr. Saindon. On behalf of the membership at NOVA, yes,
    absolutely. We have discussed this ad nauseam. It is a huge
    threat for good coordination of veteran care. We are aware that
    the contract, the next generation of the contract, is imminent
    and we strongly advise Congress to consider modifications to
    that where payment is issued upon receipt of those medical
    records. We have countless examples of how healthcare has
    failed those veterans as a result of not having those medical
    records readily accessible.
        Mr. Takano. Thank you for that answer. Again, I would point
    out that Optum, otherwise known as UnitedHealthcare, is not
    here. They were given a pass for not being here and they are an
    accountable party and they are a third-party administrator.
        I hold VA accountable also for not having contracts written
    so that this is part of how you do business. VA is forced to
    operate not as a private sector company would not think of
    operating. Any private healthcare network would make this a
    condition of reimbursement.
        How does not having these records affect VA's ability to
    properly coordinate veterans' care?
        Dr. Saindon. Countless ways.
        Mr. Takano. Yes.
        Dr. Saindon. Significantly, it poses a real threat to good
    coordination of care. A good example of this is a veteran gets
    referred out to a community network provider as a result of a
    specialty that they may need and have a follow-up with primary
    care provider a week later, 2 weeks later, whatnot. The
    veteran's information yet has still come over to the VA from
    the community provider. That puts the VA providers in a real
    problem situation, unable to determine what recommendations,
    what were the treatment plans, et cetera.
        Mr. Takano. Yes. I would have loved to have VA and
    UnitedHealthcare here to explain why this has gone on and why
    it continues to go on.
        There are kinds of care that, Dr. Saindon, that private
    sector care is simply not equipped to provide. They are just
    not going to invest the money or the resources or research into
    it. It is unwilling to provide because there is no profit to be
    made. No profit. That is why the public backs up our veterans
    when the private sector is just--there is not the incentives to
    do it.
        For example, VA has invested billions of dollars to provide
    care for veterans with complex spinal cord injuries, traumatic
    brain injuries, limb loss and prosthetic needs. What will
    happen to this very specialized care if we continue down this
    path of community care expenditures outpacing investments in
    the VA direct care system?
        Dr. Saindon. Community care for these specialized services
    that you just mentioned are just simply not available. More so
    in the rural settings. The care is not comparable. If there is
    a spar resource in the community for that specific specialized
    care, it is too finite to take care of our veterans adequately.
        Mr. Takano. Well, thank you. In your testimony you
    highlight the anticipated national shortage of primary care
    physicians that the national healthcare system will face in the
    coming years. That is not just VA doctors, but the national.
    Can you elaborate on why this makes it more important than ever
    to invest in a strong direct care network at VA?
        Dr. Saindon. NOVA is incredibly proud of our educational
    mission. We train 70 percent of healthcare professionals
    nationwide. In other words, if you ask a healthcare provider if
    they have had any type of training or stepped foot in a VA
    during the course of their training, you will hear a lot of the
    yeses there. Our goal is to grow our own, maintain those
    trainees, support training the healthcare infrastructure as it
    relates to providers. Robust scholarships, incentives,
    continuing education opportunities is a way that we could
    incentivize that. NOVA strongly supports considering those
    options.
        Mr. Takano. Not having a strong direct care network at VA
    will definitely impact the training of our future
    professionals?
        Dr. Saindon. Absolutely. We have already seen it. In fact,
    there is a gross shortage of educators in the healthcare
    industry as well as preceptors on the front lines in the field,
    limiting our ability to take student trainee placements. If we
    continue to struggle budgetary and/or with veteran care, access
    to veteran care, we will have to continue to limit our
    capabilities of taking trainee placements, which will
    ultimately collapse healthcare.
        Mr. Takano. Thank you. I yield back.
        The Chairman. Dr. Murphy.
        Mr. Murphy. Thank you, Mr. Chairman, and thank you all for
    coming today. Thank you for the service to your country. These
    are some real difficult stories to hear from somebody who has
    taken care of VA patients for 35 years and actually continues
    to do so.
        I find it somewhat ironic the ranking member brings out the
    stories that we are talking about the failures of the VA over
    the last, good Lord, I do not know how many years, but
    especially over the last administration where they continue an
    electronic medical record (EMR) system that is outdated,
    incompetent, inefficient, does not communicate. I can say this
    on the front end and the back end, it does not cost a penny, a
    penny, for me to click a button and send something, a medical
    record as a community care provider to the VA. Does not cost a
    penny. We do it all the time when we communicate with all the
    other doctors. That is not true. It is not anything has to do
    with profit. It has to do with the fact that we have a
    inefficient organization that is becoming more and more
    inefficient. I am so optimistic that with the next
    administration we are going to crack it down and actually make
    it like a private organization would be efficient and for the
    people who actually should benefit from this, our veterans.
        You know, I have said this many times here, I have veterans
    show up and I have no records in front of me, nothing.
    Community Care is supposed to take care of them. Community Care
    exists because the VA does not have the medical expertise or
    the physicians to take care of them. We have our national
    institutes that govern our medical schools now, which are
    absolutely being negligent in how they are creating doctors.
    This situation is not getting any better. It is going to get
    much worse.
        As specialties occur, I just tried to get on a website here
    to see what urologists were needed in the VA. They are all over
    the place. If you want, if a veteran needs urologic care, they
    are either going to not get it at all or they are going to have
    to go out into the community. It is just a fact. Specialty
    care, as I have said this before, costs more than other care.
        Anyway, enough of that rant. You know, I am happy. I would
    love to see UnitedHealthcare come in here. I would love to see
    that. I look forward to that day because they are killing
    people out in the regular community and they are by denying
    care and they are doing the same thing with our veterans. The
    third party stuff, I am looking so much forward to creating
    some true efficiency within the VA.
        Sergeant Major McKenna, thank you for your service. Welcome
    to--I love, you know, eastern North Carolina. We got a little
    snow today, by the way, out of the blue. I want you to tell
    your experience because you were in Florida and you thought you
    had an efficient community care system. You have come to North
    Carolina and it is not. Can you tell me the pros, cons, what
    you think that is all about?
        Mr. McKenna. Thank you, Dr. Murphy. Just to pile on your
    point, if I may, what would further assist the VA is building
    that electronic bridge with respect to medical records from our
    servicemembers, whether they do 4 years or 40 years, to be able
    to have those VA doctors and even the care and the community
    doctors access ALTA or other VA medical and dental records
    would again bring us into the 21st century.
        Mr. Murphy. Yes, I have gone on about how broken the system
    is----
        Mr. McKenna. Yes, sir.
        Mr. Murphy [continuing]. and continues to be inefficient.
        Mr. McKenna. Back to your question, sir. You know, my wife
    and I initially resided in Northwest Florida upon my retirement
    in 2021. There were several factors that drove us to that
    geographical location to retire. Number one, my wife Michela,
    who is a Federal employee, took a job in government service at
    Naval Air Station Whiting Field in Milton, Florida. Number two,
    the quality of cardiac care in northwest Florida. Michella
    received a mechanical heart valve after being diagnosed and
    treated for endocarditis in 2013. Then finally, the word from
    my fellow retired Marines that the VA healthcare system was
    first rate in that location.
        Michella's healthcare is covered by Treatment, Resources,
    and Insurance for Care or Active Duty and Retired Military
    Personnel (TRICARE) for life. As you all are well aware, that
    insurance.
        Mr. Murphy. Sergeant Major, I do not mean to interrupt, my
    time is limited, but if you can talk about the 6 months versus
    the year.
        Mr. McKenna. Oh, absolutely, sir. The process, and I think
    I already alluded to it in an earlier statement that in
    Pensacola, from seeing a doctor at the VA to getting a referral
    to be in care in the community, to being actually seen in the
    community 10 to 15 days. Conversely, eastern North Carolina,
    seeing a doctor not at the VA out in the community, to getting
    a referral, and I am talking about for specialty care needs,
    Traumatic Brain Injury (TBI), mental health, orthopedics,
    urology, I am waiting personally 9 months still for that
    referral to be approved. Let me repeat that. I am waiting 9
    months for that referral to be approved.
        Now, my fellow veterans in eastern North Carolina, this
    story is not unique. We are talking 6 to 9 months to get any
    type of specialty care in eastern North Carolina. Despite my
    best efforts to advocate for my health, you know, contacting
    the VA advocate, those calls go unreturned, you know.
        Mr. Murphy. I have got to close up with my time. The bottom
    line is, my understanding it is the bureaucracy is not allowing
    you to see the doctor in a timely fashion. As Mr. Dooley has
    shown us, that can have up to lethal consequences. Thank you
    for your service. Thank you for your testimony.
        Mr. McKenna. Thank you, Dr. Murphy.
        The Chairman. Ms. Brownley.
        Ms. Brownley. Thank you, Mr. Chairman. Thank you to the
    panel for being here and sharing your stories. I am, you know,
    deeply sorry that the VA did not provide the services and the
    quality of healthcare that each and every one of you and Ms.
    Locklear's, in your son's case, that they earned and deserve. I
    am sorry to hear that.
        I have to say I have been on this committee for 12 years,
    and over that 12-year period, I have heard over and over and
    over again that a very large percentage of veterans say they
    prefer receiving their healthcare at the VA over Community
    Care. They believe that the quality of care within the VA is
    very good and in some cases superior. What we have to kind of
    wrestle with here on the committee is the more we invest in
    Community Care, the less we invest in VA care. I think, you
    know, we have been wrestling with that and we need to continue
    to find where that balance really is.
        I believe in Community Care. For 12 years on this
    committee, I have advocated for better equality for healthcare
    for our women veterans. Women veterans have to receive a large
    portion of their healthcare outside of the VA. It is clear that
    to provide those services to our women veterans, we have to
    have Community Care. That is a true phenomena, you know, beyond
    one population, meaning women veterans.
        You know, I think in many cases also that wait times are
    largely longer in the community than in the VA. Now, I know,
    Mr. McKenna, you have talked about the processing and sort of
    the bureaucracy that goes on, and I think that is certainly
    part of the problem when we talk about longer wait times in the
    community. It is also true that in most circumstances, wait
    times in community care are just--they are just simply longer.
    It is just a fact. The way I see it, the facts that I see is
    that--and although every VA is not the same, and Mr. McKenna,
    you have pointed that out--or was it, I am sorry, Mr. Dooley,
    were you the one that said you got good healthcare one place
    and not so good?
        Mr. Dooley. That was actually Mr. McKenna.
        Ms. Brownley. Mr. McKenna. Mr. McKenna has pointed that
    out, that not every VA is not the same. If you receive
    healthcare in the VA, I think this is a fair fact to say, that
    if you receive healthcare in the VA, it is usually quality
    care. The care is also less expensive. The National Bureau of
    Economic Research recently came out with a working paper that
    found that VA also reduces total spending by 21 percent
    relative to non-VA providers. The care is less expensive in the
    VA.
        If we invest more in the VA, wait times will improve and it
    is what the veterans want. They want the large propensity, the
    larger percentage of veterans, they want their healthcare
    within the VA. That is, I think, that is in essence what we
    kind of have to wrestle with here. You know, where is the right
    balance?
        I think it is--I do not know whether all of you are
    advocating for--it sounds to me like you are advocating--I am
    not sure whether you are advocating for more community care or
    better community care. I am not sure which one it is. If it is
    better community care, I am with you all the way. If it is more
    community care, I am not sure that we have found the right
    balance. That is kind of where I am.
        Ms. Dymond, can you just respond to what I have just said?
        Ms. Murray. Absolutely, and thank you for the question. I
    would say absolutely better community care. There are many
    holes which have been illustrated by, you know, the panel,
    including myself, and I think there needs to be more meaningful
    effort put behind how veterans are assisted in accessing that
    community care. A lot of the pressure is put on the veteran
    themselves to do the work. We were handed off to--I should
    speaking for myself, I have been handed off. What I have
    illustrated here and in other experiences, interactions I have
    had with Community Care where an overwhelming amount of the
    pressure is put on me to figure out what care I need and find
    the correct providers because VA is not doing it on their own.
    It is really tough, better, absolutely.
        Ms. Brownley. Well, my time is out. I will just say, Mr.
    Chairman, I am happy to work with you to improve the process by
    which we get veterans' Community Care when we need it. I am not
    willing to, you know, have a large conversation about just
    increasing, increasing, increasing, increasing.
        The Chairman. That is not what the conversation is. The
    conversation is providing the best for our veterans and doing
    it correctly. Right now the system is broken and we have got to
    fix it because of things like this. It is a quality. The thing
    is obviously Veterans Benefits Administration (VBA) getting
    paperwork right and all of that. We have got to quit arguing on
    whether it is--whether I am right or you are right or who is
    Republican, who is Democrat, and start arguing for the
    veterans. That is what we are trying to do.
        I have told--and I will tell you this, we will also bring
    the other ones that the ranking member has asked for. To say
    that we did not bring them in because we were trying to do some
    kind of ridiculous thing about arguing over the community and
    over VA, I think that what we have to do is make sure the
    veterans get what they want, when they need it, where they need
    it, at the level that they need. I agree with you that there
    are a tremendous amount of people that have a tremendous
    experience at VA if they can get when they need it and if I am
    not traveling five hours to get there.
        We have got to keep working on it together. We cannot just
    all of a sudden say, well, you believe this and you believe
    this, and we have got to start working on it together. We have
    got to.
        Ms. Brownley. I believe we have to work on it together,
    too, but I think we have to have more hearings around this
    debate----
        The Chairman. I got it.
        Ms. Brownley [continuing]. a lot more issues and----
        The Chairman. When----
        Ms. Brownley [continuing]. make sure that we are working
    off common facts.
        The Chairman. When our staff writes our script, maybe what
    they should also pay attention to is the fact we are trying to
    work together and quit trying to make look like it is a
    partisan act. Just saying, so.
        Ms. Brownley. I yield back.
        The Chairman. All right. Mr. Hamadeh.
        Mr. Hamadeh. Thank you, Mr. Chairman. As a veteran, I
    understand the obligations we owe to our fellow veterans. Now,
    President Trump got it right when he signed the bipartisan
    MISSION Act, putting veterans in charge of their healthcare
    decisions. Yet today we are seeing bureaucratic roadblocks that
    prevent veterans from accessing timely care, especially with
    mental health services.
        Now, the stories we heard today are deeply troubling. I
    want to commend President Trump's incoming Veteran Affairs
    Secretary, Doug Collins, who many here know him very well when
    he served in Congress, for his commitment to accountability at
    the VA. We must do more to ensure veterans can choose where
    they receive care. The VA system should work for the veteran,
    not the other way around. When a veteran needs help, they
    should not face a maze of prior authorizations and arbitrary
    denials.
        The data is clear. Expanding community care access does not
    increase cost, it increases quality. We must codify access
    standards to guarantee veterans' rights to seek care outside
    the VA when needed. I want to thank all the witnesses for
    coming today and for their service and for being sharing your
    brave stories as well.
        Now, Mr. Dooley, my first question is for you. You waited 9
    months for critical treatment. If you could redesign the VA's
    authorization process for veterans seeking urgent care, like
    cancer treatments, what specific changes would ensure veterans
    get immediate access to the nearest qualified provider, whether
    VA or Community Care?
        Mr. Dooley. I think to start that off, the first thing
    would be to know how fast they can get it from the VA. That is
    the first thing to know and inform the veteran of that, of when
    they could get that treatment. The second would be going into
    community care, if that is the route that they decide to go,
    being able to reach out to different care--community care
    providers and finding what amount of time that they could
    actually get it done. In my case, if it could be done in the VA
    in, say, 3 months, that is too long. Let us see what community
    care can do. Then if community care is 5 months, obviously the
    servicemember being allowed to know that and then make a
    choice, but then also going back and seeing what other care
    providers may be available that could get it done earlier, that
    would provide me with the earliest treatment I could, and then
    also the knowledge of knowing which one would provide that so I
    can make an educated decision.
        Mr. Hamadeh. Thank you. Now, would you support eliminating
    prior authorization requirements entirely for certain urgent
    medical services, similar to how we handle emergency care?
        Mr. Dooley. Without knowing the full specifics of that, I
    cannot say that I would recommend one thing or the other. What
    I could say is I would like the opportunity to cut through the
    red tape and allowed to get my screening prior to that. It
    could have made all the difference. If anything, that would be
    cutting through the red tape and getting the servicemember to
    that type of treatment as soon as possible, I would recommend.
        Mr. Hamadeh. Thank you. Now, Ms. Locklear, you witnessed
    firsthand, tragically, how delays in mental health affected
    your son's trust in the VA system. Now, should not veterans
    have the immediate right to seek mental healthcare from any
    qualified provider in their community without jumping through
    bureaucratic hoops?
        Ms. Locklear. Yes.
        Mr. Hamadeh. How would this have impacted your family
    differently if that were to have been the case?
        Ms. Locklear. Well, Logan did that. I mean, he took it upon
    himself to get the care that he needed because of his distrust
    in the VA. Unfortunately for Logan, I think he got a provider
    that just--she just continued to prescribe him medications and
    he was so desperate to get better, to honestly get better. I
    think she was over medicating him.
        I found out recently, just a few days ago, I knew he had
    went into the Emergency Room (ER) and I found out he was in the
    ER because he had lithium toxicity. She had put him on lithium.
    When I spoke to my pharmacist about it, they said, Lori, that
    is a dangerous drug. It is old. I cannot believe It is even
    being used. He was on it and he had to go to the emergency room
    because he--it became toxic.
        I would like to say something in regards to what you are
    already saying, if you will let me do that. Sixty days to get
    community care, okay. When Logan checked in, and by the time it
    took Community Care to sign off on what he needed was 2 days
    prior to his death. Well, in those 2 days, he still did not get
    called, so.
        At the time, COVID, when COVID came in, we had staff that
    left our hospital to went home to work remote. They never came
    back. They worked from home the entire time. Still working from
    home. Trump telling these the employees to come back to work,
    they need to come back to work. I do not know that that did not
    take part and why it took 60 days for someone to look at my
    child's chart and say he has already tried to commit suicide a
    number of times. He's depression. We might need to go ahead and
    get him taken care of as soon as possible. That did not happen.
        Mr. Hamadeh. Thank you. Mr. Chairman, I yield back.
        The Chairman. Thank you. Dr. Conaway.
        Mr. Conaway. Thank you, Mr. Chairman. Thank you to the
    witnesses for bringing forward their experiences for the
    edification of this committee.
        We as a Nation should be deeply grateful for the sacrifices
    that our veterans have made on behalf of all of us and their
    families have made on behalf of all of us. As a physician and
    veteran myself and someone who spent the last 25 years trying
    to figure out how to expand access to quality care in my own
    state of New Jersey, as I listen to your testimony, I can
    easily point out the many failures on a bipartisan basis that
    have occurred in advancing access to quality care for members
    of our society. It is particularly troubling and concerning
    when we are seeing these problems among our veterans to whom we
    owe so much.
        There are failures to invest in the technology that will
    allow us to understand what is going on. If we do not
    understand data about who is being seen, when they are being
    seen, what paperwork and information that needs to flow from
    those experiences so that care can be examined and improved,
    then we are failing. This is anytime you put more and more
    bureaucracy in a situation in healthcare, and we see this all
    over the place, whether it be prior authorizations, which has
    been mentioned, all of this paperwork flowing back and forth,
    someone goes to see the physician, they get a referral, they
    follow up to make sure that referral is taken care of. You do
    not need a lot of technology around that. This idea of
    exploring how we get rid of all this paperwork and all these
    hurdles is certainly a very valuable exercise.
        Understand, as I hope everyone in this room does, that
    these hurdles have been put in place because of a concern about
    the spend. Every person who works in healthcare, every person
    receives a service, there is a dollar behind that. Our concern,
    right concern, about how much we are spending on a particular
    line item for veterans healthcare, depending on what our
    priorities are--and, again, in my view, the Veterans
    Administration has not been properly funded. It has not--does
    not have the staff it should. That says, in my view, that we
    are not paying the kind of attention we need to pay to the
    veterans who deserve our thanks.
        I am concerned, as has been raised here, that we do not
    have--and we are going to have more, and I take the chairman at
    his word, that we are going to have additional hearings on
    this, because we certainly need to see and hear from the Third
    Party Administrators (TPA)s that are managing this healthcare.
    We certainly need to hear from the VA about their processes and
    what they plan to do about these very troubling things we have
    heard today. We need to hear from the Office of the Inspector
    General about their review of the situation and what we can do
    to ensure that the data is made available to us so that we can
    actually know what is going on and where the failures are.
        Every time we have applied data, whether it is in the
    financial services, sending people to the moon, developing the
    latest technologies, it is all developing the right plans for
    healthcare so we get the outcomes we want. It is all a data-
    driven process. We sit here today with a very disturbing lack
    of the kind of data we need to decide actually what is going
    on.
        I am very sorry, ma'am, for the tragic loss of your son.
    You do not need to have children for that--I happen to have a
    couple kids. I cannot imagine the pain of losing a child,
    particularly when you did so much to try to protect that child
    as parents do.
        We have heard from the administration that there is a
    hiring freeze. I have heard from perhaps some or all of you
    that there is a real concern, and certainly, Ms. Saindon,
    excuse me, about the staffing shortages there. People need to
    power the system of care. We understand that. If there is--and
    it has been years that it has been recognized that we do not
    have enough staff in the VA, again, because of our lack of
    investment, on a bipartisan basis, by the way, in the VA.
        Can you shed some insight on how this hiring freeze will
    impact a situation which is already dramatically problematic
    and which, if it continues, will prevent the kind of
    improvements that need to be made to ensure that veterans get
    the care we need? Discuss the hiring freeze in the context of
    the current staffing shortages that we have and the difficulty
    that it will bring to making the kind of improvements that
    clearly need to be made in the provision of care through the
    VA?
        Dr. Saindon. Thank you. The hiring freeze was shocking
    yesterday for many of our membership. There is already been
    conversations as to what we can do to advocate to respond to
    this. We are grossly concerned about the impact it will have on
    bringing in new nurses, bringing in new providers, also the
    reputation for the VA. These individuals, from what we
    understand, membership, individuals that had been selected and/
    or were in the process for recruitment, received automated
    messages. That is not the way we do business in the VA. We like
    to have conversations with our candidates and our applicants.
    Yesterday they got automated messages from the platform we use
    in VA USAJobs saying that the position was rescinded. We are
    concerned about our reputation to continue to get the most
    qualified individuals within the VA system and maintain them.
        Inability to continue to staff at our ceiling levels or at
    our approved levels within budget will impact our ability to
    provide inpatient care. It will impact our ability to maintain
    clinical access and will be a continued need to coordinate care
    in the community, which is a threat, also, because that is a
    heavy, laborious process that requires more staff from the VA
    to support the coordination of care in the community.
        Mr. Conaway. I do not know if anyone wants to answer. That
    is my time, Mr. Chairman. I do not want to go over it, but if
    you permit anyone else to answer it, I would certainly
    appreciate that and I will thank you for the time.
        The Chairman. Thank you. Mr. Self.
        Mr. Self. Thank you, Mr. Chairman. On behalf of the
    veterans across America, like my constituent Mr. Dooley, thank
    you so much for making the trip to be here with us and tell us
    your story.
        I am ready to turn the page to a bright future. That last
    questioning. We are going to right size this stuff and we are
    going to get it right and I will leave it at that. Thanks to
    the Trump administration, we are going to be able to offer our
    veterans a helping hand after 4 years of cold shoulders,
    failures, and broken promises from the Biden administration VA.
    It is unforgivable that the hard-working Americans who served
    our country honorably paid the price because VA employees
    choose to serve bureaucracy rather than our veterans. There is
    a new sheriff in town and I assure you that I think the changes
    are coming.
        Mr. Dooley, in this committee in the past, I always make
    the point about the VA wants to talk about inputs. We started
    this new program, we spent this new money, we did this. They
    never want to talk about outputs. I want to thank the four of
    you for coming to talk about outputs in the VA system because
    that is what this committee ought to be talking about, outputs.
    Mr. Dooley, it took you 9 months to receive a colonoscopy. What
    do you think that did to your body over 9 months? Any ideas?
        Mr. Dooley. I am not a doctor. However, I do know time
    matters, especially when it comes to cancer. I know that from
    stage 1 my possibilities of surviving and remaining a long life
    with my children drastically goes down when it goes to stage 3.
    Stage 3--stage 1 to stage 3 is literally the mass got big
    enough and it got into my lymph node system making it stage 3.
    In that case it is a lot better possibility that it will move
    to other parts. Even if I am cancer-free now, the chances of it
    moving on and coming to another part of my body is actually a
    lot greater.
        To answer it very shortly, my life and my chances for
    remaining and living a longer life got reduced by those 9
    months. Could have taken years off of my life.
        Mr. Self. I understand. What broke through after 9 months?
    What broke through to your treatment?
        Mr. Dooley. Me waiting. Unfortunately, I waited 5 months
    for the appointment and then once I found out I had cancer,
    they said to wait another 4. To be totally honest, your office
    is the only reason that I got seen.
        Mr. Self. I want to stop right there, Mr. Chairman, and say
    our veterans should not have to have their Member of Congress
    be the first line of defense with the VA. That is my most
    important point today. The Member of Congress is not the first
    line of defense to get an appointment. Yet for my constituent,
    it was. That to me is a crucial point in this hearing.
        The system that you encountered, Mr. Dooley, do you think
    it was designed to help our veterans or to put up obstacles and
    barriers to actual care?
        Mr. Dooley. From what I personally experienced, it looked
    like it was--they made incompetence absolutely vulnerable for
    the area. I saw a lot of people that did not do their job and
    there was no way to hold them accountable for it. That was very
    as simple as I was not even given a name and a number to call
    back. The number that I would call back would be a hotline, and
    then I could not even leave a message for that person. My
    written testimony does not have a lot of names in it and
    definitely does not have any direct numbers. There is a very
    good reason for that: because I was not provided any. It is
    really hard to hold somebody accountable when you do not even
    know who they are.
        Mr. Self. With that, Mr. Chairman, I think those are
    excellent points and I yield back. Thank you.
        The Chairman. Dr. Morrison.
        Mr. Morrison. Thank you, Mr. Chair. My sincere gratitude to
    our witnesses for joining us today. Thank you to you and your
    families for your service to our Nation.
        I am glad to be here with all of you today for our first
    committee hearing of the year and my first as a Member of
    Congress. I am honored to serve on this committee because
    military service runs deep in my family. My husband John and my
    father-in-law are both combat veterans, both former proud Army
    Rangers. My dad and my grandfathers all served as well. I
    firmly believe it is our duty here in Congress to provide our
    veterans with the resources that they deserve and have earned.
        I am a physician by trade. I am one of the 70 percent who
    received some of my training at a VA. Having had the
    opportunity to care for these brave men and women, I take
    seriously our congressional oversight responsibilities on this
    committee and look forward to working in a bipartisan manner to
    ensure that VA provides the highest quality of care to our
    veterans.
        Now, I am admittedly new to the committee, but it strikes
    me that we both need community care and we need better
    oversight of community care. It also sounds like we need to
    invest in a new EMR. Honestly, as Dr. Conaway referenced, we
    are grappling with the same workforce shortages that many
    sectors of our society are facing. I am concerned about the
    hiring freeze that you just discussed.
        Dr. Saindon, as you know and referenced, VA clinicians are
    particularly well equipped to treat conditions that frequently
    affect veterans, such as PTSD, substance use disorder, and
    traumatic brain injuries. Are there currently standards in
    place to ensure that Community Care providers are adequately
    trained to treat these types of conditions?
        Dr. Saindon. This is another frequent topic of discussion
    among NOVA membership. To our awareness, there does not exist
    community indication of competencies, training, or quality, and
    it is concerning that we entrust those providers in the
    community with our veterans unaware of those data points.
        Mr. Morrison. Thank you for that answer. I assume then that
    you are concerned that the lack of training and educational
    requirements may threaten the standard of care that a
    beneficiary may receive outside of the VA. Thank you.
        Thank you, Mr. Chair. I yield my time.
        The Chairman. Thank you. General Bergman.
        Mr. Bergman. Thank you, Mr. Chairman, and thank of all of
    you for being here. This has been a long hearing when you have
    to, you know, the break for vote, so we just appreciate your
    patience. In life, you got to be patient. You got to be, but
    you got to be persistent. You have to persevere, all of those
    things. Some of us who have been on this committee for a while
    are, I am not going to say getting a little long in the tooth,
    but we are definitely getting a little frustrated, okay, over
    the lack of movement of the bureaucracy.
        During the 115th Congress, those of us who here were here,
    it was when the MISSION Act was crafted. Now, I am going to use
    a visual example. We put the MISSION Act into play, and since
    then, anybody here not know what the game Whac-A-Mole is, okay?
    That is what it has been. From the committee's standpoint, and
    even I would suggest to you from the veterans' standpoint, you
    hit one mole and it goes down and another one pops up. It is a
    moving target. It is such that in our roles and
    responsibilities here, we owe it to the veterans and we owe it
    to the doctors and the nurses, all the healthcare providers in
    the VA system to actually eliminate the Whac-A-Mole nature of
    this so the care can get right to the patient.
        What we have seen is that the mid-level bureaucrats in the
    VA have prioritized to a great extent the bureaucracy over the
    veterans themselves. They are focused on, well, let us adjust
    this process or let us do that or that, without concern that
    the end game of providing care is not there. We have not talked
    about it today and then I am going to ask a couple questions
    here, because there is an assumption if you live in an urban or
    suburban area, you either get in your car, get in the VA
    service officer's van, get in an Uber, getting on the
    transportation, and go to your local veterans, you know,
    hospital or wherever the clinic is. Well, we got rural and
    remote in our country, too, and especially add a snowstorm. I
    got a hunch there is probably nobody in South Carolina today on
    the road. Now, in Michigan, with a snowstorm, they are still
    going to go on the road to get there. Okay? We have the whole
    spectrum here of the urban, suburban, rural, and remote to
    provide the care.
        Mr. McKenna, just a quick reaction here. What is your
    reaction--was your reaction when you discovered that VA
    counselors were unfamiliar with the basics of the MISSION Act,
    and by the way, in polite Marine terms?
        Mr. McKenna. Thank you, sir. Again, to use your analogy of
    Whac-A-Mole, I think if you go back to the MISSION Act itself
    and to prevent knocking things down that you have already hit
    before with respect to training and education, training and
    education must happen continuous.
        Mr. Bergman. I am going to cut you off----
        Mr. McKenna. Yes, sir.
        Mr. Bergman [continuing]. because my time, as you know, as
    a Marine here, we are not going to waste time. You are
    absolutely right. Do not waste time. We waste enough money. You
    can recover money, but you cannot waste time once it is gone in
    veterans care. Do you think, when you mention training, that
    the VA employees should be required to undergo periodic
    training and updates to familiarize themselves, in this case
    with the Community Care Program?
        Mr. McKenna. Yes, sir. I will give you one small example.
    If you ask a VA counselor, at least my experience has been, can
    you give me any elements of the MISSION Act, specifically care
    in the community, and I am talking numerous people, not just
    one, are completely clueless to this legislation. If that is
    not an indictment on the VA and their training and education
    program, I do not know what is.
        Mr. Bergman. Yes, and it is an indictment, quite honestly,
    of the leadership, especially at mid-level. Why is the United
    States military so successful regardless of service? Our staff
    Non-Commissioned Officer (NCO) corps, our NCOs and our staff
    NCOs. It has got nothing to do with the officers. It is the
    staff NCOs and those mid-level folks within the system is what
    is going to make it work. That is where I believe we need to
    focus bipartisan because it is not Democrat or Republican. It
    is about getting the care and it is about retooling, if you
    will, the bureaucracy. I did not say eliminating it, retooling
    it, so it actually functions in a 21st century world with
    electronic health records and all of that data sharing.
        With that, I yield back, Mr. Chairman.
        The Chairman. Mrs. Ramirez.
        Ms. Ramirez. Thank you, Chairman. I want to start by
    thanking our witnesses. As you heard from other colleagues
    here, I know that between the votes and coming back, the
    schedule was a little difficult, but I want to thank you for
    being here.
        I want to especially thank Ms. Locklear for your testimony.
    I want you to know that your sharing and the pain that you feel
    was felt by every member here. I want to thank you for your
    courage to be here and to speak truth to the experience that
    you have had and the experience you do not want any other
    parent to have. I just really want to thank you from the bottom
    of my heart.
        One of the most pressing issues our veterans are facing is
    that quality healthcare, is that access. It is a concern shared
    by so many everyday Americans really trying to navigate our
    system of privatized care. In hearings like today, I think it
    is important that we reflect on some of the assumptions that we
    are making. You know, I assume we are committed to meeting the
    healthcare needs of every single veteran. I want to assume that
    caring for every veteran means providing them the full spectrum
    of services. You see, I assume we want our veterans to have the
    best, the most comprehensive, the most coordinated, the most
    timely, and the most accountable healthcare we can offer them.
    I want that for every veteran. Frankly, I want that for every
    American. I assume we mean the same thing when we talk about
    community care, but I am learning that we mean different
    things. Some of my colleagues just mean private care.
        Finally, there is another assumption operating of which I
    cannot get behind, and that is increasing access to private
    care that would automatically result in better healthcare
    outcomes for some veterans, but not the others. The evidence
    shows that public VA facilities provide higher quality veteran-
    specific care. If you believe that the private sector can do it
    better, which I do not, then you may be comfortable with the
    concerning amount of money being funneled away from the VA into
    privatized care.
        Folks, I am concerned that we are not asking whether that
    care is really leading to healthier and better outcomes,
    because choice alone is not the point. We want choice, but we
    also want quality. That is what we should be after. As we have
    heard from many of my colleagues, there are instances when our
    veterans cannot access a VA healthcare center due to distances
    or due to other barriers. However, the VA healthcare system is
    set up specifically to address the needs of veterans.
        Dr. Saindon, did I pronounce it correctly? Good, good.
    Pronunciation is important for me. Can you tell me how the VA
    healthcare providers and clinicians are uniquely prepared to
    care for our veterans? I specifically want you to tell me what
    trainings are required for you to take to ensure that you are
    providing culturally competent care to our veterans.
        Dr. Saindon. Every employee is required to do military
    competence training. In addition to that, based on the
    occupation or based on the role of the healthcare provider at
    the VA, they have a whole slew of different trainings that are
    specific to meeting the needs of those populations that they
    serve in that role specific.
        Ms. Ramirez. Dr. Saindon, let me ask you a follow-up
    question to that. Are Community Care providers required to take
    those trainings?
        Dr. Saindon. Not that we are aware of.
        Ms. Ramirez. Additionally, are there third-party
    administrators who manage a network of Community Care providers
    required to ensure that providers in the network complete these
    trainings?
        Dr. Saindon. Membership has spoke about this several times.
    It is in our written testimony. We are very concerned that
    there is no such requirement.
        Ms. Ramirez. Got it. Thank you, Doctor. Look, Community
    Care is part of the equation that we need to be discussing
    today. Yes, we certainly need to do everything in our power to
    ensure our veterans are receiving care. We need to make sure
    that that care is high-quality care in a timely manner.
    Veterans have the best, the most comprehensive, the most
    coordinated, the most timely, most accountable healthcare, that
    is what we need to be working toward in this place. As we
    discuss this conversation today about community care, as we
    talk about the impact that our veterans are experiencing every
    single day, as we talk about their own families, I truly hope
    that choice and quality are going to go hand-in-hand.
        I want to thank our witnesses here today. I want to thank
    the chairman and the ranking member and the vice ranking member
    here today as well. I look forward to having a fruitful
    conversation over the work that we do over the next few months
    where it is centered on our veterans and their career. Thank
    you.
        With that, I yield back.
        The Chairman. Thank you. Mr. Van Orden.
        Mr. Van Orden. Thank you, Mr. Chairman. I appreciate being
    here. I am very sorry I had to step away. This place pulls you
    in 50 different directions. I have read all your testimony and
    I want to thank you for coming out here.
        I spent my first day in Congress calling the widow of a
    veteran, the brother of a veteran, and the sister of a
    veteran--sister-in-law of a veteran who committed suicide
    because he did not get a mental health consultation. I printed
    that letter. It has been sitting on my desk for 2 years. It has
    got a note on there. It says, this is why I am here.
        I have learned a couple things. I chair a subcommittee.
    Learned a couple things over the last 2 years. This is the
    first Congress here. I have been in Congress for 2 minutes--or
    2 years and 5 minutes. I do not want to hear from the VA right
    now. Our ranking member said, why is not the VA here? You know
    why, because they do not tell us anything. I have essentially
    had 10 of the same damn hearings with these guys because
    nothing changes. No one is held accountable at the VA. Nobody.
        Check this out. They made a $25 million estimate to do the
    digital GI bill. It is going to be a billion dollars, 25
    million to a billion. No one is being held accountable. The
    Cerner trash, I just got off the phone again with two doctors.
    I just want to check civilians who are using this. Cerner was
    sole-sourced a contract to do the electronic medical record,
    $16 billion. They spent 14, they want to do 18. They are saying
    they had to delay it to 2026 because it does not work, $14
    billion into it. You know how much they say it is going to cost
    to get it across all the business? Take a guess. I will tell
    you: $50 billion. No one is being held accountable.
        Mr. Dooley, I am terribly sorry. I am going to formally
    apologize to you from the Federal Government. I am so sorry.
    Let me ask you something, Mr. Dooley. Has anybody that had
    anything to do with the travesty that has taken place in your
    life at the VA been held accountable? Anybody?
        Mr. Dooley. To answer shortly, no.
        Mr. Van Orden. Ms. Locklear, my heart breaks with you. It
    does, and we talked and I thank you for that. We know what it
    is like. I know what it is like to lose a child. I do not know
    where you would be and how you hold up with this grief knowing
    that it was much more preventable than the loss of our
    daughter. To your knowledge, has anyone been held--or, excuse
    me, your son. I apologize. It is our daughter. To your
    knowledge, has anyone been held accountable at the VA?
        Ms. Locklear. No.
        Mr. Van Orden. Nobody. Ms. Murray, to your knowledge, has
    anyone been held accountable for dragging you around and
    treating you like a hobo who is begging for help, for injuries
    and PTSD is an injury? Has anyone been held accountable for
    treating you like a beggar and kicking you around the country?
        Ms. Murray. None to my knowledge, sir.
        Mr. Van Orden. Okay. Well, I personally am looking forward
    to our new Secretary Collins getting in here and the people
    that are responsible for these billions and billions of dollars
    of waste are held accountable. Every single dollar that is
    wasted is a dollar that cannot go to making sure you can go to
    a program in a different region. To making sure, sir, that when
    the VA cannot possibly help you, that you go immediately to
    Community Care and that you do not have to have 57 different
    referrals for the same treatment plan. Ma'am, to make sure that
    no mother or father or brother or sister ever has to find their
    child in a bathtub after they have committed suicide because
    they did not get the mental healthcare that they needed.
        I know that the men and women on this committee mean what
    we say. I just believe that some of my Democrat colleagues are
    misguided. I get all my healthcare through the VA. I am a 100
    percent service-connected disabled veteran. I get all my
    healthcare through the VA. The people that treat me in La
    Crosse, Wisconsin, are fantastic. That is from the people that
    are checking me in to my primary healthcare facility. I am so
    proud of them. Wautoma, Wisconsin, I am so proud of them. Do we
    have problems? Yes.
        The farther up the chain we get, the farther away from
    reality we get, and I want to have some of these people that
    have been sitting in these offices at the VA collecting a
    paycheck go out and talk to you, ma'am. I want them, sir, to go
    to a medical appointment with you and your family and let them
    explain to you and your family why you could not get the
    healthcare you needed because they are too damn lazy and they
    are more concerned about protecting a bureaucracy than the
    veteran. That is what needs to happen. Nothing is changed until
    it does. That is what we are going to do under the new
    Secretary's leadership and the leadership of this chairman.
    That is my promise to you.
        I yield back.
        The Chairman. Thank you. Dr. Miller-Meeks.
        Ms. Miller-Meeks. Thank you so much, Chairman Bost, for
    this hearing.
        It is interesting, my conversation and my thoughts as we
    have listened to this hearing and listened to both members on
    this side of the aisle and the other side of the aisle proper
    questions. My questions are different now than they were when I
    first came in here.
        First, Sergeant Major McKenna, my family, my husband's
    family is all from Richland, North Carolina, and I know that
    system well. Ms. Saindon, you mentioned about, you know,
    everything being automated and how concerned you are. Let me
    just say that I applied for a job as a physician, I am a nurse
    and a doctor, applied for a job at the VA in 2014. All of my
    responses were automated, so I am not sure how that is not how
    we do things at the VA. As I recall, the President at that time
    was President Obama, and all the responses were automated and
    went through USA.gov. That is one of the issues we have with
    hiring.
        In the 4 years that I have been on this committee, there
    has not been a lack of funding to the VA. As a matter of fact,
    funding has increased every year. Even in this hearing room, we
    had a hearing on mental healthcare and suicide prevention. I,
    as the chair of the Subcommittee on Health, and through that
    hearing with the VA present, found out that the VA did not
    consider residential mental healthcare or substance abuse
    disorder healthcare to fall under the MISSION Act. Therefore,
    they did not have to get somebody in, a veteran in within 30
    days.
        Now, as a nurse and as a doctor and a person who has family
    members who had PTSD and mental health issues, if you are at a
    point where you think you need residential care for substance
    use disorder or mental health, you need mental healthcare now.
    We put forward a bill that it had to be within 10 days.
        The first bill that I passed and had signed by a President
    in 2021 was Brandon Caserta, who 5 hours after he visited the
    VA in Iowa City, which is an excellent VA, committed suicide.
    As a nurse and as a doctor and as a veteran, but most
    importantly as a mother, Ms. Locklear, we feel that we are
    responsible for our children's happiness and success. I know
    the burden that you bear, and it is not your fault. It is the
    responsibility of this committee and members on both sides of
    the aisle to make sure that what happened to your son does not
    happen to any other sons and daughters. That is why you are
    here today.
        Ms. Saindon, does the VA send veterans to get care at
    Veterans Integrated Services networks (VISN)s far away from
    where a veteran may reside?
        Dr. Saindon. To my knowledge and membership, yes.
        Ms. Miller-Meeks. Exactly. I am not sure why it is a
    problem with a veteran such as Ms. Murray, and I do not know
    your rank, Ms. Murray, my apologies, a veteran to get care for
    a specialized condition at a place because it happens to be out
    of network. That is the type of stuff we hear from private
    insurers, and both of them have problems. If their veteran is
    not able to get the care at the closest VA to them, and there
    is the care that they need recommended to them by a provider,
    they should be able to get that care. I do not give a hoot if
    it is on the East Coast or the West Coast, because the VA
    already sends people to other VISNs two or three VISNs away,
    hundreds of miles away and months away. When we consider the
    cost of care within the community, not private care, let me re-
    emphasize this once again, but care within the community.
        Let me also say I am a provider of care. I gave community
    care. I do not think I had to have training for PTSD as an
    ophthalmologist to do cataract surgery.
        Ms. Saindon, is it well known that men in age 40, if they
    have blood in their stool, that is considered cancer unless
    otherwise you are a doctor, nurse practitioner?
        Dr. Saindon. To clarify, I am a DNP, Doctor of Nurse in
    Practice.
        Ms. Miller-Meeks. Yes.
        Dr. Saindon. Not a prescriber or provider.
        Ms. Miller-Meeks. Okay. Then I will not ask you that
    question. Let me just say it is common knowledge. It is common
    knowledge, we are trained in medical school that if a male has
    blood in their stool, especially under age 40, which I think
    Master Sergeant Dooley was, if my math is correct from your
    testimony, that it is cancer unless proven otherwise. How is it
    quality of care for the VA not to order a colonoscopy from a VA
    provider? That is not quality care. Let me say that quality
    care is no--if no care is provided, that is not quality,
    whether it is at the VA or Community Care.
        Do you think the cost would have been lower, Master
    Sergeant Dooley, if when you told your physician what your
    symptoms were, and I am implying what you were, I am presuming
    as a physician, if you relayed your symptoms, they would have
    ordered a colonoscopy and then they would have allowed you to
    go for care and had your appropriate treatment? Do you think
    maybe the cost would have been less if it was a stage 1 cancer
    or stage 2 rather than a stage 3?
        Mr. Dooley. I would like the chance to live, so I would not
    have cared what the cost was. To answer your question, yes, I
    do believe treating stage 1 would have been a lot more cost-
    effective and efficient than in treating stage 3 and for the
    rest of my life.
        Ms. Miller-Meeks. As a provider and someone who knows the
    healthcare system, I am going to wholeheartedly agree with you.
    That is why we do screening. That is why we do colonoscopies
    and recommend them over age 50. Why if someone presented with
    the symptoms you had, even as an ophthalmologist at the VA, I
    would refer you for an urgent colonoscopy.
        My point is this. Our obligation is to make sure veterans
    have access to care. If you do not have access to care in a
    close-by VA and your symptoms warrant, then you should get care
    within the community. That is our responsibility as an
    organization. As a committee and as Members of Congress, you
    should not have to come to see your Member of Congress to get
    the care you have earned. You have earned the care. We are
    going to make sure that we hold the VA accountable and the
    community accountable for getting you the proper care in a
    timely fashion that you so richly deserve.
        Thank you and I yield back.
        The Chairman. Representative King-Hinds, you are recognized
    for 5 minutes.
        Ms. King-Hinds. Thank you, Chairman Bost, and ``Hafa Adai''
    to all of you. Thank you for being here today. Thank you for
    your service.
        To Ms. Locklear, my deepest condolences. Your story is too
    common to so many families and parents across America.
        I come from the Northern Mariana Islands, about 8,000 miles
    away from Washington, DC, that is my district. It is a chain of
    islands that, you know, have a lot of people signing up for the
    military. We have a lot of veterans and our issue basically is
    just access to service. We have one local physician contracted
    part-time by the VA to treat veterans 2 days a week. Referrals
    to available specialists in the district can be made out
    prior--with prior authorization from VA office in Honolulu,
    which is thousands of miles away. VHA also occasionally sends
    specialty care doctors to include neurologists and podiatrists
    about three times a year. We do have emergency care, although
    very limited even to nonveterans.
        The point is, you know, access to these services is an
    issue in the Marianas, and I have always assumed that that
    issue was limited to our islands. One of the reasons why I ran
    for Congress was to be able to improve the quality of service.
    As I am sitting here and I look at all of you and I am hearing
    about all these different challenges, I am crushed. If we are
    here on the mainland and we are not able to provide the quality
    of care here in America, then how are we going to be able to be
    able to address the challenges of our remote islands?
        I do not have any questions. I just wanted to say thank you
    and you deserve better. I truly believe in my heart that
    through Chairman Bost's leadership in this committee, that
    everybody has your best interest at heart. I am certainly here
    to fight not just for my community, but for you as well. Thank
    you so much.
        I yield my time, Mr. Chairman.
        The Chairman. We are glad we have Mr. Harris with us today.
    Mr. Harris, you are recognized for 5 minutes.
        Mr. Harris. Well, thank you, Mr. Chairman, for the
    invitation to be a part of your committee today and for the
    consent to allow me to share.
        Ms. Locklear, first of all, I want to thank you for having
    the bravery to come in today and to share your son Logan's
    story. It is truly an honor to have the privilege of
    representing a selfless American such as yourself. Your
    willingness to come and share your testimony, I really pray, is
    going to help us ensure that what happened to you and to Logan
    will not happen to future veterans and to their families.
        Your son had to wait 5 months between his initial contact
    for a mental healthcare appointment and the scheduled
    appointment date. Now, the law says that a wait time should be
    no longer than 20 days before referral to the Community Care
    Program.
        I guess I want to ask you, are you aware of any efforts the
    VA has made to improve wait times or improve awareness among
    veterans of the Community Care Program eligibility?
        Ms. Locklear. Yes, I think so.
        Mr. Harris. Well, sadly, looking at the VA wait time list
    last night at the Fayetteville VA Medical center, there is
    currently a 60-day wait time for new patients to get access to
    individual mental healthcare. You see, I am concerned about
    what you went through. I just want you to have an opportunity
    to really help us understand how this experience has affected
    you mentally and what this has led to in your own life.
        Ms. Locklear. I had worked for the VA for 12 years. I
    believed in the VA system. I love the veterans. To have my own
    veteran that I saw in front of me 4 years suffering through
    what he was suffering through, I was trying to help him. Could
    not get him to go. When I finally got him to go, this happened.
    The week he died, I thought he was actually better that
    Wednesday before he died. I thought he was doing better. Then
    that Friday when we found him, I was just crushed.
        When I went back to my facility, of course my department
    knew what had happened. They had rallied around me. They had
    taken care of me, they had provided for me. I knew I had the
    knowledge of a suicide, that it needed to be reported. When I
    went in to report it, they appeared to be very receptive,
    wanted to know what had happened. They wanted to know how--like
    I had known for 12 years. How do we fix this? How did he fall
    through the cracks?
        Then when I told him that he was my son, everything I felt
    like stopped. I kept waiting for someone to call me and say
    how--can we talk to you? How can we fix this? What happened?
    All the while I was trying to work and still trying to figure
    it out. I did not understand what was going on. I knew my child
    was gone. I did not know he had--I did not know they had given
    him a 5-month appointment. I did not know that. I did not know
    that till March of the next year. I kept asking, you know, I
    just kept waiting.
        Finally, I just called. I just called the director of the
    facility myself and I asked her about it. She was not--she
    said, I was not aware of that. From the very beginning, I just
    felt like it became a cover-up. Nobody would speak to me. I
    kept asking, you know, when I made her aware of it, she said
    she would get back to me. She never did.
        As the months continued, my work performance continued to
    fail. I worked in the pharmacy department. I have a lot of--I
    had a lot of responsibility in my job in regards to handling
    medications, handling drugs. I spent a lot of time the first
    year after Logan died, I was not at work. I could not function.
    I could not think. By half the year, I just--I had exhausted
    every opportunity, everything that I could use to help me to
    continue to work my job and stay where I was at till I finally
    decided I--I realized I could not work there. Every time I came
    through the back doors, I felt like they were--the VA did not
    help my child. Therefore, I just--in my head, I felt like the
    VA had caused my child's death. It made me feel like I
    contributed because I was part of the VA.
        In my head, I had to get away from the VA. I said, I have
    got to get away from this place. I have been diagnosed with
    PTSD, anxiety, depression. All I asked was, when my child died,
    I went in and I just said, can you help me? Can you explain to
    me? Just explain to me what happened, what happened to him? No
    one--they just--they acted like they did not see me. Now I feel
    like I am disabled. I still do not function well.
        Mr. Harris. Well, let me say this. You said something a
    moment ago that the whole attitude had been, oftentimes, you
    heard it, how did he fall through the cracks? How did they fall
    through the cracks? How did they fall through the cracks? I
    hope that you sharing your testimony today is going to help
    assure that that does not happen again.
        That, Mr. Chairman, I yield back my time.
        The Chairman. I now recognize Dr. Dexter for 5 minutes.
    Welcome to Congress.
        Ms. Dexter. Thank you so much, Mr. Chair. I apologize.
        The Chairman. I just want to let you know, this every day.
        Ms. Dexter. I am feeling indoctrinated, so thank you. Very
    much appreciate the testimony from all of the guests here.
    Particularly as a physician, as a mother, I want to acknowledge
    the challenges that our system faces.
        Having been a VA physician within the system as well as a
    physician in the private sector who has taken care of patients
    from the Veterans Administration system, we have a lot of
    challenges ahead of us. What Mr. Dooley went through, I have
    had my own patients go through. That delay in care and the lack
    of continuity of care from the outside is a frustration as a
    physician, but it is also a failure of the system. We know that
    building a more comprehensive system that is accessible to the
    veterans is better care. Our veterans want to be seen within
    the VA administration. They want to have the physicians who
    know them, who understand the challenges of having been a
    veteran. We provide better quality of care, more comprehensive
    care, and more timely care in an integrated system when it is
    appropriately resourced. I believe that that is the challenge
    that we need to rise up to.
        We need to have access for mental health, for addiction,
    for cancer services. The answer is not going to the private
    sector. It is building the VA Administration services so that
    we can build capacity within the system.
        I also speak as somebody who was a leader in a capitated
    system that provides coordinated care. When we were struggling
    financially, we made margin. We made a successful business by
    bringing services to within our system, to stop paying the
    bills outside that we have no control over, to stop the
    escalating costs that will continue. We understand that we are
    effectively supporting private practices outside of the VA
    Administration.
        Respectfully, Mr. Chair, and to our community members here
    who have so bravely and candidly spoken for veterans, I will
    fight for this system and I believe it is enforcing our need to
    serve veterans from within and to make sure that we resource it
    appropriately.
        With that, I yield back. Thank you, Mr. Chair.
        The Chairman. Thank you. As the ranking member, does Dr.
    Conaway want to have a closing?
        Mr. Conaway. Thank you, Mr. Chairman, for holding this
    oversight hearing. We understand that there is a lot more
    information we need to collect as a committee in order to
    ensure that we as a Nation are doing right by our veterans and
    making sure that they get the care that they richly deserve.
        Thank you to the witnesses for taking your time today and
    enlightening us with your personal experiences. In particular,
    thank you to Ms. Locklear for your bravery today. It is not
    easy to come and to talk about tragedy and to be as forthcoming
    as you have been. We are grateful for that and we are sorry for
    your loss.
        We look forward to working with you in a bipartisan way.
    This committee has a bipartisan history. May it always be so.
    We do better when we work together. We do things that are
    lasting and more sustainable. We look forward to our future
    work to bring attention to those things which need fixing and
    to work to make sure that our government does the job it needs
    to do by our veterans. Thank you all.
        The Chairman. I want to thank the witnesses for joining us
    here today. It is clear that the previous administration had
    problem implementing the Community Care Program. The Community
    Care Program and the MISSION Act are law. They are not
    suggestion, they are law. There is a reason for that.
        Let me clarify this, no Republican, and I guarantee you no
    Republican on this committee, has ever said we want to
    privatize, ever. Democrats have accused us of wanting to
    privatize. We do not want to privatize. We do understand that
    the VA was not created for the bureaucrats at the VA. The VA
    was created for the veterans. If we have people around this
    Nation and veterans around the world that need services, the
    MISSION Act should be able to do that.
        Now, unfortunately, I think that sometimes the bureaucrats
    in the VA, for the fear of privatization, refuse to do the job
    which we have assigned to them and that is what things have
    shown up. That is the problems--that is some of the problems we
    have. There is a lot of problems we have trying to get the
    services to the veteran at the time when they need it. As
    quickly and efficiently as we can. There is waste in the VA.
    There is. We need to make sure that it is the most unwasteful,
    best medical provider that it can be.
        Now, remember, there is a whole lot more than the medical
    side of VA. All those other things that we deal with in this
    second largest bureaucracy in the world that this committee is
    over, we are going to work to try to correct those. This is one
    issue.
        I am also going to say this. This is not the last hearing
    we are having on this. Others will be brought before us that
    are those people who are the providers and the connection
    between the patient and the Community Care provider in which
    they--and how they contract and how they communicate. It is a
    communication problem both between the VA and the Community
    Care. As Representative Van Orden said, we care about the
    veteran. We have got to figure out how to get that there and
    not put people in this condition again.
        I want to say thank you so much for being here. I want to
    thank the members for a long meeting. With that, we are looking
    forward to continuing to work on this.
        With that point, I want to ask unanimous consent that all
    members shall have 5 legislative days to revise and extend
    their remarks and include extraneous material.
        Hearing no objection, so ordered. This hearing is now
    adjourned.
        [Whereupon, at 3:49 p.m., the committee was adjourned.]

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                             A  P  P  E  N  D  I  X

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                        Prepared Statements of Witnesses

                                  ----------

                       Prepared Statement of Paul McKenna

        Chairman Bost, Ranking Member Takano, and members of the House
    Committee on Veterans' Affairs - thank you for inviting me to submit
    this written statement for the record of today's hearing on veterans'
    experiences using the Department of Veterans Affairs (VA) Community
    Care Network. I am here today as a voice for countless Veterans in
    Eastern North Carolina who continue to struggle to effectively and
    efficiently utilize this critical part of VA's health care system.
        As the committee is aware, the VA MISSION Act became law in 2018
    and was intended to improve access to health care for Veterans. My aim
    today is to illustrate the gaps and seams within several pillars of
    this legislation that are present in Eastern North Carolina, with
    specific attention on access to care, the Community Care Network, and
    the education and training of the VA workforce that coordinates access
    to care in the community. My hope is that my statement will offer the
    committee some insight to the real challenges that Veterans face with
    when using the Community Care Network in Eastern North Carolina.
    Additionally, and what may sound anecdotal, is to share with you my
    experience with using the services of VA's Community Care Network in
    two different geographical locations and the experiences of many
    Veterans I have talked to who must utilize community-based services.
        My name is Paul McKenna. I retired in 2021 after 36 years of
    active-duty service in the United States Marine Corps. I have held
    numerous Military Occupational Specialties (MOSs) throughout my career,
    with the last 20 years being spent primarily with the infantry and
    combat arms MOSs. I have 9 combat deployments in support of Operation
    Restore Hope (Somalia), Operation Iraqi Freedom (Iraq), Operation
    Enduring Freedom (Afghanistan) and Operation Enduring Freedom, Joint
    Task Force, Special Operations Force, (Southern Philippines). I have
    learned many life lessons from my nearly four decades of service as a
    US Marine, and at the top of that list is that no American can afford
    to be disinterested in any part of his government, whether it is
    county, city, state, or nation. One of the great lessons the Marine
    Corps taught me was to never take for granted of being the presence of
    other Marines and their greatness. For 36 years I walked amongst
    giants, I will forever cherish those relationships, especially the
    relationships of the American Heroes that never came home. I truly hope
    that my actions and words today bring honor to their memory and
    sacrifice.
        My wife and I initially resided in Northwest Florida after my
    retirement, and I was able to receive timely and adequate medical care
    from the VA in that region. There were several factors that drove us to
    this part of the country; one, my wife, Michela, who is a federal
    employee, took a new position within government service at Naval Air
    Station Whiting Field in Milton, Florida. Two, the quality of cardiac
    care within the area of Northwest Florida. Michela received a
    mechanical heart valve after being diagnosed and treated for
    endocarditis in 2013. And three, the word from fellow retired Marines
    that the VA health care system was first rate. Michela's medical care
    is covered by TRICARE for Life, and that insurance involves expensive
    copays for her continued care.
        The primary reason for choosing the VA for my medical needs was for
    our financial wellness and the fact that I earned it. I am 100 percent
    permanent and total disabled and I use the VA as my primary medical
    provider. The VA in Northwest Florida (Pensacola) is a VA Clinic
    associated with the Biloxi VA Medical Center in Mississippi, which was
    two hours from our home in Milton, Florida. The care at the VA
    Pensacola Clinic was first rate and Dr. Sandoval and his team always
    treated me with the highest degree of professionalism, dignity, and
    compassion. Because I require a specialist in some areas of health
    care, and the fact that the Pensacola VA clinic does not have that
    capability or capacity, I was referred to the Community Care Network,
    i.e., Mental Health (PTSD), Neurology (TBI), Orthopedics, Podiatry, and
    Dermatology. The process in Pensacola was seamless. Starting with
    seeing Dr. Sandoval and his Team to scheduling with the Community Care
    Network counselors to be seen out in the community. The entire process
    took no longer than 10 to 15 days.
        In June 2022, I relocated to Richlands, North Carolina and
    registered with the VA clinic in Jacksonville, North Carolina. Just
    like Pensacola the Main VA Hospital for this region is in Fayetteville,
    North Carolina, two and half hours away from my residence in Richlands.
    After registration at the Jacksonville VA clinic, I was informed that I
    would have to contact the Community Care Network and seek a provider
    out in the community. This was due to the lack of capacity of doctors
    and nurses at the clinic and that they were not taking any new
    patients. Community Care set me up with MEDFIRST in Richlands, North
    Carolina.
        MEDFIRST is a primary and urgent care clinic that only has nurse
    practitioners on staff. The MEDFIRST nurse practitioners can draw blood
    and perform only basic medical care. This clinic (MEDFIRST) does not
    have the expertise or capacity to treat my medical issues which include
    mental health, traumatic brain injury (TBI), post-traumatic stress
    disorder, neurology, orthopedics, podiatry, dermatology, and urology.
    MEDFIRST must put a referral in the VA system for me to be seen out in
    the community for medical treatment. That referral goes through a
    third-party vendor who then submits the referral request to the VA.
    When I call the VA Community Care line or contact the VA through
    MyHealtheVet to understand why the process is taking so long, all I
    hear is ``That's just the way it is'' or ``your primary care provider
    did not submit the correct form.'' As to the latter statement, I
    personally watched my primary care provider at MEDFIRST fax the request
    and the next day when I called to follow up was still told that the VA
    did not receive it and when I stated that I have the fax receipt, I was
    told ``sorry don't know what to tell ya.''
        More generally, the third-party vendor appears to have little to no
    oversight from either the VA or MEDFIRST. I have been waiting for over
    nine months for some of these referrals to be processed. I draw this
    conclusion as I attempted to gain their contact information, phone or
    email and was informed by MEDFIRST and the VA that they are not
    authorized to provide the contact information of this third party-
    vendor to the Veteran. My experience is not unique. I have heard the
    same concerns and complaints from countless Veterans here in Eastern
    North Carolina. Since moving to Richlands, NC, I continue to experience
    delays in care from the VA Care in the Community Network.
        Despite my best efforts to advocate for my care, I never receive a
    clear answer from the VA counselors who answer the phones. When I quiz
    the VA counselors on the fundamentals of the VA MISSION Act, they are
    clueless of this legislation. I have contacted my VA patient advocate
    (Sheldon Edwards) numerous times and left voicemails and have yet to
    hear back from him or his office. No human being, let alone a Veteran
    should have to wait six to nine months to receive treatment for any
    medical issue, especially when the injuries occurred while in service
    to their country.
        I am asking this committee to investigate why there is no capacity
    to properly treat our Veterans in Eastern North Carolina in a timely
    and adequate manner and direct the VA to properly educate and train
    their workforce within the Community Care Network on the VA MISSIOIN
    Act in Eastern North Carolina.
        Thank you again for the opportunity to participate in today's
    hearing on the VA Community Care Network. It is my hope that Congress
    and the VA can take some of those things that were working in Northwest
    Florida like the referral process and the access to care and help
    replicate those qualities for Veterans across the country so that they
    can get the care they need in a timely manner no matter where they
    choose to live after service. I look forward to answering any questions
    you may have.
                                     ______

                      Prepared Statement of William Dooley

        Thank you, Chairman Bost and Ranking Member Takano, for the
    opportunity to discuss my frustrating experiences with the VA Community
    Care program. I am a U.S. Army Veteran who enlisted in 1998, serving 20
    years on active duty and received a rating of 100 percent permanent and
    total from the Veteran Affairs. I served in several units over the
    years, including the 101st Airborne Division, 2nd Infantry Division and
    The NCO Academy at Ft. Benning, Georgia. In these short years since my
    retirement, I pursued my Master's in Public Administration, served my
    community with an appointment as the Chairman of my local county's VA
    Committee, and obtained my Juris Doctor from Creighton University. I am
    currently a Prosecutor within the DFW area and proud father of three
    amazing children between the ages of 22 to 10. I am in front of you
    today as a Veteran, Father, Husband and a Cancer Patient fighting for a
    chance to live.
        By providing the timeline of my most recent VA Healthcare
    interactions and points of discussion, I hope to provide insight and
    perspective of the current problems Veterans are facing today while
    seeking care under the VA's Community Care Program. I will highlight
    network inefficiencies, employee complacency, and incomplete case
    management with the optimism that it will create opportunities to
    improve this beneficial program and help correct current ongoing and
    systemic problems present within the Organization.

    BACKGROUND

        September 11, 2023, I attended an appointment at the Bonham VA
    Medical Clinic for a routine health check and to establish my transfer
    of care from the Omaha, NE VAMC. During this appointment I discussed a
    rising concern I had regarding a significant medical symptom. The
    physician rejected my concern and waived off any need to investigate
    the symptom further. I returned to this physician as the symptoms
    persisted around November 7th to insist that we investigate the cause
    and again inquired if a colonoscopy would bebeneficial. At this point
    the physician decided to order a lab test for me to conduct at home.
        On November 20, I received a call from the physician informing me
    that the test confirmed my reports of blood present in my stool and
    that I was being referred to GI for consultation. During this
    conversation my physician told me that there was a backlog to schedule
    a colonoscopy within the VA Network and he advised it would be faster
    to go through Community Care. Acknowledging the physician's
    recommendation and my desire to obtain answers as soon as possible, I
    agreed to his recommendations to seek the screening under Community
    Care in hopes the results would ease my concern.
        On December 8, 2023, I received the authorization to schedule a
    colonoscopy with Dr. Jenny Tseng, who was selected by the VA. The only
    information I was provided with was the physician's name, phone number,
    and the initial appointment of February 8. During this appointment, I
    was able to schedule the colonoscopy for May 20th. From the time I
    presented the concern to my Primary Care Physician at the Bonham VA
    Clinic with my initial request, to the time I was able to receive the
    screening was nine (9) months.
        On the morning of May 20th, immediately upon waking from
    anesthesia, my wife and I were informed that during the exam, Dr. Tseng
    located a large mass. She emphasized to us that it was medically urgent
    to seek an immediate consultation with a surgeon as soon as possible
    and strongly advised it needs to occur within the next week. The exam
    findings noted that the mass within my colon was already over 5 cm in
    length and occupied two-thirds of the space within the circumference of
    my colon. Think of a Hot Wheels car stuck to the inside of a cardboard
    toilet paper roll. Not only did this indicate an obvious concern of
    advanced cancer growth, but this also put me at a high possibility of
    experiencing severe risks stemming from a bowel obstruction.
        On May 22, assuming two days would give adequate paperwork
    processing time, my wife called the community care number listed on the
    Dallas VAMC website that did not work. She had to eventually call the
    VAMC general number and request to be directly transferred to the
    Community Care personnel.
        On the line with Community Care personnel, she explained the
    provider's concern for medical urgency. The personnel informed her that
    they could not locate the documentation, and they were experiencing a
    backlog. At that point CC personnel advised her that she might be able
    to receive help from the Patient Advocate and transferred. While
    communicating with Patient Advocacy, my wife inquired what the next
    step is for a Community Care referral that finds an urgent medical
    need. The Patient Advocate was not able to provide any tangible
    information regarding rules, regulations, or procedures to her. The
    Patient Advocate only advised her to wait until someone from the VA
    initiated the call. The Patient Advocate responded dismissively and
    told my wife that she could put in a complaint, but don't expect anyone
    to reach out for a week because they don't have to respond to
    complaints until a certain number of days and with the Memorial Day
    holiday coming up that would extend the deadline over that week
    anyways.
        Immediately following that interaction with the Patient Advocate we
    sought options that could produce access to care in accordance to the
    current medical urgency. We were able to schedule an appointment with a
    GI surgeon at the UTSW Harold C. Simmons Comprehensive Cancer Center
    who had an existing contract of service with Community Care and
    immediately received support and advocacy from their Nurse Navigator
    starting on May 22. On top of not having the ability to seek
    authorization for care under the VA Community Care program, I was
    unable to get ahold of my primary care physician to explore VA Facility
    options. At one point I physically walked the results indicating the
    presence of my tumor to the Greenville, TX CBOC, and requested that a
    doctor contact me as soon as possible as it is an Urgent Medical
    concern. I did not hear back from the clinic.
        It is my belief that we finally received communication from the VA
    due to the requests for assistance sent through Congressional
    inquiries. I was contacted by a VA Nurse Navigator on the afternoon of
    May 23rd. She explained that the VA has a tumor board, but I would need
    to have imaging complete prior to being put on their schedule. It was
    dependent on me, the patient, to schedule with the VA imaging
    facilities. After another round of inaccurate VA listed numbers and
    waiting multiple hours, the imaging scheduler informed us that I would
    not be able to receive complete imaging until September, having to wait
    an additional 4 months. After informing the UTSW Nurse Navigator of
    this scenario, she advocated for us and was able to coordinate with the
    VA staff to have imaging completed under Community Care at a civilian
    location. Around this time, I spoke with Patient Advocate, Ms. Veronica
    Lopez, who informed me that the Community Care Referral to be seen at
    UTSW was authorized for Six (6) months to cover treatment needed for
    Colorectal Cancer. I was not provided with any documentation that
    outlined details of this authorization and what it covered.
        After my initial appointment with the Colorectal Surgeon on May
    30th, we unfortunately learned that the imaging and testing indicated
    that I had T3N1 Colorectal cancer, more commonly referred to as Stage 3
    Cancer. This indicates that the cancer was further advanced than we
    were hoping for, and the Standard of Care directs for a Neoadjuvant
    Treatment plan prior to surgical removal. My treatment plan over the
    duration of 6 months consists of 8 rounds of two different types of
    chemotherapy, 5 rounds of concentrated radiation, and assessment for
    surgical removal of remaining cancer upon completion. I started
    receiving treatment in July 2024, under the belief that it was being
    covered by the VA Community Care authorization.
        On August 15, 2024, my wife contacted UTSW over pending billing
    statements on my account to inquire why they were not being covered by
    the VA Community Care authorization that should be on file. She was
    told by UTSW billing department that the VA rejected the billing. At
    that time, I reached out to Patient Advocate Veronica Lopez who
    informed me there was no authorization from the VA to receive
    chemotherapy or radiation, I would have to ask the UTSW staff to send
    in a request for services for additional approval. I inquired with Ms.
    Lopez why personnel at the VA were unable to contact the UTSW staff,
    she told me that she didn't have the time, and it would be best if I
    were to do it. My wife coordinated with the UTSW staff to submit the
    requested documents, on the first submission the VA rejected the form,
    and we were informed by the UTSW staff that when they also tried to
    speak to personnel at the VA to inquire what was needed, they could not
    get a hold of a single VA personnel member on the number they were
    provided. I once again reached out to Representative Self's office to
    seek assistance.
        On August 23, 2024, Savanna Douglas, RN was able to back date the
    referrals for Medical Oncology and Radiation Oncology. With the
    previous interactions of the initial authorization and the unclear
    details, I requested a copy of these documents. She informed me that it
    was not standard procedure to provide the Veteran with these documents,
    but acknowledging my concern pertaining to the miscommunication of
    previous authorizations, she was able to email me the authorization
    forms. With these forms my wife was able to coordinate with the UTSW
    billing personnel to correctly code and submit all appointments.

    Discussion of Issues

        1. The Community Care program does not communicate directly with
    the provider after original scheduling.

        As the Community Care program sets the original scheduling and only
    alerts the Veteran of the contact information, there are many
    opportunities for poor communication and misunderstandings.
    Specifically addressing my scheduling of the colonoscopy, there was no
    information provided regarding the wait time and how it compares to the
    VA facility. Relying on the Veteran to be the main individual to
    coordinate treatment and authorizations is the main reason there was
    such a misunderstanding for the billing of my treatments. Multiple
    times we were unsure of what would be covered for the comprehensive
    plan and received very little support to navigate it.
        I also believe there is a risk to evaluate within the VA use of
    Community Care. With the lack of transparency between Community Care
    scheduling combined with little to no follow up by Case Management
    personnel, there could generate a risk that wait times for procedures
    are not being accurately assessed and inaccurate information is being
    provided to Veterans to make important informed consent decisions
    regarding their access to care.

        2. Community Care Authorizations pertaining to Complicated
    Diagnosis

        I was not provided with any referral numbers or what the scope of
    treatment authorized encompassed. I was asked to fix a problem on my
    own with no resources and no information on what had or had not been
    approved. There was no coordination of care provided; however, the
    authorization was limited in scope. Is it possible for a severe
    diagnosis, such as cancer, that have an industry standard of care, to
    be approached with a duty to accept/approve, should the billing be
    submitted for a patient with a diagnosis known by the VA, by a provider
    known to the VA, and for a Veteran that is within a patient category,
    such as 100 percent P&T, that are already established to receive full
    spectrum care from the VA Medical Network and any care associated.

        3. Lack of Professionalism and Compassion from VA Employees.

        The Veteran begins their journey typically with an extremely
    frustrating phone system. Something as tangible as the phone line
    infrastructure solely lies on the accountability of the Facility's
    Director. Many phone lines listed or attached to automated menus simply
    do not work. It is extremely complicated to get in contact with the
    necessary personnel for any specific requirement. Often a caller must
    be transferred multiple times and direct numbers provided by employees
    are not answered with no consistency of availability to leave messages.
    The default response from VA employees is to take a message and wait
    for a call back. Throughout this entire process not one time has
    someone from the VA system offered to schedule any communication. In
    their responses to our inquiries, the VA claims to operate Community
    Care within a case management model but refuses to offer appointment
    scheduling to discuss their case. This is extremely difficult for
    Veterans, like me, that are working their own jobs, have obligations of
    family, and are navigating very difficult treatment plans.
        Multiple occasions have we been treated with disdain, sighed at,
    told to wait and dismissed by employees we encountered. Case Management
    is extremely inefficient and often incomplete. I did not receive end to
    end case management or proactive engagement. For complicated medical
    conditions, such as cancer, follow up by Community Care personnel to
    ensure treatment plans align with authorizations would help decrease
    misunderstandings and reduce errors that have great potential to
    negatively impact the Veteran. In my scenario, it seemed that no one
    cared until we received assistance from Representative Self's office,
    and I believe that the result would be very different if we had not
    asked and received intervention on two occasions. I have experienced
    great care from some amazing VA employees, but an attitude toward
    complacency and seemingly no accountability permeates many of my
    interactions. Often VA employees display an attitude that they would do
    whatever possible to reduce their workload, burden the Veteran with
    tasks that the employee is hired to conduct, and possess no regard to
    the fact their actions affect a Veteran's access to care. This is seen
    top to bottom by the lack of reporting of community care wait times,
    broken phone infrastructures across the entire facility and network,
    difficult scheduling procedures, and non-existent case management.
        This was especially highlighted by the responses provided to the
    inquiries submitted on my behalf. At no point has anyone taken
    ownership or assessed what could have improved the scenario. I, as the
    Veteran, was regarded as part of the problem, because I chose community
    care and not care through the Dallas VA. The response reads that I
    sought care that was not authorized, when I simply sought care, so I
    don't die.

    Conclusion

        Community Care is a great program that has expanded previously
    prohibited access to care and has the potential to continue to improve
    this access for many Veterans. I believe that Veteran Affairs has
    amazing employees that work for them. However, accountability for poor
    performance, a lack of proficiency, and low procedural transparency has
    generated a toxic atmosphere, that leaves the Veteran having to jump
    through bureaucratic hoops, holding large financial obligations for
    uncovered costs, or being denied access to life-saving and critical
    care.
        Communication between the Health care provider and the Case manager
    should be ongoing with feedback from both sides for this program to be
    successful. Especially for complex and complicated medical diagnosis
    that may require comprehensive treatment plans, case management should
    go beyond the initial scheduling interaction. Clear policies and
    procedures should be available and known to Veterans in the program.
    Wait times for services within the VA Network and the Community Care
    Network should be constantly evaluated and made transparent.
        I appreciate the time and opportunity this Committee has given me
    to share my story. I hope that it will help provide opportunities to
    improve access to care for other Veterans. I would like to thank
    Representative Self and his staff for their advocacy and assistance as
    my family has navigated this challenging time and to each and every
    member of this Veteran Affairs Committee for their continued interest
    in the care of Veterans.
                                     ______

                   Prepared Statement of Lori Willis Locklear

        Hello. I am Lori Willis Locklear. Thank you for your time and
    effort in this important matter.
        I've been a Pharmacy Technician for 30 years until recently when I
    took an early retirement from the Department of Veteran Health Care
    System at the Fayetteville VA Health Care Clinic where I was employed
    for 12 years of my service. Prior to that, I worked for the State of
    North Carolina for almost 4 years. The first years of my career were
    spent at a local hospital, Scotland Memorial and then to a private
    pharmacy in Raeford, NC.
        Let me begin by telling you a little bit about me. On August 27,
    1988, I married Raymond F. Willis, who was an Army Veteran, and he was
    so proud to have served his country. On August 16, 1995 at 8:16 am, we
    had our only child, Logan F. Willis, and it was such a wonderful day
    for us both. On July 16, 2015 my husband died and I had to learn how to
    navigate life again as a single woman with a child in college. I have
    been a woman of great faith in God and in our Nation. I believed in the
    system but I knew that there were areas that needed to be improved
    upon. I gave all I had to my job and to all my veterans that I came in
    contact with daily because I was the wife of a veteran who loved his
    country and so do I. I was proud to serve our nations veterans but
    things changed for me when my son, My Veteran, died by suicide in my
    home because of the lack of support that he received from the very
    place that I had spent years as an employee. Not only was I
    disappointed in the Fayetteville, NC VA, but there was a part of me
    that was disappointed in myself because I truly believed in Veterans
    Affairs. As an employee and mother, I felt that I had failed because I
    believed the VA would take care of my son and at times it was hard for
    me to determine if I was speaking from a mother's perspective or that
    of an employee. I believed that Logan felt that I was only the employee
    and not his mother for he would share that the VA was not willing to
    help him but I kept telling him to return to the VA. I tried as much as
    possible to follow the proper protocol, yet, MY Veteran died by suicide
    in my home, from what I believe was a failure to follow the Community
    Care Act. I believed that our trust in the system was betrayed,
    promises were not kept, and Logan's life was not valued just like so
    many other veterans who have sacrificed so much for our country.
        The year 2015 was a very difficult time for Logan and I because his
    father died of lung cancer. We were a very close knit family and Logan
    idolized his father. After his death, Logan and I received counseling
    and I struggled for a long time. Logan was in college at the time and
    he graduated from the University of North Carolina at Pembroke. He
    enjoyed his time in school and wanted to further his education. So we
    thought the military was an option for him and he wanted to be a
    Veteran just like his dad because his dad always spoke so highly of his
    service. He originally wanted to go to the Air Force, but the Navy
    talked him into going with them. I personally did not think that it was
    a good fit but Logan believed that he could do it. At the last moment,
    I tried to talk him out of it because there was something that did not
    feel right and I wish I had. Later, Logan told me that joining the Navy
    was the worst decision of his life.
        Logan enlisted in the Navy in 2018 and his first duty station was
    in Sasebo, Japan where he served as an intelligence officer. Shortly
    after he was on board, he began to mentally deteriorate; I began
    receiving emails at 3 am from him stating that he couldn't do this, he
    could not stay on the ship. I constantly told him that things would get
    better but as the days went on, he became more insistent that he had to
    get off the ship. He complained the food was terrible, often there was
    no silverware, the sailors had to eat with their fingers, his computer
    was constantly down, so his intelligence reports would not be up to
    date which resulted in him getting in trouble. He was extremely
    disturbed about the fact that he had been photographed naked while he
    was in the shower. I believe he also became claustrophobic in his
    barracks, he had not experienced it to that extreme on board the ship.
    After some time, he was transferred to San Diego Medical Center. I
    hoped and prayed that while he was in San Diego and on land that he
    would get better. One day, the doctor called and requested that I fly
    to San Diego immediately. When I arrived, I was informed that Logan had
    attempted suicide while being there and that he was being released from
    the hospital. My stay was horrible because I did not recognize the man
    who was in front of me. My son had always been kind and humble, a young
    man with a gentle spirit but this person was angry, disappointed, and
    this was not my Logan. I also discovered later that he had attempted
    suicide while aboard the ship. Due to all that Logan was dealing with,
    the Navy gave him an honorable discharge.
        Logan came home on December 31, 2018 but he was so different; it
    was so heartbreaking to witness the transformation that had occurred
    with my child. Logan was always a kind, loving person and would do
    anything to help anyone in need. During his younger years, Logan spent
    a lot of time at the Fayetteville, NC VA where he volunteered all
    through his high school years and worked at our local library for three
    years. He had an associate and a bachelor's degree. Another sad part of
    this story is that Logan was a support for a lot of individuals who had
    suicidal thoughts. So many have shared how it was Logan who talked them
    through their trauma and kept them from following through on their
    desire to commit suicide. Logan had a beautiful spirit but the man that
    returned was not the man that left home to serve his country. Logan
    felt that no one cared for him and that his life was not valued and
    sadly, this is a common theme among many who have served our country.
    The VA doesn't exist for the VA, it exists for our Veterans and their
    families and it should do everything possible to help those who are
    struggling mentally, physically, and financially. I believe my child
    would still be here if the VA had lived up to their promises that were
    made to him. Many promises are made to these young men when they enlist
    to serve their country. Some of these men are broken so much in
    training that they are never the same and that was my Logan.
        In January 2019, I told Logan to go to the VA, get his VA card and
    request a mental health provider. He came back and he said he was told
    that they were unable to help him. It was at that time, that he began
    to hate the very organization that he loved volunteering at during his
    high school summers; he lost all trust in the VA. The things he had
    experienced brought about his anxiety and depression but the way the VA
    treated him increased his mental illness. He was so angry and
    regardless of how I tried to defend the VA, the response he got from
    them led him to believe that the VA was not willing to help veterans.
    During this time, I felt like the worst mother in the world but I
    continued to encourage him to seek help but instead of seeing me as a
    support, Logan began to see me as part of the VA instead of his mother.
        In June, 2019, Logan used his GI Bill and was enrolled in Wake
    Forest University in the Master's of Divinity Program in Winston Salem,
    NC. We all know what happened in 2020, Covid, and this really took a
    toll on Logan because he was beginning to feel a little better because
    he became a part of the college community. I thought things might be
    looking up. However, when all his classes were virtual, Logan became
    more and more depressed. He would stay inside for weeks and isolate
    himself from everyone. I became more and more worried about him. He
    struggled in school and later I learned that his professors noticed
    that he was struggling and several reached out to help him. He was able
    to graduate with their help and I truly believe that is why he lasted
    as long as he did.
        I believe Logan felt trapped; in his mind, the Navy had taken his
    life and now the VA was taking from him as well. On one occasion he
    called me because he was running low on his medications and was worried
    about refills. I assured him that a pharmacy would help with his
    medication; however, I have receipts where he had to pay for his
    medications. I also have receipts where he had to pay $300 for the
    multiple calls he made to his mental health provider. When he was in
    college, he had to pay for health insurance which was very costly.
    Needless to say, I was so upset to know the lengths that he went to in
    order to receive help from an organization that was created to protect
    those who served to protect us.
        On May 14, 2022, Logan graduated from Wake Forest University and we
    were so proud to see him graduate after all the struggles he had been
    through. He seemed so happy that day and I prayed that day would be a
    new beginning for my son but little did I know it was the beginning of
    the end of my child's life. He tried to find a job and an apartment
    after graduation but was unable to find either. He was forced to return
    home so once again, he felt like a failure. I began to see him
    isolating himself again and I constantly encouraged him to seek
    additional help so he agreed to meet with our local VSO Office in
    Raeford. Officer Flagg was the officer who appeared to be helping him.
    I found out later, after his death that multiple mistakes were made on
    Logan's paperwork (i.e., wrong address). When I informed Officer Flagg
    of his death, he completed the paperwork for burial expenses and once
    again, mistakes were made. I informed his supervisor of the multiple
    mistakes so he decided to complete the paperwork himself. This is
    another example of why Logan didn't trust the VA and by this time,
    neither did I.
        In September 2022, I felt more and more that his mental health
    provider was over medicating him. I was a pharmacy technician so I
    would ask our pharmacist about his meds and they would provide
    information. I asked Logan to visit the VA and let our pharmacist go
    over his meds with him. Afterwards, I sent him to check in and request
    to be seen or given a mental health appointment. I was adamant about
    him being seen or provided an appointment. When he returned home that
    day, I questioned him, and he said I got an appointment but he didn't
    say when the appointment was and I never asked; that was my big
    mistake. I found out after his death, in March 2023, that he was given
    a mental health appointment for February 2023 which was five months out
    from when he reached out to the VA in September 2022. I was told after
    Logan's death that our protocol at that time was, if a veteran asked
    for a mental health appointment, they were either to be seen or sent to
    community care within 20 days, my child died 60 days after that and was
    never called. Once again a promise not kept.
        A few days after I buried my only child, I telephoned Washington DC
    to alert them that my child had died by suicide because he was 40
    percent service connected for his disability. Upon returning to work on
    November 22, 2022, two weeks after my son's death, my service
    department was aware of Logan's death, but per protocol I knew I had a
    responsibility as an employee to report a death. Therefore, at the
    time, I felt the patient advocate's office would be appropriate but
    truly I was not thinking clearly and as I write this today, two years
    later it is still hard to think. They seemed very interested and
    shocked to hear of a suicide from our facility and was eager to get the
    information; yet, when they realized it was my son, things changed. I
    came in as an employee, one they knew, but then I became the mother. It
    was at that time, I felt that a cover up began to take place. Over and
    over, I tried to uncover the truth and it was during that time that I
    was treated as a whistleblower. They assured me they would get back
    with me but I was never contacted. Although I returned on November 22,
    2022, it wasn't until February 2023 when I personally contacted
    Director Fryar about my child's suicide that had occurred in our home.
    She stated that she was totally unaware and sympathetic to what had
    occurred and that she would be in touch with me as soon as possible;
    yet, it was not until April 2023 that someone reached out to me. Based
    on what information was provide to me, it states that a suicide team
    was supposed to contact the veterans family as soon as they are made
    aware of the suicide but I guess that policy does not apply to
    employees of the VA.
        After waiting for weeks just for someone to help me to understand
    what had happened, the first call I received from the facility's risk
    manager informed me that I had to come and fill out a tort claim which
    I did understand what a tort claim entailed. On the tort claim, I
    claimed negligence because I felt that the VA did not help my child.
    The VA denied my initial claim because they stated they did give him an
    appointment. A week after filling the claim, I requested his medical
    records and discovered that the VA had given him an appointment but it
    was five months from the day we requested help. Why would the VA wait
    five months when someone is struggling and needing help? When I asked,
    I was informed that the computer electronically gave him the
    appointment. Someone should have looked at the date and changed it. Due
    to the new knowledge, I filled out another claim with a different
    description but once again it was denied. When I asked why, they stated
    they were unable to talk with me. I continued to speak with countless
    people and I ran into roadblock after roadblock within the VA. At this
    time, I was mentally and physically deteriorating and I could not focus
    on my job; thus, I took FMLA to go home and try to heal. I felt that my
    healing would never come as long as I was working for a system that in
    my mind contributed to the death of my son. In order to bring some sort
    of closure and healing, I sought therapy and I am still in counseling
    today. My therapist helped me realize that I have PTSD and every time I
    walked through the back door to the VA, I literally began to suffer
    because I blamed the VA for his death. I worked as best as I could to
    get to my minimum retirement age and then I left. I felt I had no
    choice because I could no longer do my job. I was holding up my
    department and causing a hardship. I simply could no longer function as
    I had prior to Logan's death. I was never processed out of the system
    as every other employee had been. When I asked my supervisor, she
    stated that she had not been informed and frankly she was as surprised
    as I was. Once again, another promise not kept. Another VA employee
    shared with me that I should seek disability because of my treatment
    from the VA after my son's death which brought on all the mental and
    physical issues that I now have. I have been sicker in the past two
    years since Logan's death than I have been my entire life. I'm almost
    58 years old. I applied for disability in November 2023 and have not
    heard back from the Office of Personnel Management.
        I called a local NC representative in January 2023 for help and he
    was very instrumental in helping me. I have also shared my story with
    other state representatives. There is so much emphasis put on the Gold
    Star families for their sacrifice what about the families when a
    veteran dies by suicide. Personally, I think the least that could be
    done is the military or VA should have to lay these young people to
    rest and not their families who entrusted their well being to them when
    they enlisted to serve. I also think the sole survivors benefits rules
    should be revisited, how old exactly is this rule. What family can live
    off of $35,000 a year to qualify for these benefits? I am my child's
    sole survivor, his father, an Army veteran, is deceased as well.
    Haven't I lost enough? So, I got remarried a year before my child died
    and so it disqualified me for this service? Really, I think it's the
    least that could be done for me! Not to mention, this entire last 2
    years of my life has been debilitating because of everything that the
    VA did to me by treating me like a ``whistleblower'' because no one
    wanted to speak to me. I was finally given a meeting over a year later
    in January 2024 and all of my questions were not answered to my
    satisfaction nor was I satisfied with the outcome of my tort claim. I
    hope my efforts will not only bring closure to me but will also help
    military families in the years to come and the VA will adhere to the
    Community Care Act which is the law. My hope is that no other veteran
    dies because the laws are not being followed. I do not want another
    mother to find their child in a bathtub with a plastic bag over his
    head with a helium tank inside. This was a total nightmare that never
    goes away.
        In closing, thank you for the opportunity to share Logan's story,
    he deserved this; his life mattered. My hope is that by sharing his
    story, this will bring some healing to my broken heart, help me reclaim
    my life and my prayer is that one day I will be able to think clearly.
    Last, I hope that no other VA employee who has a deceased veteran will
    have to endure the hardships that I had to endure. I feel like I was
    labeled a whistleblower but if it brings positive change to a broken
    system then it was worth it. I will always wear the title of mother
    with pride, Logan, my son, you will always be. I also want to thank my
    husband, Ray Locklear, who has been my constant support during this
    horrible ordeal. Once again, thank you and God bless you all.
                                     ______

                  Prepared Statement of Brittany Dymond Murray

        Chairman Bost, Ranking Member Takano, and members of the committee,
    on behalf of the men and women of the Veterans of Foreign Wars of the
    United States (VFW) and its Auxiliary, thank you for the opportunity to
    provide the VFW's and my personal remarks on this critical topic.
        The VFW believes the Department of Veterans Affairs (VA) community
    care program and its Community Care Network (CCN) of providers are a
    vital component of VA health care as it delivers the care and services
    that VA hospitals and community-based outpatient clinics either cannot
    or do not provide. Since no institution can be everything for
    everybody, community care options are force multipliers as they permit
    VA to continue providing the world-class health care that veterans
    prefer, deserve, and have earned while also ensuring they have access
    to the range of health care services they may need throughout their
    lives.
        When used properly, CCN can save lives and improve the health
    outcomes for countless veterans, but when problems with CCN arise it
    can drive people away from the care they have earned. We have also
    called on VA to lean on its third-party administrators to ensure
    consistent delivery of community care to veterans who are eligible.
    Unfortunately, VA has not heeded these calls, and we regularly hear
    from veterans whose potential community care eligibility has been
    stifled by bureaucrats at the local level. The VFW has been unequivocal
    since the Phoenix crisis in 2014 that community care must be a part of
    VA care. It always has been. However, veterans expect consistency. When
    23 Veterans Integrated Services Networks interpret the VA MISSION Act
    of 2018 in 23 different ways, veterans are overlooked, as the VA
    Inspector General pointed out earlier this year in Buffalo, New York.
        VA's CCN is plagued with too many problems that need thoughtful
    solutions. Care in the community is necessary for some veterans but, if
    given the choice, our members routinely tell us they prefer VA direct
    care. We believe some of that sentiment is driven by negative
    experiences with the community care process. We must fix those issues
    because our veterans have earned quality care regardless of who
    provides it. My story below is just one example of a negative
    experience that could have been easily avoided.
        As a nearly decade-long VA patient, I wholeheartedly agree with the
    VFW in its view of the necessity of the VA community care program, and
    it is not because I am a VFW employee or hold a life membership
    therein. I have interacted with VA community care on numerous
    occasions, including a successful surgery that VA was unable to
    perform. However, I was called here today to illustrate my recent
    experience obtaining inpatient mental health treatment through VA.
        My journey with mental health care began on active duty during my
    first deployment in 2010. Initially spurred by relational challenges
    and interest in addressing childhood traumas, my needs intensified
    after I experienced the devastating 2011 earthquake in Japan and was in
    a combat zone in 2012 where I endured months of harassment from members
    of my unit in Afghanistan. For years, I struggled to sleep because I
    was flooded with recurring nightmares and night sweats. Among other
    symptoms, I also battled persistent and sometimes explosive anger at
    home and at work, and went emotionally numb. I did not understand what
    was happening to me and, quite frankly, no one else genuinely did
    either.
        The Department of Defense (DOD) did not accurately diagnose my
    symptoms as post-traumatic stress disorder (PTSD), which meant that
    while I was receiving mental health care the treatments were merely
    band-aids that helped only to a point. I was not diagnosed with PTSD
    until after I was discharged from the Navy in 2015 and a local Vet
    Center therapist suggested I file a VA disability claim. PTSD became
    and remains my highest service-connected VA disability rating.
        My PTSD symptoms continued with little meaningful improvement after
    my transition to VA health care where, until I moved to Washington, DC,
    in 2021, I had been under the care of only VA therapists and
    psychiatrists. With medication and various forms of therapy, some
    symptoms improved while others changed and new, seemingly more
    insidious ones presented themselves. Despite consistent mental health
    care from multiple providers with the tried-and-true treatment
    modalities available at VA, I continued to battle crippling emotional
    numbness and had come to blame myself for being ``defective.'' I also
    started silently contending with what I came to learn were passive
    suicidal ideations, and concluded that my brain and my very being were
    beyond repair.
        During fall 2021, after ten years of trying to find understanding
    and relief, I was referred to a civilian trauma therapist through VA
    community care due to capacity constraints in the Washington, D.C., VA
    hospital's mental health clinic. My new therapist quickly diagnosed me
    with complex PTSD (CPTSD), which is the first time I can recall a
    mental health professional using that term. Shortly thereafter in early
    2022, I called the Veterans Crisis Line and after following up with my
    therapist, she decided that my chronic CPTSD symptoms met the criteria
    for a higher level of care including inpatient or residential mental
    health treatment.
        It took me a while to warm up to the idea of live-in mental health
    care, as I was not sure whether things were truly ``bad enough'' to put
    my life and new job on pause for a month or more. However, it soon
    became clear that my passive suicidal ideations were not abating, and
    neither was my battle with emotional numbness. Going about regular life
    with weekly therapy appointments was not enough, and I needed my
    primary daily focus to be my mental health. I agreed to pursue
    inpatient treatment in May 2022 and my community care therapist quickly
    acted.
        Based on my trauma history and symptoms as well as her clinical
    expertise, she recommended a military-and veteran-specific PTSD
    treatment program in Utah. Specifically, my therapist felt it was
    critical that I go to a women's program that had military cultural
    competence, approached treatment holistically, offered specific
    treatment modalities like Eye Movement Desensitization and Reprocessing
    (EMDR), addressed a range of traumas including those sustained during
    childhood and during military service like military sexual trauma, and
    could be completed in roughly 30 days. Since the Utah facility met
    those requirements and she had heard positive feedback about its
    program, my therapist began the nuanced community care referral process
    with VA.
        After months of trial and error submitting my referral, my
    therapist learned in September 2022 that the Washington, D.C., VA could
    not authorize a referral to the Utah treatment program due to its
    physical location in VA Community Care Network Four (CCN 4), which is
    managed by TriWest Healthcare Alliance. The VA employee assisting with
    the referral noted that we were in CCN 1, which is managed by Optum
    Serve, and requested that we choose an alternative facility in the
    Washington, D.C./Maryland/Virginia area. It is noteworthy that a
    representative at the Utah facility warned us about this by stating,``.
    . . we are not in-network with the East region. We have tried several
    times but have been told `we do not need any additional providers at
    this time.' It is frustrating because we get a lot of calls from the
    East Coast and we haven't been able to help.''
        Shortly after my referral to the Utah treatment program was denied,
    I learned that I also needed reconstructive hip surgery. Disgusted with
    the denial and knowing that I could not do both due to employment
    factors, I chose to have surgery even though it meant I would have to
    wait even longer to go to mental health treatment.
        Following my surgery recovery, and with an emboldened need to go to
    treatment, I revisited the conversation with my therapist to find a
    suitable inpatient program. However, this time around I had done an
    immense amount of research on the many symptoms I was experiencing and
    their root causes. In doing so, I came to learn that in addition to
    EMDR and other evidence-based methods, an uncommon treatment modality
    called Internal Family Systems (IFS) therapy was also effective in
    treating CPTSD. Together with my therapist, we decided to try to get
    authorization to a treatment program in Arizona that, like the Utah
    program, was in CCN 4 and offered the highly specialized and tailored
    CPTSD treatment options and holistic care that my therapist and I
    agreed were necessary. They also offered IFS, which I quickly realized
    is difficult to find.
        I had reason to believe this time would be different because while
    speaking with a representative from the Arizona program, it was
    mentioned that service members and veterans from the East Coast had
    come there in the past. However, it was noted that I would need to
    convince my VA doctor that an out-of-network exemption was needed to
    advocate for a community care referral on my behalf. So, on July 10,
    2023, I sent a detailed two-page request to my VA psychiatrist via
    secure message substantiating my interest in the Arizona program. He
    acknowledged and submitted the request, but I received no updates for
    about a week thereafter.
        Frustrated with the seeming lack of urgency on VA's part, I
    physically went to the Washington, D.C., VA hospital and found a mental
    health professional who agreed to speak with me right away without an
    appointment. She then introduced me to a social worker who could help
    me with my referral. Without hesitation, the social worker listened to
    me, did a thorough review of my symptoms and, to my great surprise and
    relief, he named the emotional numbing that had plagued me for so many
    years. He agreed that my CPTSD symptoms required the specialized
    treatment that the Arizona facility could provide and promised to
    advocate on my behalf that its program was the right fit for my
    recovery.
        On July 21, 2023, the social worker who promised to try to help me
    get into the Arizona program informed me that since the facility was in
    CCN 4, it was outside their community care consult area. He said they
    were able to submit consults only for programs in CCN 1 or CCN 2.
    Furthermore, he said he talked with the same representative from the
    Arizona facility with whom I had previously spoken, and that he would
    continue to try to find a way to get a referral authorization.
        Unfortunately, I did not hear back from the social worker, and my
    request for inpatient mental health treatment was overlooked for more
    than a month. I later learned that he went on emergency medical leave
    and my file was not given to anyone else until September 2023.
        Two VA employees -- another social worker and a community care
    referral manager -- began to help me find a treatment program in early
    to mid-September. Unfortunately, so much time had passed since my
    initial treatment request in July, that I could no longer go as soon as
    a suitable program was found that also had space available to admit me.
    I would have to wait until January 2024 for my next available window of
    opportunity to enter treatment.
        Nonetheless, the VA employees continued to help me find inpatient
    programs, but insisted that they be on the East Coast because going to
    a program in CCN 4 was not an option. At that point, I was firmly put
    in a position of having to find CPTSD treatment programs comparable
    with those in Utah and Arizona, which was the proverbial ``needle in a
    haystack.'' The employees asked what my criteria were, and they began
    presenting me with myriad in-network options.
        None of the programs they suggested were directly comparable to
    those offered in Utah and Arizona. Some programs were too long (e.g.,
    90 days, while others were not the right structure for my needs (e.g.,
    intensive outpatient programs). Some had poor reputations and my
    therapist steered me away from them. Still yet, others did not offer
    the range of treatment modalities I needed, or they were primarily
    focused on treating mental health conditions I did not have such as
    eating or substance use disorders. One facility was for patients who
    were dangers to themselves or others, which was not only inappropriate
    for me but also would have been more detrimental than therapeutic.
    Another facility I personally interviewed did not understand why I
    would want to be in a women-only program. To say I was angry and
    frustrated was an understatement, and I felt bad because while the VA
    employees were trying to help, the in-network options they presented
    always seemed to fall short in some way.
        After a few weeks of searching, we finally found an in-network
    treatment facility in Pennsylvania that met most of my criteria.
    Although the program was not military-centric and did not use EMDR or
    IFS treatment modalities, it was 30 days long, women-only, holistic,
    and employed one treatment method called Dialectical Behavior Therapy
    that could help me manage my CPTSD symptoms. After much consideration
    and knowing that it was a significant departure from the Utah and
    Arizona programs, I agreed to compromise and go to the Pennsylvania
    program.
        I checked into treatment on January 3, 2024, and was extremely
    fortunate to have been matched with a military-connected trauma
    therapist who helped me begin to identify the root causes of my CPTSD
    diagnosis and related symptoms. She also ensured that my follow-on care
    was with a qualified professional who practices both EMDR and IFS
    treatment methods. I am currently under the care of that professional,
    who agreed to join the VA CCN in order to treat me. I consider myself
    very lucky, but getting the right mental health care should never be a
    matter of luck.
        I cannot adequately express how difficult it was to simply
    acknowledge to myself, let alone others, that my mental health had
    deteriorated enough to need intensive treatment. After a decade of not
    receiving the correct diagnoses and related treatments, I felt
    defeated, defective, and helpless. I learned that passive suicidal
    ideations are actually a product of the ``fight'' portion in one's
    fight-or-flight response essentially giving out. It is unconscionable
    that I was allowed to get to that point despite consistent DOD-and VA-
    provided therapy. Considering military and veteran suicide statistics,
    I am not alone. Had I not advocated for my needs, and as a result been
    sent to a treatment program that was unequipped to truly help me, it
    could have been my last attempt at getting better. I trust that I do
    not need to spell out what that means.
        VA must stop its practice of rationing inpatient and residential
    mental health treatment based on arbitrary, seemingly thoughtless
    guidelines. Timely diagnosis and placement based on specific needs are
    crucial, regardless of location. Failure to do so is short-sighted at
    best and dangerous at worst. Providing veterans with the correct and
    appropriate mental health care the first time maximizes savings lives.
        Chairman Bost and Ranking Member Takano, this concludes my
    testimony. Again, the VFW thanks you for the opportunity to testify on
    this critical issue. I am prepared to take any questions you or members
    of the committee may have.

    Information Required by Rule XI2(g)(4) of the House of Representatives

        Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW
    has not received any federal grants in Fiscal Year 2025, nor has it
    received any federal grants in the two previous Fiscal Years.

        The VFW has not received payments or contracts from any foreign
    governments in the current year or preceding two calendar years.
                                     ______

                      Prepared Statement of Kelley Saindon

        Chairman Bost, Ranking Member Takano and Distinguished Members of
    the Committee, thank you for inviting us to testify today on the U.S.
    Department of Veterans Affairs (VA) Community Care Program (VCCP).
        NOVA is a professional organization for nurses employed by the
    Department of Veterans' Affairs (VA). The opinions provided here are
    not that of the VA, but of our members who are nurse managers,
    frontline and specialty healthcare professionals taking care of
    Veterans at VA facilities around the country.
        As nurses coordinating care and directly involved in referring
    Veterans into the community, we would like to provide our thoughts on
    the VCCP program with a focus on Veterans enrolled in the system.
        Currently there are 9.1 million Veterans enrolled in VA healthcare.
    VHA's 2024 Annual Report noted that VA delivered more than 130 million
    health care appointments of which 78.8 million involved direct care and
    48.8 million were in the community.\1\
    ---------------------------------------------------------------------------
        \1\ VHA 2024 Annual Report VA Health Care: A Strong Foundation. A
    Healthy Future.
    ---------------------------------------------------------------------------
        NOVA understands and supports Community Care when access to VA is
    not readily available, the distance is too far, or the VA does not
    provide the needed care. We recognize and acknowledge that we cannot
    serve everyone everywhere. Our priority is to ensure Veterans receive
    the highest level of health care within the VHA and utilize community
    care as needed to enhance their health care experience.
        Since the passage of CHOICE and MISSION Acts, the VCCP has rapidly
    expanded. Referrals have risen to 15-20 percent annually, and in 2023,
    44 percent of VHA health funds were spent on external care. While the
    MISSION Act expanded community care it was not meant to replace VA's
    Integrated healthcare system. The legislation was meant to provide a
    balance between non-VA care when necessary while bolstering VA direct
    care.
        Community care is an integral part of our healthcare delivery
    system. VHA continues to collaborate and build strong community
    coalitions. These partnerships are crucial to providing safe care
    efficiently for veterans. Provider shortages and budgetary constraints
    continue to affect care in the community. According to the Association
    of American Medical Colleges there is an anticipated national shortage
    of 21,400 to 55,200 primary care physicians by the year 2033.\2\
    Constriction and closures of community healthcare systems have raised
    questions and concerns about how and when Veterans can be referred to
    the community. Our healthcare communities are saturated, unable to
    absorb the needs of Veterans. As such, VHA continues to prioritize
    enhancing partnerships with CCN to deliver care to our Veterans.
    ---------------------------------------------------------------------------
        \2\ Tim Dall et al., The Complexities of Physician Supply and
    Demand: Projections from 2018 to 2033 (Washington, DC: Association of
    American Medical Colleges, June 2020).
    ---------------------------------------------------------------------------
        Veterans in rural communities are at a higher risk, where the
    provider shortage is worse, leaving them without access to primary
    care, mental health, hospital, emergency, and pharmacy services. VHA
    has worked tirelessly to bring healthcare to the Veterans, technologies
    have bridged a gap in these rural settings.
        Despite much innovation and improvement work focused on expanding
    efficiency for Community Care coordination, the steps are laborious.
    Inconsistencies in scheduling and authorizations across the system
    create confusion for Veterans and our community partners. It is vital
    that VA facilities have more control over services provided. Records
    must be received timely so the VA can coordinate additional care, if
    needed, including scheduling any diagnostic testing that may be
    requested.
        We recommend a public facing site that Veterans can view to make
    informed decisions as to where they are receiving care. The site should
    include detailed information on provider wait times, quality metrics,
    credentials, and training for both VA and VCCP providers.
        Training is critical and not required of VCCP providers at this
    time. Focusing on the veteran should require that all VCCP providers be
    mandated to complete education and training related to military culture
    and illnesses seen in veterans.
        VHA clinicians are more likely to have experience and specialized
    training in recognizing, diagnosing, and treating conditions often
    encountered by Veterans, such as trauma-related injuries, substance
    abuse, mental health disorders and toxic exposures. VHA providers have
    logged over three million toxic exposure screenings as of April 2023
    with almost 42 percent of those screenings revealing at least one
    potential exposure.\3\ VHA staff are uniquely trained not only on
    military culture but also on disease and exposures specific to the
    veteran population.
    ---------------------------------------------------------------------------
        \3\ ``VA PACT Act Performance Dashboard,'' VA https://
    www.accesstocare.va.gov/VA_PACTActDashboard.pdf
    ---------------------------------------------------------------------------
        As a VHA employee, new employee education provides Veteran specific
    training to ensure competencies are in place before administering care.
    The standards for our community network should be no different. Our
    Veterans and caregivers deserve it. As a nurse, in addition to new
    employee orientation, VA medical centers provide clinical employees an
    additional clinically focused orientation. At White River Junction
    (WRJ) the new employee education is three days for all employees, the
    clinical orientation for nursing staff is a week-long.
        Robust training includes clinical reminders, which are nationally
    generated screening assessment in the electronic health record specific
    to disease and illness commonly experienced by Veterans. This
    individualized preventative care and evidence-based practice cannot be
    found in the community. For example, suicide risk is assessed at each
    episode of care at a VA medical center. Whether the Veteran is in the
    eye clinic or the mental health clinic, this is standard. These
    standards should be no different for community providers treating
    Veterans.
        Care oversight in the community network is minimal at best, we
    recommend there is strong action to bolster quality and oversight of
    care. Failure to meet quality expectations should result in removal
    from the network. Without proper coordination between VHA and community
    providers with respect to returning medical documentation in a timely
    manner puts the Veterans at risk of not receiving relevant information
    to make sound and accurate health care decisions. For example, this
    vulnerability is especially important with lung cancer screening, lung
    nodule follow-up, mammograms, and colonoscopies. Often the community
    care staff request records 3 or 4 times with no results sent by the
    community provider, leaving the Veteran at risk for serious, in some
    cases, life-threatening poor outcomes.
        We recommend the community network have prescriptive guidelines for
    record sharing. Current practice of faxing leaves much risk for
    healthcare decision delays. We encourage Congress to reimplement
    business rules that permits payment to VCCP upon receipt of medical
    records.
        The U.S. Dept. of Veterans Affairs healthcare system in White River
    Junction (WRJ) is a fully accredited acute medical and surgical care
    facility offering primary and subspecialty outpatient care, including
    rehabilitation, and mental health services.
        The WRJ Healthcare system serves veterans in Vermont and the four
    contiguous counties of New Hampshire. Veterans are being redirected to
    the VA as primary care and certain specialty services in the community
    are not taking on new patients. The continued increase in community
    care is a threat to safe and timely access to care for Veterans.
        Studies have consistently shown that VHA care equals or exceeds the
    quality of care provided by the private healthcare sector. Recent star-
    rating reviews demonstrate that VHA hospitals score higher than non-VA
    facilities in both patient satisfaction and quality of care.
        White River Junction received a 5-star Overall Hospital Quality
    Star Rating in September 2024. It was the only facility in Vermont and
    New Hampshire to earn the top rating. The measures used to calculate
    overall CMS Star Ratings are mortality, safety of care, readmission,
    patient experience, and timely and effective care. The more stars (out
    of 5), the better a hospital performed on the available quality
    measures. Across both VA and non-VA hospitals nationwide, just over 8
    percent of facilities rated received a 5-star rating in the 2024 data.
    These findings are the latest in a series of recent evaluations showing
    the effectiveness of VA health care compared to non-VA health care,
    revealing that VA health care is consistently as good as--or better
    than--non-VA health care and the choice of most Veterans.\4\
    ---------------------------------------------------------------------------
        \4\ HCAHPS: Patients' Perspectives of Care Survey CMS
    ---------------------------------------------------------------------------
        A 2024 VFW survey showed ``overwhelming support for VA to remain
    the primary deliverer of care for veterans.'', with a majority of the
    Veterans saying they prefer using VA medical facilities for their
    health care needs.
        The VA must remain the primary provider and coordinator of Veterans
    healthcare, using community care as a supplement only when VHA services
    are unavailable. Authorizations and referrals should follow access and
    eligibility standards. Requirements for both VHA and VCCP should
    include consistent quality standards and training.
        Listening to Veterans' stories helps us understand their needs.
    NOVA is committed to working with Congress, community partners, and VA
    leaders to ensure Veterans receive timely access to the highest level
    of care.
        Thank you for the opportunity to provide our perspective on this
    critically critical issue. We look forward to working with the
    Committee as we focus on ensuring Veterans continue to receive timely,
    high quality compassionate care now and into the future.

                           Statements for the Record

                                  ----------

     Prepared Statement of Alzheimer's Association and Alzheimer's Impact
                                    Movement

        The Alzheimer's Association and Alzheimer's Impact Movement (AIM)
    appreciate the opportunity to submit this statement for the record for
    the United States House Committee on Veterans' Affairs Hearing on
    ``Restoring Focus: Putting Veterans First in Community Care.'' The
    Association and AIM thank the Committee for its continued leadership in
    ensuring our nation's veterans have the proper health care and
    resources that are important to those who are living with Alzheimer's
    and other dementia and their caregivers. We also wanted to thank the
    Committee for the enactment of The Senator Elizabeth Dole 21st Century
    Veterans Healthcare and Benefits Improvement Act (P.L. 118-210), which
    included several bipartisan and bicameral proposals to reform and
    improve the delivery of healthcare, benefits, and services at the
    Department of Veterans Affairs (VA). This statement highlights the
    importance of dementia care and support programs at the VA and outlines
    how our nation's veterans living with dementia are benefiting from such
    programs.
        Founded in 1980, the Alzheimer's Association is the world's leading
    voluntary health organization in Alzheimer's care, support, and
    research. Our mission is to eliminate Alzheimer's and other dementia
    through the advancement of research, to provide and enhance care and
    support for all affected, and to reduce the risk of dementia through
    the promotion of brain health. AIM is the Association's advocacy
    affiliate, working in a strategic partnership to make Alzheimer's a
    national priority. Together, the Alzheimer's Association and AIM
    advocate for policies to fight Alzheimer's disease, including increased
    investment in research, improved care and support, and the development
    of approaches to reduce the risk of developing dementia.
        Nearly half a million American veterans have Alzheimer's--and as
    the population ages, that number is expected to grow. In 2022, an
    estimated 451,000 veterans were living with Alzheimer's, and more than
    130,000 new cases were diagnosed. The VA has projected the number of
    veterans living with Alzheimer's dementia will increase by 8.4 percent
    through 2033 to more than 488,000.
        For veterans, the prevalence of Alzheimer's may grow even faster in
    future years because they have a higher risk of developing dementia.
    The significant increase in the number of veterans with Alzheimer's and
    other dementias will place a heavy burden on the VA health care system.
    Veterans with dementia are 2.6 times more likely to be hospitalized
    than other veterans--and hospital stays are, on average, 2.4 times
    longer. The average number of outpatient psychiatric visits is three
    times greater among veterans with dementia than veterans without. More
    than 60 percent of the VA's costs of caring for those with Alzheimer's
    are for nursing home care.
        We are grateful for the VA's participation in the Department of
    Health and Human Services (HHS) Advisory Council on Alzheimer's
    Research, Care, and Services, which plays a key role in developing and
    annually updating the National Plan to Address Alzheimer's Disease, as
    set forth by the National Alzheimer's Project Act (P.L. 111-375). The
    National Plan is a roadmap of strategies and actions of how HHS and its
    partners can accelerate research, expand treatments, improve care,
    support people living with dementia and their caregivers, and encourage
    action to reduce risk factors. The most recent update to the Plan was
    released in December 2024 and includes several highlights on the VA's
    continued work to better serve our nation's veterans living with
    dementia. We were excited to see Congress take action in the 118th and
    enact the bipartisan NAPA Reauthorization Act (P.L. 118-92) and
    Alzheimer's Accountability and Investment Act (P.L. 118-93) that will
    extend the National Plan to Address Alzheimer's Disease and ensure
    researchers at the National Institutes of Health continue to receive
    the funding necessary to sustain vital Alzheimer's and dementia
    research. These laws will ensure the nation continues addressing
    Alzheimer's as a national priority, providing continuity for the
    community.

    The VA's Continued Role in Increasing Enrollment in Clinical Trials

        The VA continues to collaborate with federal agencies on a number
    of the key goals of the National Plan, including Action 1.B.3 to
    increase enrollment in clinical trials. The VA Office of Research and
    Development (ORD) and the National Institute on Aging (NIA) have a
    strong, ongoing collaboration. Among many activities, the VA and NIA
    have partnered on a program launched in 2020 in which the NIA provided
    supplemental funds to five Alzheimer's Disease Research Centers (ADRCs)
    co-localized with VA facilities or research centers to increase the
    recruitment of veterans into NIA-funded studies. Strategic priorities
    for the pilot include recruiting veterans, especially from diverse
    populations, and investigating unique risk factors for this population.
    Research coordinators at each participating ADRC have worked directly
    with the VA and NIA staff to identify and address challenges, develop
    pragmatic solutions, and share best practices and materials to increase
    veteran outreach and sustain enrollment. The pilot program successfully
    enrolled 99 veterans into ADRC studies, including 39 individuals from
    historically underrepresented racial and ethnic groups. The project
    also registered 172 veterans in AD registries. The results and impact
    of this pilot program were published in February 2024 and laid the
    groundwork for future collaborations between the NIA and the VA. Last,
    tools specific to veteran recruitment have also been included in the
    NIA's Alzheimer's and Dementia Outreach, Recruitment, and Engagement
    (ADORE) repository.

    The VA's Continued Role in Addressing Alzheimer's Disease in Rural
    Areas

        The VA continues to collaborate with federal agencies on a number
    of the key goals of the National Plan, including Action 2.A.1 to
    educate health care providers on Alzheimer's disease. The VA's
    GeriScholars program offers staff training to integrate geriatrics into
    primary care practices in three training programs: (1) intensive
    individual training with didactics, quality improvement coaching, and
    clinical practicum experiences; (2) limited team-based training,
    including Rural Interdisciplinary Team Training (RITT); and (3) self-
    directed learning through webinars, simulation learning, case studies,
    and enduring educational materials (such as dissemination of pocket
    cards on dementia, delirium, and depression). VA GeriScholars includes
    a wide variety of training activities, many of which include or are
    focused on dementia training. Examples of Fiscal Year 2022 trainings
    include webinars such as ``Treating PTSD in the Context of Cognitive
    Impairment,'' ``Dementia and the Age-Friendly Health Systems
    Initiative: Integrating the 4M's of Mobility, Mind, Medications, and
    What Matters into the Care of Older Veterans'', and ``Enduring
    Education''--as well as case studies and virtual geriatrics
    conferences, such as Healthcare Planning and Management for Older
    Adults with Dementia and Geriatric Patient with Cognitive Impairment.
        We also ask that the Committee continue to support the Veterans
    Health Administration's 20 Geriatric Research, Education, and Clinical
    Centers (GRECCs), which are geriatric centers of excellence focused on
    aging. GRECCs reported in the 2024 National Plan Update that their work
    included 78 research grants in dementia covering basic science to
    clinical care and health services research and 25 clinical innovation
    projects that directly served veterans with dementia and their
    families. GRECC faculty have developed numerous clinical programs to
    aid family members and care providers, including e-Consults for
    Behaviors in Dementia, Health Care Directives for Veterans with
    Dementia, Reaching Out to Rural Caregivers and Veterans with Dementia
    Utilizing Clinical Video-Telehealth, and Virtual Dementia Caregiver
    Support Programs. The GRECC Program produced 56 educational programs
    for staff and trainees on best practices in dementia care, including
    the use of simulation technology to demonstrate techniques for
    communication and facilitating activities of daily living for veterans
    with dementia. Finally, GRECC authors published 259 manuscripts in
    peer-reviewed journals in Fiscal Year 2022 on their research and
    clinical work in dementia. The VA must continue supporting the GRECCs
    in disseminating findings from this research to integrate
    scientifically proven dementia interventions into local and rural
    communities.

    Educating Health Care Providers in the Indian Health Service and Tribal
    Care Systems

        The VA also continues to collaborate with the Indian Health Service
    (IHS) and Centers for Disease Control and Prevention (CDC) on the
    National Plan Action 2.A.6 to strengthen the ability of primary care
    teams in Indian country to meet the needs of people with Alzheimer's
    and related dementias and their caregivers. For example, in 2022, the
    IHS launched the Indian Health GeriScholars Pilot, developed with the
    support and collaboration of the VA Office of Rural Health. Modeled
    after the highly successful VA GeriScholars Program that has built
    geriatric expertise into the primary care workforce over the past
    decade, the Indian Health GeriScholars pilot is providing primary care
    clinicians at IHS, Tribal, and Urban Indian Organizations (UIO)
    programs with an individual intensive learning track for professional
    continuing education, including a week-long intensive training in
    geriatrics through an approved Geriatrics Board Review course, mentored
    geriatric improvement project at their local facility, mentorship in
    geriatric practice, and ongoing education, training, and peer support
    as an Indian Health GeriScholar.
        During the pilot's first two years, 31 providers and pharmacists at
    28 sites across 10 IHS areas participated in training and finished
    projects focused on detecting and diagnosing dementia, medication
    safety, fall prevention, and other locally relevant topics. Demand
    increased for the 2024 cohort to include eight physicians, one nurse
    practitioner, and 14 pharmacists from 21 sites, representing seven IHS
    areas. The Indian Health GeriScholars are encouraged to participate in
    the educational offerings available to the VA GeriScholars.
        These are only a few examples of ways in which the VA remains
    involved in working to ensure a high-quality, well-trained dementia
    care workforce and continue bridging the gap in cognitive services in
    rural areas. The National Alzheimer's Project Act as a whole has led to
    great achievements in the treatment and research of Alzheimer's
    disease, and we are looking forward to seeing more progress in the
    119th Congress.

    Conclusion

        The Alzheimer's Association and AIM appreciate the Committee's
    steadfast support for veterans and their caregivers and the continued
    commitment to advancing issues important to the millions of military
    families affected by Alzheimer's and other dementia. We look forward to
    working with the Committee and other members of Congress in a
    bipartisan way to advance policies that will ensure access to high-
    quality dementia care and support in rural areas, especially as the
    population of veterans living with dementia continues to grow.
                                     ______

                    Prepared Statement of Mission Roll Call
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

     Prepared Statement of American Psychological Association, Association
    of VA Psychologist Leaders, Association of VA Social Workers, National
       Association of Veterans Affairs Physicians and Dentists, National
    Association of Veterans' Research and Educational Foundations, Veterans
          Affairs PA Association, Veterans Healthcare Policy Institute

        Chairman Bost, Ranking Member Takano, and distinguished members of
    the committee:
        On behalf of our organizations, we thank you for inviting us to
    submit a statement for the record for today's hearing on how the U.S.
    Department of Veterans Affairs (VA) can improve the care of veterans in
    the community. Many members of our organizations are veterans or have
    family members who are veterans. Many of us have had long careers
    serving veterans, have published papers on veterans' healthcare in
    peer-reviewed journals, or have previously presented testimony to your
    committee. In today's statement, we wish to convey our appreciation for
    your leadership and abiding commitment to ensuring that veterans
    receive the highest level of health care within the Veterans Health
    Administration (VHA) and supplementary care in the private sector when
    it's both needed and authorized by the VHA.
        Problems in VHA scheduling and coordinating community care--a focus
    of the hearing--are real, and every veteran's experience deserves
    careful attention and efforts to rectify. There are stories from
    multiple vantage points, including veterans who received substandard
    care in the community. For example, we have a report of a Gulf War
    combat veteran who, after unusual sleep study results, was referred to
    a community cardiologist. The cardiologist recommended implanting a
    pacemaker and offered to perform the invasive procedure the next week.
    The self-referring and possibly profit-motivated aspect raised doubts
    in the veteran's mind about whether a pacemaker was necessary, and a
    second opinion from another cardiologist confirmed that it was
    contraindicated. Consider also the Vietnam veteran who, despite
    indicating his strong preference to wait for VHA services, faced
    pressure from a scheduler to accept community care because the facility
    felt compelled to reduce its' average wait times. Or reflect on the
    Iraq War veteran in need of posttraumatic stress disorder treatment who
    did not feel understood by his community care clinician.
        It is essential, however, that we not just listen to the individual
    stories brought to us, but take into account the aggregate data and
    research that represent the experiences of all our veterans.
    Information that encompasses the 9.1 million veterans enrolled in the
    VHA system is the strongest foundation upon which to base policy
    decisions and craft legislation. That is putting veterans first.
        Our organizations support the need for supplemental community care
    options when access to VHA services is too delayed or too far away. We
    share the bipartisan goal of ensuring that the Veterans Community Care
    Program (VCCP) lives up to its promise--still unrealized--of delivering
    timely, high-quality care without the prospect of undermining VHA care.
    To help achieve this aim, we delineate significant challenges within
    the VCCP that merit thoughtful review and offer recommended
    improvements.
        These are:

        1. Ensuring VCCP quality standards,

        2. Ensuring VHA authorization for care is not bypassed,

        3. Addressing the impact of VCCP usage on VHA staffing and
    exceptional veteran-centric care,

        4. Ensuring the defined meaning of ``veterans' health care choice''
    is applied,

        5. Providing veterans with crucial information needed to make
    educated health care decisions,

        6. Addressing the VCCP payment model that encourages unnecessary,
    costly overtreatment,

        7. Addressing the deficiencies with health information sharing
    between the VA and VCCP,

        8. Properly including telehealth in VHA access standards,

        9. Protecting the VHA's 2nd, 3rd and 4th Missions by ensuring VHA
    is fully funded and staffed

    Ensuring VCCP quality standards

        The VA MISSION Act of 2018 established the VCCP with a laudable
    purpose: ensuring veterans could access high-quality healthcare,
    whether at VHA facilities or in their communities when VA care was not
    quickly available or conveniently located. The strong focus on quality
    was unmistakable. In its charter language, the word ``quality'' appears
    50 times, far surpassing mentions of both ``choice'' and
    ``community''--a point we'll explore further when discussing veterans'
    choice.
        The quality of veterans' healthcare should always be the north star
    of Congressional policymaking, yet it has failed to set and enforce
    quality standards for contract providers. Study after study has found
    that veterans referred for care in the community have a higher
    likelihood of dying and are more likely to receive lower quality care
    than those treated at VHA facilities. Another study published earlier
    this month in Health Affairs found that the quality of care metrics of
    VCCP providers are substantially lower than those of other private
    sector clinicians, especially in primary care and mental health care.
    Given this track record of lower quality of healthcare and potential
    risks to veterans' health, it is imperative that Congress mandate
    uniformity on quality and training metrics for VHA and VCCP providers
    and programs.

    Ensuring VHA authorization for care is not bypassed

        With increasing frequency in recent years, legislative proposals
    have sought to give veterans unfettered access to private healthcare,
    bypassing VHA referrals, authorization, and oversight entirely. Though
    they have not yet come to pass, we mention them here because enacting
    such legislation would fundamentally alter the VHA's core function.
    Instead of primarily serving as the provider of specialized, high-
    quality care for the unique health needs of veterans, the VHA would
    become more of a payer of private sector services. This would
    essentially transform the VHA from a comprehensive healthcare system
    into an insurance company. Notably, many Congressional proposals even
    omit traditional insurance company utilization review functions, which
    would make the care paid for even more risky to veterans.

    Addressing the impact of VCCP usage on VHA staffing and exceptional
    veteran-centric care

        A comprehensive report last year by six healthcare experts raised
    serious concerns that community care utilization was endangering
    Congress's intent for the VCCP to supplement, not supplant, the VHA.
    VCCP care has been relentlessly increasing 15-20 percent year after
    year, and by 2022, its share of VHA health dollars reached 44 percent.
    The report concludes that even if no additional changes are made as to
    who is eligible to receive private sector care, the VHA system's future
    is at risk due to this unsustainable growth. It is incumbent upon the
    committee to ensure that new legislation doesn't further exacerbate the
    issues that the report raises. Should Congress further widen
    eligibility for the VCCP, it will accelerate spending and imperil the
    basic survival of the VHA system and thus, the continued availability
    of choice that so many on this committee have deemed essential to
    veterans.
        Expanding VCCP eligibility, including by allowing the bypassing of
    VHA authorization, will intensify private sector referrals and divert
    funding from VHA facilities, forcing staff reductions, curtailment of
    programs, and closures of inpatient units, emergency rooms, and entire
    facilities. It would also prevent needed infrastructure upgrades
    despite growing demand for services.
        If the VHA does not maintain its position as the sole authorizer of
    care, and receive sufficient funds to fully meet care demand, its
    indispensable integrated healthcare system specifically designed to
    serve veterans will be gradually dismantled. This includes coordinated
    team-based care, comprehensive prevention screenings, wrap-around legal
    and transportation services, homelessness programs, caregiving, and
    enrollment in VA registries. It includes veteran-centric care
    specialization that deftly address veterans' complex military-related
    conditions. (For example, VHA clinicians are more likely to have
    experience and specialized training in recognizing, diagnosing and
    treating problems such as posttraumatic stress disorder (PTSD),
    traumatic brain injury (TBI), and exposure-related illnesses.)
        As we elaborate further below, jeopardizing the VHA will also have
    a devastating impact on the training of our nation's healthcare
    workforce and deprive future clinicians of expertise in veterans'
    complex health conditions. Additionally, research on veterans' health
    conditions--research that also helps non-veterans--will also be
    compromised, as will the ability of the VHA to serve as the nation's
    healthcare safety net during public health emergencies. It also
    undermines VA's ability to support the military in time of war or
    terrorist attacks (a critical capacity in maintaining military
    readiness) or communities in times of natural disasters.
        It is true that many veterans deeply appreciate the convenience of
    receiving authorized care closer to home rather than traveling long
    distances to VHA facilities. But when they are polled about preserving
    the VHA system, veterans' priorities are clear. A VFW survey last month
    of its members found ``overwhelming support for VA to remain the
    primary deliverer of care for veterans.'' A prior VFW report of over
    10,000 members found that 92 percent explicitly prefer that the VHA to
    be ``fixed not dismantled.'' As a Veterans Healthcare Policy Institute
    report noted, and many studies confirm, many veterans who live in rural
    areas would have no choice of care providers should the VHA be turned
    into an insurance provider. This is because of a long-standing crisis
    in rural healthcare that now deprives rural residents of primary care,
    mental health care, as well as access to hospital, emergency, and
    pharmacy services.

    Ensuring the defined meaning of ``veterans' health care choice'' is
    applied

        In the years since the passage of the VA MISSION Act of 2018, there
    has been a pervasive mischaracterization that the bill gave veterans
    the ``choice to obtain their health care where and when they
    preferred.'' That was not the case. In the legislative language, a
    veteran would be offered the option of receiving healthcare outside of
    the VHA under six clearly defined criteria. Veterans could choose
    whether to exercise the option of private sector care only after they
    first qualified under the eligibility rules and were authorized by VHA.
    The Independent Budget's analysis of the MISSION Act affirmed the
    understanding at that time that eligibility for VCCP care should not
    occur ``solely based on convenience or preference of a veteran.''
    However, the critical phrases ``when eligible,'' ``when qualified'' or
    ``when authorized'' are often dropped when alluding to veterans having
    the choice of where and when to receive their healthcare.
        Should the VHA be eliminated as the authorizer of care under the
    promise of more choice, there will be fewer, not more, options for
    veterans. When VHA funds are diverted to the private sector, millions
    of veterans who depend on the VHA--especially those with service-
    connected conditions who rely exclusively or near exclusively on the
    VHA for all their health care needs--will be deprived of the freedom to
    choose the VHA when units and programs they depend on vanish. Many have
    catastrophic war-related ailments, like lost limbs, traumatic brain
    injuries, or a variety of toxic exposures, which civilian providers are
    ill-equipped to recognize, much less treat. Granting the option for
    unrestricted personal choice is not unequivocally advantageous; it
    comes at the expense of the majority of veterans, many of whom are in
    extreme need.

    Addressing the VCCP payment model that encourages unnecessary costly
    overtreatment

        VCCP overtreatment and the overuse of expensive testing have been
    identified in recent scientific and governmental studies. One study
    scrutinized the care of veterans with prostate cancer. This is the most
    common cancer among veterans, particularly those who served in the
    Vietnam War, and were exposed to the carcinogenic herbicide Agent
    Orange which was used as a defoliant. The study, in the medical journal
    JAMA, tracked 10,000 veterans with newly diagnosed prostate cancer
    whose biopsies revealed ``clinically insignificant'' low-risk disease.
    The JAMA authors explained that the professionally recommended standard
    of care for these patients is what is called ``watchful waiting.''
    Watchful waiting is the accepted standard because recommending
    aggressive testing and procedures does little good and can cause
    serious harm to patients whose tumors aren't progressing. Complications
    of prostate surgery and radiation of include impotence, incontinence,
    hair loss, bowel problems, and even death. Despite these well-known
    problems, the JAMA study found that VCCP providers were twice as likely
    to provide veterans whose prostate cancer was deemed low risk with
    expensive, unwarranted, and potentially risky surgery or radiation.
        Reviewing the use of imaging services in the VCCP for various other
    medical conditions, a 2021 Congressional Budget Office (CBO) analysis
    mirrored the findings of the JAMA study. When veterans were referred
    for imaging services, VCCP contractors used magnetic resonance imaging
    instead of less costly tests like computed tomography scans and X-rays.
    The CBO explained, ``Some of those practice differences might stem from
    the cost control and incentive structures of VHA physicians and private
    sector providers. VHA does not control the amount or type of services
    veterans receive once they have been referred to outside providers for
    a particular episode of care.''
        Excessive use of expensive and/or unnecessary procedures isn't the
    only way that VCCP providers endanger veterans and extract resources
    from the VHA's healthcare system. Another is overcharging for services.
    One form of this is called ``upcoding,'' i.e., assigning an inaccurate
    billing code to a medical procedure to increase reimbursement. For
    example, a provider bills for a ``Level 4'' complex evaluation and
    management procedure even though the documented medical notes reveal
    only Level 3 elements were furnished.
        The VA's Office of Inspector General (OIG) found that, in FY 2020,
    ``at least 37,900 providers of about 218,000 community care providers
    billed level 4 and level 5 evaluation and management services
    significantly more often than all other providers in their specialty--a
    potential flag for upcoding.'' A separate 2021 OIG audit found that 76
    percent of acupuncture claim treatments and 55 percent of chiropractic
    claim treatments were not supported by medical documentation. Another
    well-designed ambulance study found that non-VA hospitals were five
    times more likely to report high complexity (and more highly
    reimbursed) evaluation and management services than VHA facilities.
        This pattern of overtreatment and fraudulent billing in the VCCP is
    hardly unexpected. VHA providers, all on salary, work in a mission-
    driven system that focuses on enhancing patient outcomes. VCCP
    providers are paid fees for discrete services and work in a system that
    emphasizes profit maximization. (Our first anecdote above speaks to
    this trend.)
        Also, the rising cost of outsourced dental care has become
    financially unsustainable. Medical centers are spending anywhere from
    $25 to $80 million annually on community dental services alone. While
    some facilities carefully monitor community care referrals, others
    automatically refer all eligible veterans to outside providers without
    considering quality and cost. The situation is further complicated by
    community dentists who routinely propose treatment plans costing tens
    of thousands of dollars per veteran. The recently enacted Dole Act
    pilots, in two VISNs, a stringent review process of community dentist
    treatment plans, but the most cost-effective solution would be to
    expand the VHA's in-house dental staff. By providing these services
    directly, the VHA could deliver the same or better quality of care at a
    fraction of what is currently being spent on community providers.

    Providing veterans with crucial information needed to make educated
    health care decisions

        Another issue in dire need of overhauling in the community care
    program is the lack of available information that veterans need to make
    informed health care decisions. Future community care legislation must
    require private sector transparency about comparative VHA-VCCP wait
    times and quality metrics.
        Veterans also deserve easy access to information as to whether
    providers treating them have the training, education, and competence to
    address their specific health concerns. Yet, the directory that is
    available online doesn't include all the providers in the network, and
    the listings lack any details about providers' qualifications.
        Further, third party administrators evaluate their providers and
    designate those delivering high-quality care as ``High Performing
    Providers'' (HPPs). However, this assessment ignores behavioral and
    mental health providers, despite the prevalence of mental health
    challenges that many veterans face. The evaluation system should expand
    to include mental health providers, and veterans should have direct
    access to HPP designations through the public directory.

    Addressing deficiencies with health information sharing between the VHA
    and VCCP

        For years, including last week, the OIG has documented
    ``difficulties caused by community care providers failing to return
    medical documentation.'' When all the relevant healthcare information
    isn't properly shared between VHA and community providers, care becomes
    fragmented, and veterans are put at risk. VCCP mental health providers
    routinely submit requests for treatment reauthorization that lack
    clinical documentation needed to make decisions. To address these
    serious issues, Congress should establish sanctions for failures to bi-
    directionally share information between the VHA and VCCP in a timely
    manner.

    Properly including telehealth in VHA access standards

        When establishing the VA MISSION Act eligibility rules, the VHA
    made a significant oversight: they did not include the availability of
    VHA telehealth when calculating distance or wait times for care. We
    believe this was a shortsighted decision that has had serious negative
    consequences. By not considering telehealth options, the VHA has
    unnecessarily limited veterans' access to quality healthcare while
    wasting taxpayer money. Telehealth is a valid means of providing health
    care to veterans who prefer that option. In a survey of veterans
    engaged in mental health care, 80 percent reported that VHA virtual
    care via video and/or telephone is as helpful or more helpful than in-
    person services. And yet, because of existing regulations, VHA
    telemental health (TMH) does not qualify as access, resulting in
    hundreds of thousands of TMH visits being outsourced yearly to
    community practitioners that could be expeditiously and beneficially
    furnished by VHA clinicians. The best action that Congress can take is
    to stipulate that VHA telehealth care constitutes ``access to
    treatment.'' If implemented, this correction would save taxpayers a
    vast sum--up to 1.1 billion dollars yearly according to a VA's
    September 2022 ``Congressionally Mandated Report: Access to Care
    Standards.''

    Protecting the VHA's 2nd, 3rd and 4th Missions by ensuring VHA is fully
    funded and staffed

        Congressional legislation on community care must attend to the
    impact on the VA's vital role in researching veterans' complex health
    conditions. For decades, VHA's electronic health records and access to
    VHA patients have enabled groundbreaking discoveries and treatments
    through large-scale data analysis of veterans' healthcare conditions.
    The VA's innovations in diagnostic testing, disease management,
    rehabilitation, geriatrics, patient safety, and numerous other fields
    have advanced healthcare for all Americans. The VHA has also proved
    invaluable and irreplaceable in its ability to study and compare the
    efficacy of different medications on patients' health This crucial
    research capability would disappear if veterans' care fragments across
    the private sector, where no unified system exists to study veterans'
    health outcomes or implement and evaluate innovative treatments
    systematically.
        Congress should also be wary of expanding access to community care
    in a way that would jeopardize the critical role the VHA plays in the
    training of future healthcare professionals across the nation. More
    than 70 percent of all U.S. physicians train at a VHA facility early in
    their careers. At a time of dire mental health professional shortages,
    VHA is the largest single educator of psychiatrists and psychologists.
    Expanding care in the community will have jarring effects far beyond
    VHA itself by constraining the development of a critically needed
    workforce.
        Likewise, expanding care in the community that downsizes VHAs will
    degrade VHA's capacity to support its ``Fourth Mission:''-assisting the
    nation in times of emergencies and disasters. The VHA has supported
    this mandated mission with direct patient clinical care, testing,
    education and training in response to natural disasters, pandemics
    (like COVID-19), and other crises. VHA also serves as the first
    fallback to the military health system in times of war. The VHA is
    uniquely suited to support these missions because of the national
    distribution of its facilities, the unique training and experience of
    its staff, and the exceptional integration of its services.

    Suggested solutions to improve the provision of community care.

        To strengthen use of community care, we propose these essential
    reforms:

        1. The VHA and VCCP must operate under uniform quality standards
    and training requirements.

        2. The VHA and VCCP should publicly disclose wait times, and
    provider directories must detail healthcare professionals'
    qualifications and quality metrics.

        3. Predictive modeling capabilities to forecast how varying levels
    of VCCP utilization will impact VHA's operational capacity should be
    quickly developed.

        4. The VHA's internal staffing should be expanded to fully meet
    demand.

        5. The VHA should retain clear authority in determining community
    care eligibility.

        6. It's crucial to reinforce the message that veterans' access to
    community care depends on first meeting established criteria.

        7. Timely VHA telehealth should be recognized as meeting the access
    to care standard.

        8. Timely health record sharing between VHA and community providers
    should be reinforced through meaningful penalties for non-compliance.

        9. Rigorous monitoring must be implemented to identify and sanction
    community providers who engage in unnecessary testing, optional
    procedures, or fraudulent billing practices.

        We respectfully thank you for the opportunity to provide our
    perspectives on these essential matters. We look forward to working
    with the committee to ensure that veterans can receive timely, high-
    quality compassionate care in the VHA and the community now and in the
    future.

                   Prepared Statement of The American Legion
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

       Prepared Statement of American Association of Nurse Anesthesiology
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

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