[House Hearing, 119 Congress]
[From the U.S. Government Publishing Office]
VA FIRST, VETERAN SECOND:
THE BIDEN-HARRIS LEGACY
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED NINETEENTH CONGRESS
FIRST SESSION
__________
THURSDAY, FEBRUARY 6, 2025
__________
Serial No. 119-3
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via http://govinfo.gov
_______
U.S. GOVERNMENT PUBLISHING OFFICE
59-613 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
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
JEN KIGGANS, Virginia, Chairwoman
AUMUA AMATA COLEMAN RADEWAGEN, DELIA RAMIREZ, Illinois, Ranking
American Samoa Member
JUAN CISCOMANI, Arizona TIMOTHY M. KENNEDY, New York
KEITH SELF, Texas HERB CONAWAY, New Jersey
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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THURSDAY, FEBRUARY 6, 2025
Page
OPENING STATEMENTS
The Honorable Jen Kiggans, Chairwoman............................ 1
The Honorable Delia Ramirez, Ranking Member...................... 2
The Honorable Mark Takano, Ranking Member, Full Committee........ 5
WITNESSES
Mr. Ted Radway, Acting Assistant Secretary, Office of
Accountability and Whistleblower Protection, U.S. Department of
Veterans Affairs............................................... 7
Accompanied by:
Ms. Tracey Therit, Chief Human Capital Officer, Office of
Human Resources and Administration, Security, and
Preparedness, Veterans Health Administration, U.S.
Department of Veterans Affairs
Dr. Mark Upton, Deputy to the Deputy Under Secretary for
Health, Veterans Health Administration, U.S. Department
of Veterans Affairs
Mr. David Case, Acting Inspector General/Deputy Inspector
General, U.S. Department of Veterans Affairs, Office of the
Inspector General.............................................. 9
Mr. Donald Sherman, Executive Director and Chief Counsel,
Citizens for Responsibility and Ethics in Washington........... 11
APPENDIX
Prepared Statements Of Witnesses
Mr. Ted Radway Prepared Statement................................ 29
Mr. David Case Prepared Statement................................ 31
Mr. Donald Sherman Prepared Statement............................ 38
Statements For The Record
Government Accountability Project Prepared Statement............. 45
American Federation of Government Employees, AFL-CIO Prepared
Statement...................................................... 46
Disabled American Veterans Prepared Statement.................... 50
Concerned Veterans for America Prepared Statement................ 56
VA FIRST, VETERAN SECOND:
THE BIDEN-HARRIS LEGACY
----------
THURSDAY, FEBRUARY 6, 2025
Subcommittee on Oversight and
Investigations,
Committee on Veterans' Affairs,
U.S. House of Representatives,
Washington, D.C.
The subcommittee met, pursuant to notice, at 2:03 p.m., in
room 360, Cannon House Office Building, Hon. Jennifer A.
Kiggans [chairwoman of the subcommittee] presiding.
Present: Representatives Kiggans, Ciscomani, Self, Ramirez,
Kennedy, and Conaway.
OPENING STATEMENT OF JEN KIGGANS, CHAIRWOMAN
Ms. Kiggans. Good afternoon, everyone. The subcommittee
will come to order.
I would like to welcome everyone to the first hearing of
the Subcommittee on Oversight and Investigations of the 119th
Congress. While not new to the committee, all of our members
other than myself are new to the subcommittee.
I am confident that we will continue to work in a
bipartisan manner to hold the VA to its mission of providing
world-class care for our veterans.
Additionally, I would like to congratulate Mr. Doug Collins
on his confirmation to serve as the VA Secretary. I look
forward to working with him this Congress.
Last Congress, we uncovered countless instances where the
VA failed to hold bad employees accountable and ultimately let
veterans down. Time after time, career government employees
were protected at the expense of veterans. Protecting bad
employees from the consequences of failing the veterans they
serve is unacceptable, especially at the cost of the taxpayer
dollar.
Veterans should always be at the forefront of VA's mind
when they make decisions. Unfortunately, too many times
bureaucracy is put first and veterans come in second. I do
believe that 99 percent of VA employees are dedicated and
hardworking public servants that in many cases want to serve
their fellow veterans while still working in a productive,
accountable workplace.
Over the past few years, whistleblowers continue to
describe situations where VA leaders face little discipline
despite investigations substantiating the allegations against
them.
It takes an incredible amount of strength and fortitude to
come forward to blow the whistle on wrongdoing in the VA. I
want to take a moment to thank the whistleblowers who have
courageously come forward to the VA and to Congress to bring
attention to these problems. Your bravery is one of the reasons
we were able to do our oversight work in Congress.
In Buffalo, one veteran with cancer did not receive care
for 10 weeks because the leadership at the facility failed to
connect him with the care he needed. This committee sent
multiple questions regarding ongoing investigations or
disciplinary actions for this failure in care, and our
questions went unanswered.
In my own district, the poor management at the Hampton VA
Medical Center caused the facility to be left with one
anesthesiologist to serve every patient. Despite VA taking
action, I have heard continued allegations about the quality of
care issues at Hampton. To date, I have still not received
clear indication that the VA fully investigated the local
leaders at this facility. As a former provider and nurse
practitioner, these stories are heartbreaking. Our patients
deserve better.
Unfortunately, this is not an isolated issue. Even more
shocking, there have been instances where the VA promoted
leaders even after they were found to have engaged in
misconduct. This is why Chairman Bost, along with every
Republican on this committee, reintroduced the Restore VA
Accountability Act of 2025.
This legislation makes clear that bad VA employees need to
be held accountable to ensure that the best Federal employees
are serving veterans. Congress needs to solidify this good
government measure.
This legislation will address many of the concerns and
challenges that we will hear from our witnesses during today's
hearing. As a provider myself, I know that leaders at local
hospitals play a critical role in ensuring patient safety. They
are responsible for creating a positive work environment that
allows nurses and doctors to care for the patients they serve,
and at the VA that is veterans. If the leaders are not holding
themselves to a high standard, then they do not need to be in
leadership. It is that simple.
As someone with experience working with the VA in veteran
care, I know firsthand the bulk of VA employees do good work
and provide safe patient care for our veterans. This work is
valuable to our Nation, and these employees deserve safe and
sanitary working conditions. The American people have given us
a mandate to make sure their government works for them, not
poor-performing career government employees, and the VA is no
different.
It should go without saying that veterans have earned a
system that serves them well. I am looking forward to working
with the Trump administration to course-correct the mistakes
from the previous 4 years. I look forward to hearing from our
witnesses today about how the VA will hold its employees
accountable to the mission. By restoring accountability at the
VA, we will ensure that the VA puts veterans first.
I now recognize Ranking Member Ramirez for her opening
comments.
OPENING STATEMENT OF DELIA RAMIREZ, RANKING MEMBER
Ms. Ramirez. Thank you, Chair Kiggans. I look forward to
working with you on the Oversight and Investigations
Subcommittee as its ranking member.
I believe we, as members of this committee, have an
obligation and a shared responsibility to ensure that the VA is
succeeding in its mission to provide veterans world-class
healthcare and benefits that they have not just earned but that
they deserve.
The title of this hearing and the Republican majority's
approach to this topic makes it clear to me that not everyone
in this room takes that responsibility seriously. It is clear
the intent of the majority is to undermine the VA and its
mission by vilifying and persecuting an important asset, the
hundreds of thousands of public servants who show up to work
every single day to serve our veterans.
Let us keep in mind that a third of VA employees are
veterans themselves. The end goal of their vilification is the
privatization of the VA for the profit of Trump's billionaire
bosses. I want to suggest a more appropriate title. Perhaps
this should be more like Unaccountable Billionaires First,
Veterans Last: The Musk-Trump agenda.
In the 18 days that Trump has been in office, he has gone
on a chaotic rampage to make the Federal Government a hostile
workplace for its employees, for its three million employees.
Trump wants to either fill those positions with Make America
Great Again (MAGA) operatives and loyalists or outsource
contracts for his billionaire bosses who were lined up right in
the front row at the inauguration.
Folks, that does not feel like it is about our veterans. It
is not about accountability. It is about profit. Trump is not
even hiding that. On January 31st, he sat in the Oval Office
after sending Federal employees a buyout email identical to the
unelected, unaccountable President Musk, who sent to his former
Twitter employees and said, quote, ``It is our dream to have
everybody, almost, working in the private sector.''
Trump and Musk are the definition of horrible bosses, and
they are using the bad boss playbook to push public servants
out of their jobs. For those VA employees listening, look, I
want to say this to you: I know you have figured this out
yourselves, but do not take deceptive offers. Stay in the fight
with us. We need you. Our veterans need you.
What Musk and Trump are doing to the Federal workforce
through various executive orders (EO), Office of Management and
Budget (OMB) memoranda, and tweets is demeaning, it is
shameful, and it is threatening. Their actions are going to
have dangerous impacts for our veterans, because within hours
of being back in the office Trump ordered an across-the-board
hiring freeze at Federal agencies. After the outpour of
confusion, of concern, and Trump-inflicted chaos VA employees
experienced, Trump eventually gave in to the onslaught of
pressure from Democrats and exempted some VA healthcare
positions from the freeze.
Let me be clear. Despite our advocacy and pressure, there
are still thousands of vacancies for jobs at the VA that will
go unfilled. These jobs are mission-critical claims processors,
disability examiners, maintenance workers, environmental
management technicians, food service workers, just to name a
few.
The VA cannot deliver the benefits our veterans have earned
and deserve without these people. Patient safety cannot be
compromised, because we know what is going to happen. Veterans
are going to suffer. That is the whole point, right? That is
exactly what Trump and Vance want. They want to cripple VA so
they can sell it off piece by piece to the highest bidder.
The greedy billionaires sitting in awe in the front row at
Trump's inauguration stand to turn their billions into
trillions at the expense of Federal workforce, everyday
working-class American taxpayers, and ultimately veterans.
I want to make myself very clear. I take our oversight
responsibility very seriously, and in my role as the ranking
member extremely seriously.
Since I joined this committee, there have been several
investigations into employee wrongdoing that came to our
attention, and they were alarming. We heard hearings last
Congress that touched on issues at the VA Central Office,
Hampton, Loma Linda, eastern Colorado, Buffalo and Mountain
Home.
In each of those cases, the Inspector General (IG) and VA
identified wrongdoing, rooted it out and disciplined the
employees in accordance with the law.
It is a misrepresentation of the law to say that VA does
not have adequate legal authority under Title V to hold
employees accountable. VA disciplined employees under Title V
every single day. I have no problem with holding employees
accountable, and I implore the VA to do so to ensure veterans
are receiving the best care and benefits they deserve.
What I am not going to be standing for is an excuse of my
colleagues across the aisle as they complicitly work with the
Trump administration to abuse their power, subversion of due
process rights afforded to Federal employees and the
deconstruction of the services and programs that provide
veterans the benefits they have earned and they deserve.
Look, if you want to have real conversations about
accountability at the VA, let us have it. I am at the table
ready to talk, and I know that my colleagues are as well.
Let us talk about ensuring that veterans get the benefits
they promise. Let us talk about improving training for HR and
supervisors. Let us talk about breaking down reporting silos
for employees to disclose misconduct when they actually see it.
Let us talk about our expectations for leadership when issues
arise at a facility. Let us talk about ensuring VA staff work
in an environment that empowers them to put veteran safety
first.
When we have a President who removes over a dozen
Inspectors General charged with being independent arbiters of
truth and transparency in government in the middle of the
night, I find it hard to believe that this is the party that is
truly interested in making the VA more accountable for
veterans.
With that, I want to introduce our minority witness today,
Mr. Donald Sherman, who is going to be joining us from Citizens
for Responsibility and Ethics in Washington, or CREW. CREW's
ethos is Americans deserve a democracy that is ethical,
accountable, and open. I could not agree more. If there is an
expert on government accountability out there, it is you, Mr.
Sherman.
Thank you for being here. I look forward to your testimony.
With that, Chairman, I yield back.
Ms. Kiggans. The chair now recognizes Ranking Member Takano
for 5 minutes for any remarks.
OPENING STATEMENT OF MARK TAKANO, RANKING MEMBER, FULL
COMMITTEE
Mr. Takano. Thank you, Chair Kiggans, for this courtesy.
Let us talk about accountability at the VA. If my majority
colleagues want to use this committee's time to take a look
back at the Biden-Harris administration, I offer to take us
back a bit further. I appreciate the opportunity to do a
history lesson for those who may be unfamiliar or who have
forgotten how Trump and his lackeys sabotaged the VA from
within during his first administration by sowing fear and
hostility in its workforce. He is following that same playbook
now that he has regained power, and it is clear that Trump is
on a witch hunt against VA employees.
Just earlier this week, he sent Elon Musk's entourage to
the VA Central Office to do who knows what. Trump has allowed
Musk's team of teenage interns to access, collect, and poke
around the private information of American citizens at
Treasury, some of which includes veterans' data. I am deeply
concerned that they are doing the same at VA.
Veterans are at very real risk, and we demand answers.
Unelected bureaucrats and billionaires now have access to
hordes of private data, but are not being held to any of the
same privacy standards we ask of VA employees or partners. That
does not sound very accountable to me, but perhaps this is all
part of the Republicans' plan for VA.
As I have explained many times, a key step of the
Republican VA death spiral is an erosion of veteran trust in
the VA workforce. That is the purpose of this hearing today. My
colleagues are painting a distorted picture of the past to make
sure--to make their case as to why Congress needs to rush
past--rush to pass their incredibly flawed and unconstitutional
Restore VA Accountability Act of 2025.
Let me tell you why their case fails. This is their third
bite at the apple, of the apple to attempt to make--and I say
to attempt to make--it easier for VA to fire employees. I say
``attempt'' with emphasis, because when the Republicans tried
this in 2014 and 2017, they failed egregiously, and veterans
and taxpayers were left holding the bag.
The 2014 Veterans Access, Choice, and Accountability
(CHOICE) Act included expedited authorities to remove VA senior
leaders or demote them to a lower position. Employees who were
removed or demoted using that authority challenged the law's
constitutionality in court. The Department of Justice
ultimately declined to defend the law from those challenges,
and VA ceased using the law to discipline employees.
Now, I want to be clear that I did, in fact, vote in favor
of CHOICE and the VA Accountability and Whistleblower
Protection Act of 2017. We were still dealing with the fallout
of the Phoenix wait time scandal, and at the time these bills
seemed like they would help VA weather that crisis.
However, hindsight is 20/20 and I learned a valuable
lesson, not to trust Trump with power. Instead of using the
2017 law to improve VA, Trump and his corrupt allies weaponized
the bill to intimidate employees who were perceived to be
unloyal to Trump and to remove employees without due process.
During Trump's first go-round at VA, his team set up the
Office of Accountability and Whistleblower Protection,
otherwise known as OAWP, as required in the 2017 law. They then
used that office to retaliate against the whistleblowers they
were supposed to protect. I wish I was making this up, but it
is well-documented truth.
The Inspector General and other watchdog organizations,
like the Project on Government Oversight and Government
Accountability Project, helped bring this malfeasance to light.
Ultimately, however, during the Biden-Harris administration,
OAWP was able to turn things around and become a respected
organization we regularly relied on to investigate and
recommend discipline for employee misconduct.
The death knell for the 2017 law came when the Court
scrutinized its implementation and VA ultimately quit
disciplining employees under its so-called Section 714
authorities to avoid further litigation.
As a reminder, this is exactly what happened with the 2014
law. Settlements from the use of the 2017 law resulted in 140
million taxpayer dollars being paid out to former employees. If
that is not a failure for veterans, I do not know what is.
The Restore VA Accountability Act of 2025 is just more of
the same. It is essentially a codification of Trump's various
executive orders to give his political appointees sharpened
tools to exact swift justice on VA employees for perceived
disloyalty or insubordination. They want to make it as easy as
possible to fire VA employees without cause. It is that simple.
Restore is opposed to--is opposed by nearly every major
labor union. VA has testified time and time again that they do
not need the authorities in Restore to hold employees
accountable for misconduct, nor will Restore speed up the
disciplinary process, contrary to what my colleagues believe.
Hampton, Loma Linda, eastern Colorado, Buffalo and now Ann
Arbor all present issues that warrant our attention so that we
can help VA improve patient safety and veteran
dissatisfaction--veteran satisfaction at those facilities.
Let me be absolutely clear. The Restore VA Accountability
Act will not fix those issues. The Restore Act is not going to
hire more people to process referrals. It is not going to bring
in more qualified executive leadership. It is not going to
improve patient outcomes. What Restore will be is an empty
promise to veterans and a tool used to harm the Federal
employees that serve them.
I know that Ranking Member Ramirez and I are committed to
work to ensure VA is an accountable organization that holds its
employees to the highest standards for our veterans. Let us
come back together and explore opportunities for
bipartisanship.
I yield back.
Ms. Kiggans. Thank you.
Before the chair introduces the witness from our first
panel, I just think there is a time and place for partisan
politics, and I really wish it was not in this committee. I
think it is really important for us to continue to focus on the
issues at hand, rooting out misconduct and ensuring the VA
effectively holds those accountable who allow it. That should
not be partisan. I have said it before and I will say it again.
Partisan games have no place when veterans' care is on the
line.
With that, I would like to recognize the witnesses on our
first panel. Testifying before us today, we have Mr. Ted
Radway, the Acting Assistant Secretary of the Office of
Accountability and Whistleblower Protection.
We have Ms. Tracey Therit, the Chief Human Capital Officer,
Office of Human Resources and Administration, Security, and
Preparedness.
We have Dr. Mark Upton, Deputy to the Deputy Under
Secretary for Veterans Health Administration (VHA).
Then we have Mr. David Case, the Acting Inspector General
of the Inspector General.
We also have with us Mr. Donald Sherman, executive director
and chief counsel of Citizens for Responsibility and Ethics in
Washington.
If the witnesses could please stand and raise their hand,
and we will swear you in.
[Witnesses sworn.]
Ms. Kiggans. You may be seated.
Let the record reflect that the witnesses answered in the
affirmative.
Mr. Radway, you are now recognized for 5 minutes to provide
VA's testimony.
STATEMENT OF TED RADWAY
Mr. Radway. Good afternoon, Chairwoman Kiggans, Ranking
Member Ramirez, Ranking Member Takano, distinguished members of
the subcommittee. Thank you for inviting us today to discuss
the VA's efforts to improve accountability within the
Department.
Joining me is Ms. Tracey Therit, Chief Human Capital
Officer in VA's Office of Human Resources and Administration/
Operations, Security, and Preparedness; and Dr. Mark Upton,
Deputy to the Deputy Under Secretary for Health.
VA is committed to providing veterans with the care and
benefits they have earned through service to our country. Our
veterans and their families, caregivers, and survivors deserve
nothing less. We and the more than 450,000 VA employees are
devoted to the sacred duty and work diligently daily to fulfill
this mission.
Sometimes, even with the best intentions, VA recognizes
that the performance and action of some employees and leaders
fall short of expectations and what our veterans deserve. When
that happens, holding employees accountable is integral to
effective management and we take that responsibility seriously.
In today's hearing, we welcome the opportunity to discuss our
improvements to strengthen our accountability.
The Office of Accountability and Whistleblower Protection
promotes and improves individual and organizational
accountability across VA in numerous ways.
First, we investigate allegations against senior leaders
involving misconduct and poor performance and allegations
against all supervisors involving retaliation against
whistleblowers. Our highly skilled professional investigators
and analysts work hand in hand with our attorneys, who ensure
that investigations are properly scoped, within our
jurisdiction, all relevant issues and potential misconduct are
identified and the conclusions and recommendations are legally
supportable and appropriate.
We issue reports with recommendations for disciplinary
actions, but we do not carry out those actions. Instead, our
report is issued to the appropriate management official with
authority to propose and/or carry out those actions. If our
recommendations are not taken, we report that, along with the
deciding official's reasoning, to Congress.
OAWP employees have led a remarkable turnaround in
productivity, success, and impact on individual accountability.
From Fiscal Year `21 to `24, the number of incoming complaints
increased by over 60 percent to 3,305 complaints. This shows VA
employees' trust in OAWP's ability to resolve complaints fairly
and efficiently.
Despite the rapid increase in case volume, OAWP's efforts
have dramatically reduced the time it takes to close a case.
From Fiscal Year `21 to `24, we reduced the time it takes to
close a complex case by over 75 percent.
In addition, we have seen a jump in acceptance by
management of our recommendations. In Fiscal Year `21,
management took some action or the employee retired or resigned
in only 64 percent of our disciplinary recommendations. In
Fiscal Year `23, that number jumped to 100 percent; and in
Fiscal Year `24, we doubled the number of recommendations we
issued and management took some action or the employee retired
or resigned in all but three cases, or 92 percent.
We also issue nondisciplinary recommendations for relief
for the whistleblower, training, or policy modifications.
Management regularly takes these recommendations between 96 and
100 percent of the time.
OAWP also drives organizational accountability. By statute,
we provide advice, reports, and recommendations to the
Secretary on all matters relating to accountability. In the
past two years, this included providing the Secretary with
eight reports on the VA's efforts to support veterans with
military sexual trauma (MST). Half of the 32 recommendations
have been implemented to date, driving greater organizational
accountability and a better experience for our veterans with
MST.
OAWP also launches climate reviews that give leadership
insight into the whistleblower reporting environment and make
recommendations to improve the reporting culture to drive
greater accountability and whistleblower protection.
In 2019, VHA began a transformational modernization. The
transformation into a high-reliability organization, or HRO,
was central to this effort. An HRO is an organization that
experiences fewer than anticipated accidents or events of harm
despite operating in highly complex, high-risk environments
where even small errors can lead to tragic results.
The Department empowers all staff to lead continuous
process improvements, and we strive to create an environment
where employees feel safe to report harm or near misses. We are
committed to continuing to build on the great strides we have
made in improving safety and quality of care.
As VHA advances toward HRO maturity, leaders are applying
an organization-wide commitment to zero harm by developing an
even stronger safety culture, featuring empowered frontline
teams supported by engaged leadership within a climate of trust
and continuous improvement.
The Office of Medical Inspector (OMI) is responsible for
assessing the quality of VA healthcare through investigations
of VA facilities. OMI issues comprehensive reports of its
healthcare investigations, including recommendations for
corrective action and/or improvements to the quality of
veterans' healthcare. While it does make referrals to OAWP, OMI
generally does not make specific recommendations related to
discipline. Instead, it focuses on oversight and improvement in
veterans' healthcare.
VA is proud of its large dedicated workforce who work hard
to carry out VA's great mission every day. The Department is
committed to and engages in continuous improvement of
accountability to assess how to help identify and effect
cultural improvements within the VA, hold employees
accountable, and continue to work to protect whistleblowers.
Thank you, and we look forward to responding to any
questions you may have.
[The Prepared Statement Of Ted Radway Appears In The
Appendix]
Ms. Kiggans. Thank you, Mr. Radway.
Mr. Case, you are now recognized for 5 minutes to provide
your testimony.
STATEMENT OF DAVID CASE
Mr. Case. Thank you, Chairwoman Kiggans, Ranking Member
Ramirez, and members of the subcommittee. I appreciate this
opportunity to discuss how the Office of Inspector General's
(OIG) work enhances VA's accountability.
The OIG shares your goal of putting veterans first, and we
do that by conducting effective independent oversight of VA so
it can better serve veterans, their families, survivors and
caregivers.
In fiscal 2024, our office released more than 300 oversight
publications with over 1,100 recommendations to VA. We made
nearly 250 arrests and secured 179 convictions. We had a
monetary impact of more than $6.5 billion in addition to the
invaluable work of our healthcare inspectors, who enhance
patient care and safety.
These efforts to improve benefits and services for veterans
and their families would not be possible without the funding
and support we receive from Congress. The engagement of
Veterans Service Organizations (VSO)s and other stakeholders
has also been crucial to our success. In addition, we have a
strong collaborative relationship with Government
Accountability Office (GAO). We coordinate our efforts with
them to promote more consequential oversight.
In my written testimony, I lay out the five principles that
the OIG has determined are foundational to accountability and
provide examples of each.
First, there must be strong governance and clarity of roles
and responsibilities. We have found tension between the VA
office with its policy and oversight functions and the leaders
in the field who are not accountable to those offices. In other
cases, staff do not fully understand their roles and
responsibilities due, in part, to outdated or conflicting
guidance. Several of our healthcare inspections identified
facilities where leaders did not act on known issues, resulting
in greater risk to patients or delays in veterans receiving
care.
Second, there must be adequate and qualified staff to carry
out clear duties. VA faces staff vacancies in key occupations,
especially within VHA. These longstanding shortages make it
challenging for VA to carry out some programs and functions.
When implementing new programs, staff often must navigate
rapidly changing guidance for processing VA benefits. The
resulting confusion can affect the amount of money and services
veterans receive.
Third, VA needs updated IT system and effective business
processes. VA is modernizing significant systems critical to
its operations. We have been proactively overseeing VA's
implementation of these systems, including publishing 22
reports on the transformation of VA's electronic health record
(EHR) system alone. Our work has identified poor planning,
billions of dollars in unanticipated cost, patient safety
issues, low user acceptance and gaps in functionalities, making
it difficult for personnel to efficiently do their jobs.
Fourth, effective quality assurance and monitoring is
essential. VA often lacks controls to consistently ensure
quality standards are met. Breakdowns in routine monitoring and
workarounds undermine efforts to identify and fix problems as
well as make certain the eligible veterans and their families
receive timely services and benefits.
Last, consistent and effective leadership is critical.
Engaged and dedicated leadership fosters open communication,
efficiency, and accountability among all staff.
These five themes are routinely highlighted in OIG reports.
Although report findings and recommendations are often directed
to a single facility, system, or program, they serve as a
roadmap to help prevent or correct similar problems in other
facilities or offices.
We recognize that VA is working to build a stronger sense
of accountability. We routinely observe personnel committed to
providing the highest quality care, benefits, and services to
veterans and their families despite obstacles.
The OIG will continue to provide practical and meaningful
recommendations to help VA remove these obstacles to serve
veterans first, address fraud and other crimes, as well as
waste and improve efficiency.
Finally, I want to thank Congress for passing the Elizabeth
Dole Act, which includes a requirement that all new VA
employees receive training on how to report and cooperate with
the OIG.
Chairwoman Kiggans and members of the subcommittee, this
concludes my statement. I look forward to answering any
questions you may have.
[The Prepared Statement Of David Case Appears In The
Appendix]
Ms. Kiggans. Thank you, Mr. Case.
Mr. Sherman, you are now recognized for 5 minutes to
provide your testimony.
STATEMENT OF DONALD SHERMAN
Mr. Sherman. Chairwoman Kiggans, Ranking Member Ramirez,
and members of the committee, thank you for the opportunity to
testify before you today.
The Department of Veterans Affairs' mission to provide for
the care, benefits, and support of veterans is the fulfillment
of a promise that our Nation made and must continue to honor to
those who have protected our Nation in the Armed Services.
My own family includes veterans who served in combat, and
my grandfather proudly worked at the VA in his hometown of
Tuskegee, Alabama. I thank our Nation's veterans and military
families for their service and sacrifice for our country.
In order to meet its critical mandate, the VA plays many
roles, including administering pensions, insurance and home
loans for veterans, providing survivor support for veterans'
families, and running the Veterans Health Administration, the
largest integrated healthcare network in the United States.
The VA cannot falter in this mission. Yet, managing such
complex systems is a daunting task. The VA has experienced
challenges across both Democratic and Republican
administrations that demand robust, independent oversight.
It is certainly reasonable to look backward at the Biden
administration's stewardship of the VA and acknowledge areas of
success and challenge. That is why it would have been useful to
have former VA IG Michael Missal in attendance here today.
During his tenure, Mr. Missal's leadership of OIG garnered
bipartisan praise, and he released numerous reports critical of
VA officials during both President Trump's and President
Biden's terms in office.
In 2024 alone, IG Missal's team published more than 300
reports with over 1,100 recommendations to help the VA improve
the lives of veterans, with a monetary impact on at least $6
billion in taxpayer funds.
Under Mr. Missal's leadership, VA OIG pushed the agency to
address deficiencies in its assessment of suicide risk,
healthcare failures at facilities like the Hampton VA Medical
Center, as well as longstanding management challenges.
Despite that staggering impact, President Trump fired Mr.
Missal last month, along with more than a dozen other
Inspectors General. That is not normal. In fact, these firings
were illegal. Provisions of the bipartisan Securing Inspector
General Independence Act require the President to provide
Congress with 30 days' notice and an explanation before firing
an IG. President Trump did neither.
Although it is beyond my expertise to opine on VA's
mission-specific operations, independent oversight is essential
for the agency to better support our Nation's veterans.
President Trump's firing of IGs, including Mr. Missal, was
unethical, and our veterans will be among the many communities
harmed as a result of these and other authoritarian actions.
These attacks include President Trump's gutting of the
nonpartisan Civil Service. Veterans make up roughly 6 percent
of the American working-age population, but nearly a third of
the Federal workforce. Efforts to fire, suspend, and demote
civil servants across agencies disproportionately impacts
veterans. President Trump's hiring freeze on many components of
the VA likewise undermines the agency's work to meet the needs
of veterans and military families.
In January, my organization filed a lawsuit to force
President Trump's billionaire-led Department of Government
Efficiency (DOGE) to stop operating in the shadows and to the
exclusion of veterans and other stakeholders.
The administration has also terminated programs aimed at
meeting the unique experiences of diverse veterans. Having an
independent permanent IG here today would be valuable to assess
the impact of these policies and opine on reforms that this
committee is interested in pursuing. That is why CREW has
pressed for IG vacancies to be filled and for independent
oversight under both Presidents Trump and Biden.
The VA OIG vacancy is especially concerning, given the
corruption scandals at VA during the first Trump
administration, including President Trump allowing cronies to
help run the agency from Mar-a-Lago. OIG's investigation of
Secretary Shulkin's lavish taxpayer-funded travel helped to
lead to his removal in 2018.
In closing, President Trump's ouster of Mr. Missal suggests
that even his successor could be fired on a political whim.
That fact does nothing to help the VA better serve veterans and
military families, address the longstanding challenges the VA
has faced across administrations or prevent the corruption that
plagued the VA during the first Trump term.
If this committee is serious about oversight of the VA,
then I would expect Members of both parties to vocally oppose
President Trump's illegal attack on IGs and the Civil Service.
Thank you. I welcome your questions.
[The Prepared Statement Of Donald Sherman Appears In The
Appendix]
Ms. Kiggans. Thank you, Mr. Sherman.
We will now move to questions, and I yield myself 5
minutes. Just before that, in accordance with committee rule
5(e), I ask unanimous consent that Representative Moylan from
Guam be permitted to participate in today's subcommittee
hearing.
Without objection, so ordered.
Mr. Case, the VA Inspector General has published three
different reports about concerns with the clinical care
veterans receive at the Hampton VA in my district. Each report
highlights the importance of having quality assurance processes
in place. If these are not in place, patients bear the
consequences.
Can you tell me your opinion about why it is important for
leaders to have quality measures in place for patient care, and
can you also give us some examples of these quality measures?
Mr. Case. Chairwoman Kiggans, we have published those
reports, and the whole goal is to put the veteran first there.
Quality assurance and important quality measures have to be in
place. Adherence to defined processes and objective assessments
of basic patient safety activities is critical.
Leaders must be proactive in monitoring compliance and
tracking and trending compliance. They then have to intervene,
modify, or enhance resources in real time to keep patients
safe. If they see problems, then there is constant monitoring.
An example from Hampton, is there were ineffective
monitoring of the processes to address substandard care by a
surgeon. By doing that, you allow a surgeon to stay in place
who is believed to be not operating at the highest level or
even at an acceptable level. By monitoring those processes,
paying attention, demanding accountability, you ensure safety
and patient safety.
Ms. Kiggans. The IG also published a report that showed
severe mismanagement in veterans' oncology care, resulting in
serious delays, which is unacceptable.
How can leaders be proactive in their oversight and
involvement in patient care? You talked about hands-on and just
managing that care, but can you give me specific examples? Is
this reviewing charts? Is this periodic reviews with small
groups? Just a little more specific.
Mr. Case. Yes. As a general matter, trust is critical
between leaders and staff, but verification of performance and
adherence to policy and standards is absolutely necessary. The
stakes are too high, and the data is too readily available to
assume patients are getting the care they need, especially
those at high risk.
The best example that comes to mind is in Buffalo, where
there was--the chief of oncology, the staff oncologist were
demanding that a patient get an appointment scheduled in the
community. The response from others was: we are taking care of
it. We will get it done. It was not getting done.
That is an instance where you can trust, but you have to
verify. You have to intervene and make sure that that patient
is getting the care he needs, especially incumbent upon
facility management, the staff oncologist and the oncologist.
Ms. Kiggans. Which takes manpower and then also people who
are very thorough and attention to detail in doing this. A
follow up for their jobs, which I can appreciate. Thank you,
Mr. Case.
Mr. Radway, from your experience in the last 4 years, what
has OAWP identified as repeat areas of concern across the VA in
patient care?
Mr. Radway. We have not, Congresswoman, really focused on
patient care issues per se. We have really looked more at
misconduct.
We have seen several cases where there was a failure to
oversee providers who were alleged to have committed misconduct
in terms of patient care and improperly treated patients. Then
we will look at the activities of those senior leaders who
failed to oversee their providers, their chiefs of surgery,
things like that.
Ms. Kiggans. The office--and Mr. Radway again--the Office
of Medical Inspector is responsible for assessing VA's quality
of care. How do the recommendations made in the OMI reports
work to mitigate repeated errors in the care provided in the
VA?
Mr. Radway. Dr. Upton, do you want to----
Dr. Upton. I would be happy to take that, Madam Chairwoman.
The OMI recommendations come to both the leaders of the
facilities as well as to our senior leaders in VHA. They, as
was mentioned earlier, look at important quality and safety
issues within our system, often charged by the Under Secretary
for Health or others.
We--the OMI specifically makes sure that those
recommendations are followed through, and we take them very
seriously as part of our commitment to quality.
Ms. Kiggans. You follow up at each facility individually?
Dr. Upton. We review them as leaders, as the senior
leadership team. They also work with each facility, because
many of these are very facility-specific. We certainly try to
take lessons learned across the system as well.
Ms. Kiggans. Very good. Thank you.
Let us see. Then we will now--I want to--we will now move
to questions from the ranking member.
Ranking Member Ramirez, you are recognized for 5 minutes.
Ms. Ramirez. Thank you, Chairwoman.
I want to just thank all of you for being here again. I
really appreciate your testimonies and having an opportunity to
read through them.
I want to do a little quick level-setting exercise with
some of the witnesses here today, because we are I know a
little bit in a time crunch. I want to go down the row with
three of you and ask you each to answer a question.
Ms. Therit, in your work, do you put veterans or VA first?
Ms. Therit. Congresswoman Ramirez, yes.
Ms. Ramirez. Veterans?
Ms. Therit. Veterans first.
Ms. Ramirez. Mr. Radway, in your work, do you put veterans
or VA first?
Mr. Radway. Veterans.
Ms. Ramirez. Dr. Upton, you are a provider who cares for
veterans. Do you put veterans first or VA?
Dr. Upton. Veterans first every time.
Ms. Ramirez. Thank you. I want to make sure that the record
shows that it is crystal clear that these public servants
before us put veterans first. I believe them.
We relied on each of you during the last 4 years to ensure
the VA continued its journey to becoming an accountable
institution that prioritizes patient safety, and I just want to
thank you for your service.
Now, Ms. Therit, I appreciated VA's testimony that you
provided regarding actions taken to hold employees accountable
for misconduct. I want to ask you a couple follow-up questions.
How frequently does the VA use its authority under Title V
to remove employees?
Ms. Therit. Congresswoman Ramirez, last Fiscal Year we used
our authority under Title V and the Accountability Act, because
we use both of the authorities. We use 713 in the
Accountability Act for our senior leaders and the Chapter 43
and Chapter 75 authorities in Title V.
There were over 5,000 actions that we took to remove, to
suspend, or to demote employees who engaged in poor performance
or misconduct. That number mirrors about the same number that
were taken the first year after the Accountability Act was
passed.
Ms. Ramirez. Pretty frequently.
How recently have you used Title V authority? When was the
last time?
Ms. Therit. We use the authorities that we have on a daily
basis.
Ms. Ramirez. Got it. I am looking at a chart right now that
compares year over year the total number of adverse actions
taken by the VA. It says that for year 2024, there were 5,875
adverse actions. You just mentioned that. In year 2024, the VA
would have been using Title V authorities for adverse actions,
as you mentioned, correct?
Just to follow up, the chart says that in 2018, `19, `20,
`21 and `22, the VA had 5,952, 5,653, 5,694, 4,673 and 4,068
adverse actions, respectively.
During that period, which authority or authorities for
adverse actions would the VA have been using?
Ms. Therit. Prior to Fiscal Year 2023, we were using a
combination of Accountability Act, Chapters 713 and 714
authorities in addition to our Title V authorities.
I would say that we are always using all of our
authorities, whether under Title 38 or Title V, to ensure our
Title 38 and our Title V workforce are being held accountable.
Ms. Ramirez. Got it. VA uses Title V at the same or higher
rates for adverse actions than they did with the authorities in
the 2017 Accountability law, correct?
Ms. Therit. Correct. We have a track record of legally
defensible actions under Title V, because they have been before
the Merit Systems Protection Board, they have been before third
parties. Any time we take an action, we want to make sure that
that employee does not come back if we remove them, if they are
suspended that suspension is upheld.
We try and look at the case law to make sure that the
actions that we are taking are legally defensible and that we
will not have to reinstate bad actors who should not be at the
VA serving veterans.
Ms. Ramirez. That sounds efficient.
Ms. Therit, my understanding is that you sit on Council
with other agency chief human capital officers. Is that
correct? Yes?
Ms. Therit. Yes, ma'am.
Ms. Ramirez. I have another follow up. Are there other
Federal agencies that also employee physicians, nurses, and
housekeepers, like the VA?
Ms. Therit. There are. The Department of Health and Human
Services. The Department of----
Ms. Ramirez. Let me ask you, though. I have a couple
seconds left here.
Do those agencies also use Title V to discipline employees?
Ms. Therit. They do.
Ms. Ramirez. Ms. Therit, can you describe an instance when
you could not remove an employee under Title V?
Ms. Therit. If there are instances when an employee cannot
be removed under Title V or Title 38, it is typically, as Mr.
Radway had alluded to, because of a lack of evidence, you know,
an inability to support the level of discipline that is being
proposed.
Rarely is it the authority that is limiting it as opposed
to the substance of the investigation or the prior conduct or
performance of that individual.
Ms. Ramirez. Thank you, Ms. Therit.
Just a quick question to Mr. Sherman. Thank you for being
here again. How would you describe the first 20 days of the
Trump's second administration in the last 10 seconds? Hard, I
know.
Mr. Sherman. Lawless, evasive, chaotic. You know, I think
if the President was serious about oversight of the VA in
particular, he would not have fired the IG and he would not
have sent minions from DOGE to root around there.
Ms. Ramirez. Thank you, Mr. Sherman.
I yield back.
Mr. Self. [Presiding.] Thank you. I recognize myself for 5
minutes.
First of all, I want to thank you for being here. I want to
assure you that you are not stage props. The hysteria and the
hyperbole that you have heard today will not stop this
committee from conducting reasonable oversight, which is our
duty.
Mr. Case, your testimony, particularly your written
testimony, is pretty damning. I will just quote a few sentences
from it. ``Accountability, components of accountability
identified by the OIG are often lacking within VA programs and
operations.'' You listed the five, gave a very detailed.
``The OIG regularly identifies instances of misconduct,
broken systems, confusing and conflicting governing policies or
guidance, and inefficiencies or missteps in implementing
programs.'' Further, you say, ``Misconduct, failures to take
appropriate action, and persistent problems are often the
result of VA personnel or contractors not understanding their
roles or responsibilities. In other cases, they understand
their duties, simply do not or cannot fulfill them. This may be
due in part to outdated policies and procedures, conflicting
guidance, lack of clear decision-making--often by those best
positioned to act lacking the authority to do so,'' and you go
on.
Everything that I just read is a leadership issue. I will
tell you that during my first term in Congress on this
committee, we spent an inordinate amount of time on countless
scandals throughout the VA, normally at the leadership level.
In the past 2 years under the Biden administration, we have
been made aware of many cases, not executing their jobs,
employees not executing their jobs. This subcommittee sent over
80 letters--80 letters--to try to uncover why that is. I can
only compare it to a dumpster fire in a windstorm. If you think
it cannot get any worse, it blows up again.
Mr. Case, I want to go to you first. Have you found
Veterans Integrated Service Network (VISN) directors exercise
inconsistent oversight--and this is leading to another
question--leading to major disparities in quality of care and
leadership across the VISNs?
Mr. Case. We have found disparity in oversight by VISN
directors, largely attributable, we see often, in the fact they
do not have clear definitions of what their responsibilities
are and what their duties are. This is not just VISN directors.
It goes to all leadership, mental health directors at the VISN
level.
Once the responsibilities and duties are clarified, then I
think they will be in a position to move forward.
Mr. Self. Do you attribute this to lack of leadership at
the VA leadership level to a Secretary administrative level, or
is it they have too much autonomy at the VISN director level?
Again, leading to another question.
Mr. Case. Yes. How the VA got itself in the situation is
probably a long story. Autonomy can work if there is
standardization of duties at the highest level, at the VISN
level, and those duties are clear. As it exists right now,
there is not that clarity for VISN leaders to act on their
duties.
Mr. Self. Okay. Let me go to the EHR, because--and I
realize it probably is not in the core mission of this hearing.
Is it not true, from the OIG perspective, that we cannot get to
a clear EHR solution because of the customization at the VISN
level? Is that a true statement or not?
Mr. Case. That could be part of it, and it is probably part
of it. There are many reasons, though, why EHR is in the state
it is in at the present time.
Mr. Self. The ethics violations. We covered, oh, probably
all the way from sexual to the bonuses, those scandals that I
referred to, to what would you owe that?
Mr. Case. That depends on the instance that we are trying
to address. Sometimes it is personal malfeasance. It boils down
to that. Other times, malfeasance is allowed to go on. It just
varies, and it is individualized. That is why our reports are
very specific, focused, and practical.
Mr. Self. In the last couple of seconds, Mr. Radway, do you
track instances where VISN leadership intervenes--no. Do you
identify cases where interference allows people to be
transferred as opposed to held accountable? Quickly.
Mr. Radway. We do not track whether people are transferred.
We just track whether the VISN leaders, if they are the
deciding official, implement the recommendation for discipline
or not.
Mr. Self. Okay. Thank you. I yield back and recognize Mr.
Conaway.
Mr. Conaway. Thank you.
Mr. Self. Dr. Conaway. I apologize.
Mr. Conaway. Well, thank you for that. I appreciate that.
Thank you, Mr. Chairman.
Thank you, lady and gentlemen, for presenting yourself to
us today. Hopefully we, working together, can bring about the
necessary improvements to ensure that the VA meets the demands
of the American people and certainly the desires of our veteran
community to receive first-rate service at the VA.
I would like to follow up, however, on a question that was
just raised about ethics and to raise a concern about the
President's actions upon--in office with respect to EOs.
My notes say here that among the recisions that the
President made changed the ethics commitments by executive
branch personnel and others with respect to gifts and the like.
Have any recent changes in the administration impacted the
ethics rules governing the highest reaches in the VA? That is
either for Mr. Case or Mr. Sherman. I will help out that way.
Mr. Sherman. Well, I think when President Trump came in, he
rescinded the ethics pledge for appointees in the government,
and significantly weakened those rules, making it easier for
appointees to accept gifts and to move back and forth between
the private sector and the public sector.
Certainly, I would be concerned about conflicts of
interest, you know, undermining the efficacy of service that
the American people, including our veterans, get from their
government.
Mr. Case. From the IG perspective, we will look at issues
that are raised to us, and we will investigate those and do
reports. We do investigate those, but we do not address broad
policy issues, and we do not address in a significant way what
is the result of those policy issues until we have specific
requests to go and look at specific instances. That is
basically are people meeting standards. That is how we operate
in doing our reports.
Mr. Conaway. I thank you for that. I just have to say that
these ethics rules are intended to ensure that the vendors who
work for the VA, you know, public money is being spent there.
If someone is getting gifts or not behaving appropriately with
respect to awarding contracts and overseeing those because of
gifts, then we are going to see waste and we are going to see,
as we have seen, unfortunately, throughout the VA, serious
problems with implementing the systems for everything from
getting appointments, the Electronic Medical Record (EMR) which
you just mentioned, and many other things in the reports that
we have gotten that have looked at cost overruns and the
inability to get these critical systems implemented and online.
Mr. Radway, again, thank you for being here. Can you
describe how the OAWP improved the quality of investigative
work over the last 4 years during the Biden-Harris
administration, and have improvements been made, not been made?
You noted here that there are a number of investigations
under the current authorities that have led to more than 5,000
people being removed from their jobs for various infractions.
Can you describe the--how the OAWP process has worked with
respect to quality of investigations?
Mr. Radway. Sure, Congressman. A lot of it has to do with
hiring the right people. I hired skilled 1810 administrative
investigators who--many of whom are retired military or retired
law enforcement and are on their second career.
We instituted standard operating procedures, based on the
Council of the Inspectors General on Integrity and Efficiency
Investigative Standards, and we modelled those standards for
our investigation. We have given our folks training, and we
established the Investigative Attorneys Division, which ensures
that our reports are legally sufficient and our recommendations
are legally supportable.
Mr. Conaway. That is all I have.
Mr. Sherman, can you talk about the--regarding the
reinstatement of Schedule F by the current administration, how
will this executive order create a VA that is more prone to
corruption versus one that prioritizes accountability and the
well-being and care of veterans?
Mr. Sherman. Well, certainly weakening Civil Service
protections makes it easier to fire government workers,
nonpartisan government workers, when they report misconduct by
the political leadership of the agency.
It makes it less likely that people will report misconduct,
and it makes it more likely that the Civil Service is subject
to partisan pressure, which is exactly what we do not want our
veterans to experience when they come to the government for
help.
Mr. Conaway. Well, with the time I have, I just want to say
that we need a professionalized Civil Service and not people
who are amateurs coming in there on political appointments that
are not accountable to their mission but, rather, to the
appointing authority.
Thank you, Mr. Chairman.
Mr. Self. I recognize Mr. Ciscomani.
Mr. Ciscomani. Thank you, Mr. Chairman.
Our ultimate duty here on the committee is to ensure
veterans come first and not senior executive bureaucrats. It is
one thing to be able to say that and then another to act on
that.
Arizona is, sadly, the epicenter of what can go wrong when
oversight is not taken seriously, as we saw in 2014. It was
referred to that earlier today as well.
While we seek to ensure the VA is effective, we also have
worked to create great public, private, and VSO partnership
programs to fill the void in the community in Arizona as a
result of what happened.
One example is the Be Connected program that for years has
partnered with VA to ensure veterans are able to access the
resources and benefits they have earned. While ensuring these
partnerships continue, I want to make sure recent events in
Arizona, such as a veteran passing away in the parking lot of
the Phoenix Medical Center or a physician improperly
administering care to veterans cease to occur.
Now, when we--Mr. Radway and Mr. Case, this will be going
to you on the issue and the topic of the senior executive staff
improper bonus pay.
Last Congress, it was discovered--and in this area I would
like you to please provide some insight as well as getting into
the OIG's work.
Last Congress, it was discovered Senior Executive Service
(SES) pay bonuses were paid despite the purpose of these
dollars being allocated for frontline healthcare workers who
are day in and day out serving our veterans.
What is the VA doing to, one, regain trust; two, ensure
this does not happen again; and, three, how do you plan to
continue oversight of work with the new administration, given
its Presidential memo regarding additional accountability for
SES employees?
Mr. Radway. Congressman, in response to the IG report on
critical skills incentives, or CSIs, our office was tasked with
conducting an investigation into that episode, issued a 165-
page report to the Secretary with recommendations for
disciplinary and nondisciplinary action, including policies and
procedures that would prevent that from reoccurring.
Most of our recommendations to date have been implemented.
We have not seen any issues of reoccurrence brought to our
attention, but if they were we would certainly investigate
those, as appropriate.
Mr. Case. We have received a response to our
recommendations, asking that they have been closed, from the VA
That came on January 10th. The closure of recommendations and
whether the VA has met the action plans they put forward is not
a binary process. It is not a yes or no process.
Oftentimes it requires a discussion with VA as to what they
have done, have they done enough, and see what their response
is. We are analyzing those right now. From our perspective, I
think some of those could probably be closed, but I think
others are going to require this ongoing discussion as to what
has been done and is it sufficient to meet the action plan of
the recommendations.
Mr. Ciscomani. What about my last part of the question
regarding the new administration giving the Presidential memo
regarding additional accountability for SES employees? How does
that play into what you just explained?
Mr. Case. Yes. When we do our work, we hold VA to
standards, and those standards could include legislation,
regulation, VA policies, clinical policies. Whatever it is that
we are trying to investigate we hold them to standards, and if
they come up short on those standards, then that would be part
of our report, our findings, and we will make recommendations
and then follow up to see if the action plans are implemented
in the way that meets those recommendations. This would be part
of that process, sir.
Mr. Ciscomani. We are running out of time here, but just
moving on, one of the major concerns is the number of times I
have seen individuals resign while under investigation as well
in an attempt to avoid accountability to their actions or for
actions of those they oversee as well. That happened
repeatedly. It was mentioned by the chairman in terms of how
many of those we saw in this committee.
How does this impact accountability and the investigation
processes?
Mr. Radway. It does happen, sir. It does not impact the
investigation itself. We are continuing to close out our
investigation. I am going to defer to Ms. Therit to speak about
the consequences of that.
Ms. Therit. Congressman Ciscomani, two things that I would
offer. One is we do have authority under 5 USC 3322 to annotate
personnel records when someone resigns under an investigation.
I will tell you that authority is very limited to certain
circumstances, and we cannot use it broadly.
I know later this month we have a legislative hearing, and
we are looking forward to sharing some views that we have on
more things that we can do to approve accountability at the VA.
Mr. Ciscomani. I am interested in participating and helping
in any way on that.
Mr. Chairman, I think that whenever someone saves
themselves from any consequences by resigning, that is an
accountability problem.
Thank you.
Mr. Self. Mr. Kennedy.
Mr. Kennedy. Thank you. Thank you all for your testimony.
Thanks for your service to our great country.
Dr. Upton, I understand that you have been involved in
improving the care in the community program of the Buffalo
Medical Center. Are you fully read into the OIG report and what
was found in that report and what has been recommended for the
Buffalo VA Medical Center in the fall?
Dr. Upton. Thank you, Congressman.
As a healthcare provider myself, this was mentioned
earlier, as well as some of the works nationally, we need to
make sure that when veterans are referred for care, that it
happens timely and in a high quality way. Certainly that was
the challenge, you know, the significant concern we heard in
Buffalo.
I will say when that concern came to us, our under
secretary for health very swiftly pulled a team of experts
together from various disciplines to go to Buffalo directly, as
you know, sir, and really look at all aspects of the issue
there, from process to education to staffing to ensuring the
right reviews are occurring of leadership as well.
Mr. Kennedy. You are familiar?
Dr. Upton. I am very familiar, yes.
Mr. Kennedy. Excellent. Well, thank you.
The under secretary came up at my invitation, and we had a
very productive meeting with the leadership of the staff at
that hospital, and one of the issues that came up was a lack of
staffing.
Through what you have read in the OIG report and in order
to achieve the OIG recommendations, do you believe that it is
important that the staff is hired to a level that is necessary
to provide the service to our veterans?
Dr. Upton. I do, Congressman.
Mr. Kennedy. The VA is currently under a hiring freeze, is
it not?
Dr. Upton. We are complying with the, you know, orders from
the administration, but we have received a number of exceptions
for important critical roles within the healthcare delivery
system.
Mr. Kennedy. What is the VA doing to get more hires at the
Buffalo VA specifically to help the veterans get the care that
they need?
Dr. Upton. I know that the current leadership at the
Buffalo VA, as well as the VISN, are taking that very
seriously, and I would be happy to follow up with you directly,
Congressman, on the specific hiring in various key areas there.
Mr. Kennedy. Well, it is important that the hiring is up to
a level that the hospital and the system functions.
When the fork in the road email went out, there was a
department of VA memo that stated that there were approximately
1,900 plus jobs that were rescinded and 716 job postings that
were removed from USAJobs. Those are positions that are
effectively providing service to our veterans, are they not?
Dr. Upton. We are absolutely committed to hiring all the
key positions we need, Congressman, and were able to repost a
large number of those.
Mr. Kennedy. I understand what you are saying, but I would
like to know precisely how. Buffalo VA is indicative of what is
happening around the country. If there is a hiring freeze in
place, and what we are hearing, not only in my district but
across the country, is that there are individuals that are
being put on performance improvement plans, there are people
that are on probation that are being cut without explanation,
and are those positions being hired?
It sounds to me and others that we are hearing from, again,
my constituents that we are blowing a hole in the staffing
levels at not only the Buffalo VA and the Buffalo network, VA
network, but across the country.
Can you speak to that?
Dr. Upton. I will say that we are absolutely committed to
hiring key staff, and I agree with you, Congressman. It is so
important that we bring the staff in to serve veterans. The
specifics of Buffalo in the network I would be happy to follow
up with you with, but I certainly understand your concern.
Mr. Kennedy. How can we be confident that the VA network
across the country is being staffed appropriately when, in
fact, there have been jobs that have been rescinded, offers
that have been rescinded, and postings that have been removed,
thousands of jobs and postings, and, you know, there are
reports of individuals, again, being put on performance
improvement plans that ultimately we know is the first step
toward termination, and individuals that are currently in a
probationary hiring period that are being terminated without
cause?
Dr. Upton. I will say we are going to stay laser focused as
a health administration to hire all the employees that we can
and follow all accordant directives and guidance, but we are
laser focused on bringing the critical healthcare workers we
need, Congressman.
Mr. Kennedy. I would like you to, please, provide in
writing to this committee, this subcommittee a hiring chart of
exactly what is happening, where the hirings are, where the
staffing levels are open, and all of which have transpired
since the fork in the road memo went out.
I yield back. Thank you.
Mr. Self. Mr. Moylan.
Mr. Moylan. Thank you, Chairman Self and Ranking Member
Ramirez. I would like to thank the subcommittee for the
opportunity to speak on behalf of the veterans of Guam who have
been some of the most dedicated and selfless members of our
Nation's armed forces.
Now, despite Guam having the highest enlistment rate per
capita in the United States and one of the highest
concentrations of veterans, our island has consistently been
left behind when it comes to access to resources and benefits
they deserve from the VA under the previous administration.
There is an ongoing discrepancy between the number of
veterans reported by the government of Guam and those
recognized by the VA. This is likely due to the VA's reliance
on the number of veterans registered without considering the
need for increased outreach and support to those who have not
been connected to the system.
We know that our veterans in Guam have sacrificed so much
in service to this Nation. It is our responsibility to ensure
that they are not left behind simply because they live in
geographically isolated territory.
The failure of the VA to provide adequate staffing,
oversight, and resources for Guam's veterans under the previous
administration is a situation that demands immediate
correction.
Today's hearing is a crucial step in ensuring that the
brave men and women of Guam who have served our country are no
longer neglected. We must take action to provide the support
and services they have earned.
For my first question, Dr. Upton, Guam currently falls
under the VA Pacific Island's healthcare system which services
the largest geographic region in the country. How does VHA
determine resources, allocations for its facilities and the
territories which face unique challenges in accessing Federal
resources and services?
Dr. Upton. Thank you, Congressman.
I want to echo how important it is that we serve the
veterans of Guam and appreciate their service. As you
mentioned, Guam is part of that particular VISN network, and we
look at the veteran population, the services they need, the
location of various facilities, as well as in VA and in the
community.
I would be happy, Congressman, to sit down with you and
that VISN leadership to talk about the needs in Guam from the
healthcare perspective. I know that, you know, it sounds like
we can do better. They need support, and I would be happy to
work with you.
Mr. Moylan. The next question will be for Mr. Radway. How
much oversight exists when issues arise in Guam and the other
territories? How often are visits conducted, and how does the
VA address these matters?
Mr. Radway. I can only speak to oversight of the senior
leaders. I do not have numbers for you on how many
investigations we have had in Guam. I can certainly get those
numbers for you, Congressman. If we receive allegations, we
would treat those just the same and investigate them just as we
would any other VISN or facility.
Mr. Moylan. All right. Thank you.
Last question. Ms. Therit, a consistent issue brought forth
by my constituents is how does the VA decide where staffing is
needed? How is the annual review conducted to determine if
staffing needs to be increased?
Ms. Therit. Congressman Moylan, thank you for that
question.
In terms of the staffing resources and models that the
Veterans Health Administration uses, those are assessed on an
ongoing basis. We publish data on a recurring basis. On a
monthly basis, we publish a public-facing report that looks at
staffing levels. Then on a quarterly basis, we report it on the
Mission Act 505 section with respect to our vacancies and our
staffing levels.
Where those staffing levels need to be adjusted, I think as
Dr. Upton mentioned, that local leadership will work with their
VISN leadership to make sure that they are getting the
resources and the budget and the allocations that they need to
ensure that the services are being provided in a timely and
high quality manner. Those assessments are ongoing.
If there are any circumstances that you want to discuss
specifically in your area, I am glad to take a closer look at
that with the VHA HR team.
Mr. Moylan. I appreciate your time and you all coming and
testifying before the subcommittee. I thank you very much.
Mr. Chairman, thank you.
Mr. Self. Thank you.
I want to thank the witnesses for coming today for your
candor, for your willingness to come, and to the VA for
providing the witnesses, the expert that they have.
We need to ensure the VA has good governance. Veterans are
getting the quality care that they deserve and they have
earned, to quote several members from this side. Absolutely,
that is imperative. That starts with ensuring that all
employees are held accountable. Leadership culture matters.
Restoring accountability remains a top priority of this
committee, and I am speaking for the chairwoman. We all look
forward to continuing to ensure that VA remains committed to
this goal. We all look forward to the leadership of Secretary
Collins, and I believe that we will see a dramatic difference
Ranking Member Ramirez, closing comments.
Ms. Ramirez. Thank you, chairman.
I also want to echo the sentiments from the chairman now.
We are really incredibly thankful for you to be here today.
This committee is going to be incredibly important over the
next few weeks, over the next few years. We have to make sure
that we use oversight and we use every authority in our power
to ensure that we put our veterans first, that we ask hard
questions, that we make sure that in everything we do, we are
centering veterans and their families.
For many years, I got to shelter them. I fed them. I helped
them find jobs. It is the work that I have done from a very
young age--I know I look young, but that was almost 20 years
ago.
I want to say that as I am thinking about and transitioning
out of this hearing today, I am concerned that at no point
during this hearing today we mentioned on this side--we
certainly heard it from Mr. Sherman--but we did not address the
removal of the VA's inspector general, Mike Missal.
Let me just say despite the fact that in this last
Congress, Republicans relied on his testimony 22 times--let me
repeat that. Republicans relied on his testimony 22 times. I
have not heard anyone talk about his removal, and it does not
surprise me, but it does not make it right.
I have said it once and I will say it again. Accountability
for Members of Congress has to be one of our priorities.
The President made it very clear when he removed over a
dozen qualified inspector generals, including the VA's former
inspector general, Missal. From our own records, we can agree
that Mr. Missal's work was apolitical. He did his job and held
the VA to standards that ensured veterans were treated with
dignity and got the care they earned.
Not once did my colleagues raise concerns or question Mr.
Missal's integrity as they relied on his testimony. In fact,
they thanked him for his transparency. They thanked him for his
directness when discussing issues he and his staff uncovered at
the VA. Yet now my Republican colleagues are silent, following
their marching orders.
For a group of people fixated on qualifications, it seems
like the only qualification that now matters is loyalty to the
President or Musk.
Let us be real here. We cannot have an honest conversation
about accountability at the VA without addressing Mr. Missal's
removal, and that is why I want to make sure, Mr. Case, that
you know and you hear this from me I am deeply concerned about
reports that Elon Musk and his teenage intern team who are not
government employees, at least I am not aware that they are,
were at the VA central office earlier this week.
Look, I do not think they have legal authority to direct
the people and the resources of the VA, and they do not have
authority to access the VA data. This feels like an abuse of
power.
I am going to be officially requesting the inspector
general to initiate an investigation into this and report back
to Congress as to whether Musk or his team were or are
currently working at the VA, who they are meeting with, who is
being discussed, what veteran data is being assessed, and
whether that access is lawfully.
That is the responsibility that we have here, oversight and
accountability. I look forward to working with you.
Mr. Chairman, I yield back.
Mr. Self. Thank you, ranking member, and thank everyone for
being here, and the audience included.
I ask unanimous consent that all members shall have 5
legislative days in which to revise and extend their remarks
and include any extraneous material.
Hearing no objection, so ordered.
This hearing is now adjourned.
[Whereupon, at 3:18 p.m., the subcommittee was adjourned.]
?
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A P P E N D I X
=======================================================================
Prepared Statements of Witnesses
----------
Prepared Statement of Ted Radway
Good afternoon, Chairwoman Kiggans, Ranking Member Ramirez, and
distinguished Members of the Subcommittee. Thank you for inviting us
today to discuss the VA's efforts to improve accountability within the
Department. Joining me today is Ms. Tracey Therit, Chief Human Capital
Officer in VA's Office of Human Resources and Administration/
Operations, Security, and Preparedness, and Dr. Mark Upton, Deputy to
the Deputy Under Secretary for Health.
VA is committed to providing Veterans with the care and benefits
they have earned through service to our country. Our Veterans and their
families, caregivers, and survivors deserve nothing less. We and the
more than 450,000 VA employees are devoted to this sacred duty and work
diligently daily to fulfill this mission. Sometimes, even with the best
intentions, the VA recognizes that the performance and actions of some
VA employees, including some leaders, fall short of what we expect and
what our Veterans deserve. When that happens, holding employees
accountable is integral to effective, efficient management, and we take
that responsibility seriously.
We look forward to working with the House and Senate Veterans
Affairs Committees to strengthen our accountability policy, processes,
procedures, training, and systems. Accountability starts long before we
propose disciplinary actions; thus, VA continues to strengthen its
employee relations, which supports its ability to hold employees
accountable promptly and appropriately. In today's hearing, we welcome
the opportunity to discuss our improvements to strengthen our
accountability.
Office of Accountability and Whistleblower Protection
The Office of Accountability and Whistleblower Protection (OAWP)
actively promotes and improves individual and organizational
accountability across VA. We do this in several ways. While OAWP is
most well-known for its investigations of senior leader misconduct and
poor performance and of supervisor retaliation against whistleblowers,
as the Office has matured, we have taken substantial steps to implement
and operationalize the non-investigatory parts of our statute to help
drive accountability in different ways.
First, we investigate allegations against VA senior leaders
involving misconduct and poor performance; we also investigate
allegations against all VA supervisors involving retaliation against
whistleblowers who have made a protected disclosure. OAWP conducts
these investigations using highly skilled professional 1810-series
investigators under standard operating procedures modeled in part on
the Council of the Inspectors General on Integrity and Efficiency
Quality Standards for Investigations. The Investigations Division works
hand-in-hand with our Investigative Attorneys Division (IAD), formed in
2022, which gives us complete independence from the VA's Office of
General Counsel in conducting our investigations. The attorneys ensure
investigations are properly scoped and within our statutory
jurisdiction, all relevant issues and potential misconduct are
identified, and the investigative conclusions and recommendations are
legally supportable and appropriate.
After investigating allegations of senior leader misconduct and/or
poor performance or whistleblower retaliation by a supervisor, OAWP
issues a report that includes the allegations, background information,
factual findings, conclusions, and recommendations for disciplinary
actions where appropriate. OAWP does not carry out those disciplinary
actions. Instead, our report is issued to the appropriate VA official
with the authority to propose and/or carry out those actions. If OAWP's
recommended actions are not taken, or not taken within 60 days, OAWP
reports the decision not to take the recommended action, along with the
deciding official's reasoning, to the House and Senate Veterans Affairs
committees.
Our work training our investigators, standardizing procedures, and
forming the Investigative Attorneys Division has led to a remarkable
turnaround in OAWP's productivity, success, and impact on individual
accountability. For example, in fiscal year (FY) 2021, management took
some action, or the employee retired or resigned, on only 64% of our
disciplinary recommendations. In FY23, that number increased to 100%.
In FY24, we issued a record number of recommendations, and management
has taken some action, or the employee retired or resigned in all but
three (3) cases, or 92%. We may also issue non-disciplinary
recommendations for relief or corrective action for the whistleblower,
training, or policy modifications. Since FY21, management has
consistently taken those non-disciplinary recommendations between 96%
and 100% of the time.
The growth in investigative work quality and the resulting
recommendations occurred while the volume of complaints coming to OAWP
has increased yearly. The number of complaints increased by over 60%
from FY21 to FY24 and 22% from FY23 to FY24 alone, to 3,305 complaints
in FY24. This shows VA employees' trust in OAWP's ability to resolve
complaints fairly and efficiently. A majority of complaints come in
through our redesigned, user-friendly online portal, which allows
whistleblowers to file reports anonymously and still track their
complaints.
Despite the rapid increase in case volume, OAWP's efforts have
dramatically reduced the time it takes us to close a case. In FY21, it
took an average of 496 days to close a case that resulted in a written
report of investigation. By contrast, in FY24, it only took an average
of 122 days, a greater than 75% reduction in time to close a case. By
comparison, according to its recent public filing, the Office of
Special Counsel (OSC) closes 87% of its prohibited personnel cases in
240 days or less.\1\
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\1\ Office of Special Counsel, Performance and Accountability
Report for Fiscal Year 2024, January 7, 2025, at p. 29 (https://
osc.gov/Documents/Resources/Statutory%20Reports%20and%20Notices/
Performance%20and%20Accountability%20Reports%20(PAR/
Performance%20Reports/
FY%202024%20Performance%20and%20Accountability%20Report.pdf).
---------------------------------------------------------------------------
By statute, OAWP also receives whistleblower disclosures that do
not fall within its direct investigatory authority; for example,
violations of law, rule or regulation, or gross mismanagement by a non-
senior leader are referred to the appropriate VA organization to
address potential problems and concerns. OAWP maintains oversight of
those referrals, ensuring the investigations meet procedural
requirements.
OAWP's success in fostering more significant reporting of
wrongdoing and completing fair investigations promptly, resulting in
recommendations that are acted on by VA management, drives greater
individual accountability across the VA.
Beyond carrying out investigations, we also drive organizational
accountability. By statute, OAWP provides advice, reports, and
recommendations to the Secretary on all matters relating to
accountability. In the past two years, this included providing the
Secretary with eight reports on the VA's organization and efforts
surrounding how we interact with and provide care to Veterans with
Military Sexual Trauma, or MST. The eight reports contained 32
recommendations for VHA, VBA, and VA, all of which were concurred with,
and more than half have already been implemented, with the rest
scheduled for implementation in FY25 - driving greater organizational
accountability and, more importantly, a better experience for our
Veterans with MST. OAWP is also executing its statutory authority to
confirm and review VA's implementation of recommendations from Office
of Inspector General (OIG), Government Accountability Office (GAO), and
the Office of the Medical Inspector (OMI), partnering with VA and those
other oversight entities to identify repeated areas of concern,
determine if VA is still implementing the closed recommendation, and
identify any root cause solutions that might be scalable across the
enterprise, thus identifying best practices to drive greater
accountability and better service for our Veterans.
OAWP also launched Climate Reviews, on-site evaluations that
include interviews and focus groups in addition to an anonymous all-
employee survey that gives leadership insight into the whistleblower
reporting environment at their facility and makes recommendations to
improve that reporting culture to drive greater accountability and
whistleblower protection.
OAWP also dramatically increased the data trend analyses it
performs under its statute. It now shares that data, for example, with
VISN leadership so they can identify and address any potentially
problematic trends.
Finally, OAWP has expanded its training on whistleblower rights and
protections, not just providing the bi-annual Training Management
System (TMS) recorded training to all employees and annual TMS
supervisor training but also providing live, in-person, or TEAMS
training to a number of Administrations, VACO offices, VISN leadership
teams, and individual facilities that have all reached out and
requested we provide additional training. In FY24, OAWP provided
approximately 226 of these supplemental training sessions.
VHA as a High-Reliability Organization (HRO)
In 2019, the Veterans Health Administration (VHA) began a
transformational modernization. Our transformation into a High-
Reliability Organization (HRO) was central to this modernization. An
HRO is an organization that experiences fewer than anticipated
accidents or events of harm despite operating in highly complex, high-
risk environments where even small errors can lead to tragic results.
The Department empowers all staff to lead continuous process
improvements within their workspaces. We created an environment where
employees feel safe to report harm or near misses. This framework
requires our leaders to focus on the why, not the who, when errors
occur.
The work to become an HRO not only unleashed the incredible talent
and commitment within our system to do great things but also underpins
our efforts to strengthen the trust of Veterans and the American people
in VA. We are committed to continuing to build on the great strides we
made in improving safety and quality of care. In the most recent CMS
Overall Hospital Quality Star Ratings, more than 58% of VA hospitals
included received 4-or 5-star ratings compared to 40% of non-VA
hospitals.\2\ As Veterans Integrated Service Networks (VISNs) and VA
Medical Centers (VAMCs) advance toward HRO maturity, leaders are
applying an organization-wide commitment to Zero Harm by developing an
even stronger safety culture featuring empowered, collaborative
frontline teams supported by engaged leadership within a climate of
trust and continuous improvement.
---------------------------------------------------------------------------
\2\ https://www.Medicare.gov/care-compare/
---------------------------------------------------------------------------
Office of Medical Inspector (OMI)
The Office of Medical Inspector (OMI) is responsible for assessing
the quality of VA health care through investigations of VA facilities
Nationwide. OMI investigations are initiated after receiving
allegations and/or disclosures, including those referred by Veterans,
VA employees and leadership, OAWP, OIG, Office of General Counsel, and
Congress. Once a concern is identified, the Under Secretary for Health
directs OMI to assemble and lead a team to initiate an investigation.
OMI issues comprehensive reports of the health care investigations that
generally include the allegations investigated, necessary background
information, factual findings, conclusions, and actionable
recommendations for corrective action and/or improvements to the
quality of Veterans' health care.
When OMI uncovers evidence of potential misconduct or poor
performance by a senior leader during one of its investigations, it
refers the allegations and/or evidence to OAWP for investigation of the
alleged misconduct and/or poor performance. OMI generally does not make
specific recommendations related to discipline. Instead, it focuses on
oversight and improvement of Veterans' health care.
Conclusion
VA is proud of its large, dedicated workforce, who work hard to
carry out VA's great mission every day. The Department engages in
continuous improvement of accountability to assess how to help identify
and affect cultural improvements within the VA, hold employees
accountable, and continue to work to protect whistleblowers. VA is
committed to holding employees accountable, including taking
disciplinary actions when necessary, and still celebrates VA's many
accomplishments. Chairwoman Kiggans, Ranking Member Ramirez, and
distinguished Members of the Subcommittee, we look forward to
responding to any questions you may have.
______
Prepared Statement of David Case
Chairwoman Kiggans, Ranking Member Ramirez, and subcommittee
members, thank you for the opportunity to discuss the efforts of the
Office of Inspector General (OIG) to enhance VA's accountability and
aid in its continuous improvement. The OIG's mission is to serve
veterans and the public by conducting meaningful independent oversight
of VA's services, programs, and operations. OIG staff execute this
mission by conducting accurate, fair, and impactful audits, reviews,
healthcare inspections, and investigations across the nation. For
fiscal year (FY) 2024, the OIG produced 316 oversight publications with
1,106 recommendations to VA for corrective action. Our personnel made
nearly 250 arrests, fielded more than 34,000 contacts to our hotline,
and testified before congressional committees on 14 occasions, as well
as conducted nearly 200 briefings to members of Congress and their
staff. Our work has resulted in a monetary impact of more than $6.8
billion for that 12-month period. This would not have been possible
without the funding and other support we receive from Congress. We are
also grateful to the veterans service organizations from whom we
regularly solicit concerns and the many VA personnel and other
stakeholders who bring to our attention a wide range of problems with
VA programs and operations.
Integral to every OIG effort is intense scrutiny of the
effectiveness of leadership and the quality management of VA operations
that makes the most efficient use of taxpayer dollars. In a department
the size of VA, with the nation's largest integrated public healthcare
system, an aging infrastructure, and massive information technology
(IT) modernization efforts, the OIG must remain vigilant to all risks
to veterans, their families, and survivors. This requires the use of
sophisticated data analytics and modeling; being responsive to hotline
contacts and other allegations of misconduct; and rigorous and
continuous oversight. OIG staff monitor programs and operations for
breakdowns in processes; noncompliance with mandates; failures to
provide quality health care; and deficiencies in the delivery of
benefits and services. In addition, the OIG advances accountability by
conducting an expansive range of administrative and criminal
investigations that include, fraud, waste, and abuse of authority.
OIG leaders have testified before this subcommittee and other
congressional committees many times in the past about enhancing
accountability at VA.\1\ There are several recurring themes and
deficiencies that remain unchanged. These key elements of
accountability are routinely identified by OIG staff and shared with VA
leaders across the enterprise to encourage positive change and
efficiencies within their respective programs and operations. OIG
recommendations that focus on even a single medical facility or
benefits process are often a road map for other facilities and offices
across VA to help prevent or correct similar problems that have gone
undetected or unaddressed.
---------------------------------------------------------------------------
\1\ Recent OIG testimony to Congress can be accessed here.
---------------------------------------------------------------------------
This testimony focuses on five components of accountability
identified by the OIG as often lacking within VA programs and
operations, and highlights several illustrative oversight reports:
1. Strong governance and clarity of roles and responsibilities
2. Adequate and qualified staffing to carry out those duties
3. Updated IT systems and effectual business processes to
support quality healthcare delivery, accurate and timely
benefits, and efficient operations
4. Effective quality assurance and monitoring to detect and
resolve issues
5. Leadership that fosters responsibility for actions and
continuous improvement
The OIG appreciates the work VA personnel--the vast majority of
whom work under challenging conditions and are committed to continuous
improvement--do every day on behalf of veterans. Despite these efforts,
the OIG regularly identifies instances of misconduct, broken systems,
confusing and conflicting governing policies or guidance, and
inefficiencies or missteps in implementing programs. Given the
importance of VA's mission, every individual at VA should feel a
responsibility to identify and report risks and any resulting problems,
and then take action to address the underlying causes and mitigate the
chances for future occurrences. To underscore the need for personnel to
report potential crimes and issues that put veterans, VA employees, and
resources at risk, the Senator Elizabeth Dole 21st Century Veterans
Healthcare and Benefits Improvement Act recently codified the
requirement that all new VA employees receive training on how to report
and cooperate with OIG staff.\2\ Ensuring employees and leaders
understand their duty to report and remediate problems is meant to
foster a culture of accountability across VA.
---------------------------------------------------------------------------
\2\ Senator Elizabeth Dole 21st Century Veterans Healthcare and
Benefits Improvement Act, Pub. L. No. 118-210 Sec. 501.
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STRONG GOVERNANCE AND CLARITY OF ROLES AND RESPONSIBILITIES
Misconduct, failures to take appropriate action, and persistent
problems are often the result of VA personnel or contractors not
understanding their roles and responsibilities. In other cases, they
understand their duties, but simply do not or cannot fulfill them. This
may be due in part to outdated policies and procedures, conflicting
guidance, or a lack of clear decision-making--often with those best
positioned to act lacking the authority to do so. Offices in
administrations can be responsible for developing policy, but not for
implementing or overseeing it. For example, financial officers in
different administrations within VA do not report to the VA chief
financial officer.
Two recent OIG reports serve as examples of how leaders did not act
on known issues, resulting in delays in patients receiving health care.
Last fall, the OIG published the results of a healthcare inspection
regarding community care consult (referral) appointment scheduling
practices. It examined delays for patients with serious health
conditions who received community care through referrals from the VA
Western New York Healthcare System in Buffalo.\3\ The OIG found the
system's community care staff did not timely schedule patients'
radiation therapy and neurosurgery appointments, which resulted in
delays in providing care and, in some cases, caused or increased the
risk of patient harm. In particular, had there not been the delay in
scheduling, and eventual cancellation of community care radiation
therapy to treat a patient's cancer-related pain, efforts could have
been made to alleviate that pain and improve the quality of life in the
patient's final months. The Buffalo healthcare system and its community
care leaders did not resolve the scheduling delays, despite advocacy by
care providers and staff. The OIG found healthcare system leaders
relied on inaccurate assurances from their community care managers that
urgent, high-risk patient care consults were reviewed and prioritized,
even as they received ongoing alerts about care concerns regarding
those patients. The healthcare system and community care leaders'
inactions were inconsistent with VA's stated commitment to the
principles and values of high reliability organizations, as they failed
to consistently focus on patients, get to the root causes of concerns,
and predict and eliminate risks before causing patient harm. The OIG
made two recommendations to the Veterans Integrated Service Network
(VISN) director related to the healthcare system leaders' response to
patient concerns and oversight of community care; and two
recommendations to the Buffalo system's director related to
establishing community care policies aligned with Veterans Health
Administration (VHA) standards, as well as the disclosure of an adverse
event (which has now been completed).\4\
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\3\ VA OIG, Leaders Failed to Address Community Care Consult Delays
Despite Staff's Advocacy Efforts at VA Western New York Healthcare
System in Buffalo, September 27, 2024.
\4\ VA has 18 VISNs across the nation--a regional network of care
in which each VISN oversees VHA local healthcare facilities in their
assigned area. An adverse event disclosure happens when a healthcare
provider informs a patient or their family when a medical error or
unexpected complication occurs during treatment that resulted in harm.
---------------------------------------------------------------------------
Following an OIG analysis of VHA data, our healthcare inspectors
reviewed the VA Loma Linda (California) Healthcare System's high use of
community care providers for primary care, the impact, and system
leaders' related oversight of VA outpatient clinics.\5\ The OIG found
that a new contractor responsible for the healthcare system's five non-
VHA-operated community-based outpatient clinics experienced challenges
staffing them. As a result, system leaders paused enrollment of new
patients at all five of these clinics. VHA-operated clinics were unable
to absorb the additional patients leading to an increase in the
system's use of community care providers for primary care. Further, the
system's community care office was not able to timely process the
consults and schedule community appointments. The OIG did not identify
any patients who experienced poor outcomes as a result. However, the
lack of a formal oversight structure for non-VHA-operated clinics,
turnover in the system's leadership positions, and the new contractor
together created a vulnerability in the management of primary care
services provided at the system's clinics. The OIG's three
recommendations to the system director are unimplemented at this time.
They focus on monitoring primary care staffing and panel sizes (the
number of patients assigned), timeliness of community care consult
processing, and oversight of all the system's clinics.
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\5\ VA OIG, Increased Utilization of Primary Care in the Community
by the VA Loma Linda Healthcare System in California, April 23, 2024
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ADEQUATE AND QUALIFIED STAFFING TO CARRY OUT DUTIES
Historically, VA has faced high vacancy rates across its programs
and operations, especially within VHA. Shortages of qualified personnel
in key positions have made it difficult for VA to carry out its goals
and functions. Having the right people in the right positions committed
to doing the right thing is essential to building workforce
accountability, as is instilling that sense of responsibility in new
hires.
As for persistent shortages, VA is not alone. Medical systems
across the country are facing challenges in finding and retaining
qualified personnel. The OIG is required by law to annually identify
clinical and nonclinical VHA occupations with the largest staffing
shortages within each VHA medical center.\6\ The FY 2024 review, the
11th and most recent that the OIG has conducted, found that 137 of 139
surveyed VHA facilities reported at least one severe occupational
staffing shortage.\7\ The total number of their reported severe
shortages was 2,959, a 5% decrease from FY 2023, when facilities
reported 3,118 total shortage occupations. Every year since 2014, the
medical officer and nurse occupations have been identified as severe
shortages, with the designations of medical officer as a severe
occupational shortage generally decreasing since FY 2018. Following
staffing increases in FYs 2022 and 2023, the nurse occupation was
reported as a shortage by fewer facilities in FY 2024. Psychology was
the most frequently reported clinical severe occupational staffing
shortage in FY 2024, by 61% of facilities (85 of 139). Facilities also
reported custodial worker and medical support assistance as the most
frequent nonclinical shortage occupations, the same as for FYs 2022 and
2023.
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\6\ VA Choice and Quality Employment Act, Pub. L. No. 115-46, 131
Stat. 958 (2017).
\7\ VA OIG, OIG Determination of Veterans Health Administration's
Occupational Staffing Shortages Fiscal Year 2024, August 7, 2024.
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An OIG review published last week highlights the impacts of
insufficient staffing and hiring delays at the Joseph Maxwell Cleland
Atlanta VA Medical Center's contact center for appointment scheduling.
Callers experienced long hold times that led to abandoned phone
calls.\8\ Significantly, the facility's leaders were not attentive to
concerning call center performance metrics, such as wait times and
abandonment rates. The report also identified that the VISN had not
been using available data to determine if its own call center was
properly staffed.
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\8\ VA OIG, Atlanta Call Center Staffing and Operational
Challenges Provide Lessons for the New VISN 7 Clinical Contact Center,
January 30, 2025. The three recommendations to the VISN director and
the recommendation to the facility director are not yet implemented.
The OIG will begin to follow up with VBA for progress on the
recommendation's implementation on or about May 1, 2025. At quarterly
intervals commencing 90 calendar days from the date of the report's
issuance, the OIG sends a follow-up request to the VA office overseeing
corrective action asking for an implementation status report. The OIG
follow-up staff provides VA with 30 calendar days to respond. Nothing
precludes VA from providing interim progress reports.
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In addition to addressing staffing shortages, VA should also ensure
its existing personnel are equipped and prepared to do their jobs. The
OIG has published numerous reviews over the last few years that
examined whether staff at the Veterans Benefits Administration (VBA)
were sufficiently trained for their duties.\9\ For example, VBA uses
the VA Schedule for Rating Disabilities (the rating schedule) to
determine monthly compensation to eligible veterans for service-
connected disabilities based on documented medical severity. In 2021,
updates were made to the rating schedule for the musculoskeletal body
system. The OIG performed a review to assess the effectiveness of VBA's
implementation of the rating schedule changes for hip and knee
replacements. The report on the review's findings, published in
February 2024, found an estimated 38% of claims had an improper payment
during the review period.\10\ VBA paid an estimated $3.3 million in
total improper payments for hip and knee replacement claims during that
same period--including both underpayments and overpayments for these
claims.VBA concurred with the OIG's four recommendations.\11\ VBA has
since provided sufficient documentation for the OIG to close its
recommendations to supplement training on the rating schedule updates,
including how to apply the changes to help ensure claims processors'
comprehension.
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\9\ See, e.g., VA OIG, Rating Schedule Updates for Hip and Knee
Replacement Benefits Were Not Consistently Applied, February 21, 2024;
VA OIG, VBA Needs to Improve Accuracy of Decisions for Total Disability
Based on Individual Unemployability, July 17, 2024; VA OIG, Veterans
Are Still Being Required to Attend Unwarranted Medical Reexaminations
for Disability Benefits, March 16, 2023; VA OIG, VBA Could Improve the
Accuracy and Completeness of Medical Opinion Requests for Veterans'
Disability Benefits Claims, September 7, 2022.
\10\ VA OIG, Rating Schedule Updates for Hip and Knee Replacement
Benefits Were Not Consistently Applied, February 21, 2024. The OIG team
reviewed a random sample of 112 in-scope claims from a universe of
about 3,200 claims for convalescence for hip or knee replacements or
resurfacing, received and decided from February 7, 2021, through August
31, 2022.
\11\ There were two other recommendations that address issues
unrelated to quality assurance and training.
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The importance of a well-trained workforce to implementing VA's
major initiatives cannot be overstated. Signed into law in August 2022,
the PACT Act dramatically expanded access to VA health care and
benefits for millions of veterans exposed to toxic substances.\12\ The
OIG assessed whether VBA staff processed PACT Act claims for
presumptive disabilities in accordance with applicable laws and
procedures before denying them--recognizing the potential impact on
eligible veterans if claims were improperly denied. The OIG review team
found errors resulting in unnecessary payments for examinations and
medical opinions, as well as underpayments to veterans. A VBA leader
told the OIG team that some claims processors said that information
came at them quickly and there were too many changes. They further
stated the implementation of PACT Act legislation was very challenging,
but VBA did the best it could given the circumstances. In an interview,
the former Compensation Service quality assurance rating review chief
stated PACT Act guidance changed repeatedly after the initial rollout.
Further, the chief stated VBA hired many new employees to process the
most complex claims, which, combined with the changing guidance, may
have caused confusion when regional office staff were working these
claims and resulted in errors. VBA concurred with the OIG's two
recommendations to update the claims processing manual to clarify when
examinations and medical opinions are needed and to continue to develop
tools to aid claims processors in determining when they are needed and
to evaluate their effectiveness. The OIG has issued other reports on
implementation of the PACT Act and will continue to monitor VA's
implementation of the legislation.\13\
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\12\ Sergeant First Class Heath Robinson Honoring our Promise to
Address Comprehensive Toxics (PACT) Act of 2022, Pub. L. No. 117-168.
\13\ VA OIG, VBA Provided Accurate Training on Processing PACT Act
Claims but Did Not Fully Evaluate Its Effectiveness, January 15, 2025;
VA OIG, Staff Incorrectly Processed Claims When Denying Veterans'
Benefits for Presumptive Disabilities Under the PACT Act, December 3,
2024.
EFFECTIVE IT SYSTEMS AND BUSINESS PROCESSES TO SUPPORT QUALITY HEALTH
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CARE, ACCURATE AND TIMELY BENEFITS, AND EFFICIENT OPERATIONS
VA is modernizing numerous significant systems that are critical to
its operations. However, as detailed in multiple proactive reports, the
OIG identified breakdowns with upgrading or replacing key systems that
support patient care, supply management, benefits to veterans and their
families, and the stewardship of taxpayer dollars. VA's process for
replacing crucial IT systems faces significant ongoing challenges.
These have typically included weaknesses in planning, insufficient
stakeholder engagement, failures to promptly fix known issues, and
program management or coordination deficiencies. The results have been
long delays, billions of dollars in over-budget costs, low user
acceptance, and gaps in functionalities that make it more difficult for
VA personnel to do their jobs. In some cases, the modernization efforts
have put patients, beneficiaries, and resources at greater risk for
harm or loss. The OIG understands the tremendous complexity of these
efforts and continues to provide recommendations that are as practical
and actionable as possible to support VA personnel working to ensure
patient safety and to deliver benefits and services to eligible
veterans, their families, caregivers, and survivors.
The Electronic Health Record Modernization (EHRM) program is
probably the largest contract in VA history and critical to continued
patient safety and care at VHA. Since April 2020, the OIG has released
22 oversight publications on VA's rollout of its electronic health
record system that identify critical missteps and lack of
remediation.\14\ Of the 93 recommendations issued to date, 32 have not
yet been implemented--with eight open for more than three years. The
open recommendations include VA minimizing the number of required
mitigation strategies healthcare providers must use when the system
goes live, determining whether veterans' appointments are being
scheduled correctly, and addressing unresolved issues that could hinder
the system from resolving major performance incidents and outages.
Unless VA more effectively manages all affected offices and
contractors, IT solutions will continue to be delayed, more cost
overruns will occur, and the risk to patients and VA operations will
increase.
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\14\ OIG reports may be found on the website at All Reports. A list
of EHRM reports can be found by searching on the key word ``EHRM''.
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Although VA lifted the June 2022 EHRM rollout pause, users of the
new system continue to raise issues that the system hinders the
delivery of prompt, high-quality patient care. Moreover, VA has not
adequately addressed open OIG recommendations focused on the need to
develop a reliable, high-quality schedule for future rollouts, in
addition to the many other open EHRM recommendations. The effects on
staff, workload, and the risks for errors are also concerning. In March
2024, the OIG reported that an error in the system led Columbus (Ohio)
facility staff to not complete the minimum scheduling efforts following
a missed appointment for a patient who later died by drug overdose.\15\
The OIG team determined that for sites using the new electronic health
record system, VHA required fewer patient contact attempts following
missed mental health appointments. Essential to implementing and
budgeting this multibillion-dollar effort, VA needs a high-quality,
reliable, integrated master schedule to ensure all tasks are properly
accounted for and fully completed. A 2022 OIG audit found, however,
that this foundational master schedule had significant weaknesses,
including missing tasks, no baseline schedule, and no risk analyses,
meaning VA cannot offer reliable assurances on timelines and costs.\16\
That schedule has still not been completed at this time. The OIG will
continue to conduct oversight on VA's plan to begin deployment
operations next year in Michigan.
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\15\ VA OIG, Scheduling Error of the New Electronic Health Record
and Inadequate Mental Health Care at the VA Central Ohio Healthcare
System in Columbus Contributed to a Patient Death, March 21, 2024.
\16\ VA OIG, The Electronic Health Record Modernization Program Did
Not Fully Meet the Standards for a High-Quality, Reliable Schedule,
April 25, 2022.
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VA's delivery of education benefits to veterans is also tied to a
new IT system. In 2024, the OIG reported on VBA's delays and increased
costs in transitioning to the Digital GI Bill platform.\17\ Unclear
contract requirements and unrealistic expectations led to delays. In
addition, the project's integrated master schedule was not updated
consistently due to the lack of an overall schedule that tracked
external dependencies. Poor communication between VBA and the
contractor contributed to critical scheduling failures that caused
delays and increased costs. VBA later renegotiated the original
contract, more than doubling the cost to $932 million. The OIG made
three recommendations, all as yet unimplemented, to the then under
secretary for benefits to increase the chances of successful
implementation under the new contract through improved monitoring,
regular communication with the contractor to ensure a consistent and
updated master schedule, and strategies to address critical path
failures.
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\17\ VA OIG, VBA Needs to Improve Oversight of the Digital GI Bill
Platform, August 28, 2024.
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There are many other IT modernization efforts that are also
interdependent and have had significant stalls, setbacks, or stops.
These include financial and supply chain management--also the subject
of myriad OIG oversight reports.
EFFECTIVE QUALITY ASSURANCE AND MONITORING TO DETECT AND RESOLVE ISSUES
VA often lacks controls that adequately and consistently ensure
quality standards are met. Breakdowns in routine monitoring and the
continual use of work-arounds undermine efforts to provide timely,
high-quality services and benefits to eligible veterans and their
families. Ineffective quality assurance and monitoring relate not just
to systems and processes, but to personnel as well--particularly in
areas such as personnel suitability programs, credentialing,
privileging, and monitoring of healthcare professionals entrusted with
veterans' care.\18\
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\18\ In March 2018, the OIG reported on deficiencies within the VHA
personnel suitability program, concluding that neither VA nor VHA
effectively governed the background investigation process to ensure
requirements were met at medical facilities nationwide. VA OIG, Audit
of the Personnel Suitability Program, March 26, 2018. In September
2023, the OIG reported on similar deficiencies during a follow-up audit
of VHA's personnel suitability program. VA OIG, VA's Governance of Its
Personnel Suitability Program for Medical Facilities Continues to Need
Improvement, September 21, 2023. These prior audits identified issues
that could affect the entire VA enterprise, prompting the OIG to audit
the background investigation process for VBA and the National Cemetery
Administration staff and determine whether investigation actions were
completed on time and recorded reliably. The OIG determined there were
problems at every step of the process, making four recommendations, all
still open, to the under secretaries of benefits and memorial affairs.
VA OIG, VBA's and NCA's Personnel Suitability Programs Need Improved
Governance, September 30, 2024.
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In September 2024, the OIG testified to this subcommittee and its
full committee about issues at the Hampton VA Medical Center in
Virginia.\19\ For each of the last three years (2022-2024), the OIG
published healthcare inspections of the Hampton facility that
substantiated concerns related to clinical care.\20\ In the most recent
2024 report, there were unaddressed clinical care concerns involving
the facility's then assistant chief of surgery.\21\ The facility
leaders at the time mishandled the processes for professional practice
evaluations of surgeons, the surgical service's quality management, and
institutional disclosures to patients or their representatives of an
adverse event that resulted in harm. Facility leaders made numerous
errors when determining whether changes were needed to the assistant
chief of surgery's clinical privileges.\22\ Leaders also did not report
the assistant chief to the state licensing board. Failing to report
providers may result in medical facilities within and outside of VHA
hiring providers who do not meet generally accepted standards of
clinical practice. These leaders also lacked a basic understanding of
the quality assurance processes that support the delivery of safe
health care. These three reports collectively uncovered issues with
care coordination, communication, quality of care, administrative and
clinical oversight, quality assurance, and overall employee engagement.
The identified deficiencies contributed to increased risks to patient
safety and adverse outcomes.
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\19\ VA OIG, Statement of Inspector General Michael J. Missal
before the House Committee on Veterans' Affairs, September 10, 2024; VA
OIG, Statement of Jennifer Baptiste, MD, before the House Committee on
Veterans Affairs, September 24, 2024.
\20\ VA OIG, Multiple Failures in Test Results Follow-up for a
Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center
in Virginia, June 28, 2022 (multiple healthcare providers did not
appropriately manage abnormal test results for this patient and staff
and leaders did not initiate or submit patient safety reports or peer
reviews); VA OIG, Delay in Diagnosis and Treatment for a Patient with a
New Lung Mass at the Hampton VA Medical Center in Virginia, September
29, 2023 (facility leaders were unaware until the OIG inspection and
the facility lacked oncology care controls due to missing/ineffective
cancer committee, tumor board, and cancer registry); VA OIG, Mismanaged
Surgical Privileging Actions and Deficient Surgical Service Quality
Management Processes at the Hampton VA Medical Center in Virginia, July
23, 2024.
\21\ VA OIG, Mismanaged Surgical Privileging Actions and Deficient
Surgical Service Quality Management Processes at the Hampton VA Medical
Center in Virginia, July 23, 2024.
\22\ Clinical privileging is defined as the process by which a VA
facility authorizes a physician to independently (i.e., without
supervision or restriction) provide healthcare services on a facility-
specific basis. Clinical privileges are based on the individual's
clinical competence as determined by peer references, professional
experience, health status, education, training, and licensure.
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In their oversight work, what OIG healthcare inspectors find most
troubling is when facility managers and leaders are either unaware of
personnel and patient concerns or do not ensure the required quality
management processes are carried out that would detect and correct
them. High reliability organization principles foster a culture of
``collective mindfulness,'' in which all staff look for and report
small problems or unsafe conditions before they pose a substantial
risk. If leaders are not aware of concerning singular events or more
systemic challenges, they cannot ensure the appropriate steps are taken
to safeguard patients. Implementing quality improvements to address
specific patient safety issues requires open and honest communication
from, and among, staff at every level of a facility.
LEADERSHIP THAT FOSTERS RESPONSIBILITY FOR ACTIONS AND CONTINUOUS
IMPROVEMENT
The OIG published a report that was featured in congressional
hearings and the national media on senior executives in VA's central
office being improperly awarded $10.8 million in critical skills
incentives authorized by the PACT Act. It uncovered weaknesses in VA's
governance, leadership, and accountability, with excessive deference to
both VHA and VBA leaders by individuals responsible for providing
necessary checks and balances.\23\ The PACT Act authorized VA to award
critical skill incentives to only those staff who possessed a high-
demand skill or skill that is at a shortage. As detailed in OIG
testimony before this committee in June, officials at multiple levels
across VA did not ensure their actions met the requirements and intent
of the law and did not successfully escalate concerns to then Secretary
McDonough.\24\ VA concurred with the OIG findings that the awards were
inconsistent with the PACT Act and VA policy and that VA's internal
controls were ineffective to prevent the improper awards. The OIG
continues to monitor VA's progress in implementing these
recommendations until sufficient evidence is provided to enable
closure.
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\23\ VA OIG, VA Improperly Awarded $10.8 Million in Incentives to
Central Office Senior Executives, May 9, 2024.
\24\ VA OIG, Statement of Inspector General Michael J. Missal
before the House Committee on Veterans' Affairs, June 4, 2024.
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Other oversight work has revealed that VA leaders at every level
often do not get the information they need to make effective decisions.
Some also do not take necessary and prompt action, while others
struggle to create a workplace in which every employee feels they can
and should report problems. The frequent turnover in key positions or
the long-term use of acting positions exacerbates these challenges.
In 2024, the OIG released three reports on the VA medical facility
in Aurora, Colorado, also describing the kind of accountability
failures that every facility leader should be vigilant in preventing.
The OIG's first report found that key senior leaders created an
environment in which a significant number of clinical and
administrative service and section leaders and frontline staff felt
intimidated, deeply disrespected, and dismissed.\25\ For example, staff
feared that speaking up or offering a difference of opinion to the Peer
Review Committee would result in reprisal. In a second report, an OIG
team substantiated that leaders' actions to change the facility's
intensive care unit from an open to a closed model (affecting which
providers had patient care responsibility) were made without adequate
planning and input from relevant leaders and staff.\26\ These problems
were allowed to persist because VISN leaders did not fulfill their own
required oversight of the medical center.\27\ The third report found
that telemetry medical instrument technicians were not properly
monitoring patients and that staff did not properly enter a Joint
Patient Safety Report following a patient's death.\28\
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\25\ VA OIG, Leaders at the VA Eastern Colorado Health Care System
in Aurora Created an Environment That Undermined the Culture of Safety,
June 24, 2024. One of seven recommendations has been closed.
\26\ VA OIG, Extended Pause in Cardiac Surgeries and Leaders'
Inadequate Planning of Intensive Care Unit Change and Negative Impact
on Resident Education at the VA Eastern Colorado Health Care System in
Aurora, June 24, 2024. All recommendations remain open.
\27\ VA administers healthcare services through a nationwide
network of 18 regional systems referred to as Veterans Integrated
Service Networks that oversee the medical facilities in their
designated area.
\28\ VA OIG, Failures by Telemetry Medical Instrument Technicians
and Leaders' Response at the VA Eastern Colorado Health Care System in
Aurora, August 13, 2024. Five of the six recommendations remain open.
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As to work that is forthcoming that illustrates the OIG's
commitment to enhancing VA accountability, OIG teams are finishing work
on the conditions and contributing factors to the FY 2024 supplemental
request by VBA and the multibillion dollar shortfall in VHA's budget
for FY 2025.\29\ In accordance with the governing statute, the OIG will
publish these reviews before March 19, 2025.\30\ VA's ability to
accurately forecast its administration and staff office budgets, and
then properly execute appropriated funds, is dependent on adhering to
the foundational elements of accountability.
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\29\ According to the budget submission dated March 2024, VHA
initially estimated needing about $149.5 billion to care for patients
in fiscal year (FY) 2025. However, by July 2024, VHA estimated that it
would need an additional $12 billion in FY 2025 for medical care. By
November, that request was modified to $6.6 billion.
\30\ The Veterans Benefits Continuity and Accountability
Supplemental Appropriations Act, 2024, Pub. L. No. 118-92 Sec. 104.
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CONCLUSION
The OIG has experienced that the overwhelming number of VA leaders
and personnel are committed to serving veterans, their families, and
caregivers, as well as answering the call for assistance from their
local communities in times of crisis. They often have to navigate
obstacles and overcome challenges to make certain that patients receive
prompt high-quality care and that veterans and other eligible
beneficiaries receive the compensation and services they are owed.
Unfortunately, the OIG has found that VA has struggled with the
foundations of accountability, including strong governance and clarity
of roles and responsibilities; adequate and qualified staffing; updated
IT systems and effectual business processes; effective quality
assurance and monitoring; and leadership that fosters responsibility
for actions and continuous improvement. The OIG strongly encourages VA
personnel at every level to lead by example and escalate matters that
put veterans' health and welfare at risk, undermine VA's services and
operations, or waste taxpayer dollars.
Chairwoman Kiggans, Ranking Member Ramirez, and members of the
Subcommittee, this concludes my statement. The OIG looks forward to
working with you and this Congress to advance VA's delivery of care and
services to veterans, their families, and caregivers. I would be happy
to answer any questions you may have.
______
Prepared Statement of Donald Sherman
Chairwoman Kiggans, Ranking Member Ramirez, and members of the
Subcommittee, thank you for the opportunity to testify regarding
accountability at the U.S. Department of Veterans Affairs (VA).
The Department of Veterans Affairs is a large agency with a
similarly large and important mission. The care, benefits and support
veterans receive through the VA is the fulfillment of a promise that
our nation makes, and must continue to make, to those who serve and
protect our country. My family includes veterans who served in World
War II, the Korean War and in the Marines as well as the Army. My
grandfather proudly worked for many years at the VA in his hometown of
Tuskegee, Alabama, made famous by the Tuskegee Airman. On behalf of
myself and my organization, Citizens for Responsibility and Ethics in
Washington (CREW), I thank our nation's veterans and military families
for their service and sacrifice for our country.
In order to meet its critical mission, the VA plays many roles. It
is one of the largest federal agencies in the government with functions
including administering pensions, insurance and home loans for
veterans, providing survivor support for veterans' families and running
the Veterans Health Administration, the largest integrated healthcare
network in the United States. It is incumbent upon Congress and the
president to ensure that the VA does not falter in fulfilling its
mission. It is equally important to acknowledge that managing such
complex systems is a daunting task. It is therefore perhaps
unsurprising that the VA has experienced challenges across multiple
administrations, Republican and Democratic. The inherent risks and
challenges associated with operating a large agency make ensuring
robust oversight and accountability absolutely critical.
As the members of this Committee know well, the VA's Office of
Inspector General (OIG) has consistently played a key role in providing
oversight to help the VA fulfill its mission and to ferret out waste,
fraud and abuse in the agency. For decades under both Republican and
Democratic administrations, the OIG has issued numerous reports and
recommendations to improve the VA's operations, including 189 open VA
OIG reports in 2020 during the final year of President Trump's first
term and 197 open VA OIG reports in 2016 during the final year of
President Obama's administration.\1\
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\1\ Department of Veterans Affairs Office of Inspector General,
Semiannual Report to Congress Issue 76 (Apr. 1, 2016 to Sept. 30,
2016), https://www.vaoig.gov/sites/default/files/document/2023-08/
VAOIG-SAR-2016-2.pdf; Department of Veterans Affairs Office of
Inspector General, Semiannual Report to Congress Issue 84 (Apr. 1, 2020
to Sept. 30, 2020), https://www.vaoig.gov/sites/default/files/document/
2023-08/vaoig-sar-2020-2.pdf).
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Inspector General (IG) Michael Missal led VA OIG for more than
eight years.\2\ Mr. Missal was confirmed by the Senate in April 2016
after being favorably voted out of the Republican led Senate Veterans'
Affairs Committee and unanimously voted out of the Republican led
Senate Homeland Security and Governmental Affairs Committee.\3\ Mr.
Missal's confirmation was ``urge[d]'' by Chairman Ron Johnson so that
the VA OIG could have ``permanent, independent leadership.'' \4\ The
Chairman of the House Veterans' Affairs Committee at the time, Rep.
Jeff Miller, expressed relief at Mr. Missal's confirmation, saying that
he was ``glad'' that the Senate ``finally confirmed a permanent''
IG.\5\
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\2\ Council of the Inspectors General on Integrity and Efficiency
(CIGIE), Inspector General Historical Data (July 25, 2017) https://
www.ignet.gov/sites/default/files/files/IG%20History%20(PAS)%20-%207-
25-17.pdf; Department of Veterans Affairs, Staff Biographies: Inspector
General Michael J. Missal (last accessed Feb. 4, 2025) https://
department.va.gov/staff-biographies/michael-j-missal/.
\3\ PN897, 114th Cong. (2016), https://www.Congress.gov/nomination/
114th-congress/897; Council of the Inspectors General on Integrity and
Efficiency (CIGIE), Inspector General Historical Data, (July 25, 2017)
https://www.ignet.gov/sites/default/files/files/
IG%20History%20(PAS)%20-%207-25-17.pdf; Department of Veterans Affairs,
Staff Biographies: Inspector General Michael J. Missal (last accessed
Feb. 4, 2025) https://department.va.gov/staff-biographies/michael-j-
missal/.
\4\ Press Release, Senate HSGAC, Johnson, Committee Unanimously
Approve Michael Missal For VA Inspector General, Jan. 21, 2016 https://
www.hsgac.senate.gov/media/reps/johnson-committee-unanimously approve-
michael-missal-for-va-inspector-general/.
\5\ Press Release, House Veterans' Affairs Committee, Miller
Statement on Senate Confirmation of VA Inspector General, Apr. 20,
2016, https://veterans.house.gov/news/
documentsingle.aspx?DocumentID=876.
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In fiscal year 2024 alone, former VA Inspector General Missal's
office issued ``a total of 316 reports and 1,106 recommendations'' and
made a monetary impact of nearly $6.8 billion amounting to ``a return
on investment of $28:1'' for every dollar spent on the inspector
general's oversight.\6\ And those savings still pale in comparison to
the extraordinary work that VA OIG did to address veteran suicides and
improve health outcomes for veterans and military families throughout
the many years of Mr. Missal's leadership of the office.\7\ That impact
is priceless. Inspector General Missal's leadership of OIG garnered
bipartisan approval for independent and vigorous oversight of the
agency across the Obama, Trump and Biden administrations.\8\ As the
Military Times noted, Mr. Missal released numerous reports critical of
VA officials during President Trump's first term as well as President
Biden's term in office.\9\
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\6\ Department of Veterans Affairs Office of Inspector General,
Semiannual Report to Congress Issue 92 (Apr. 1, 2024 to Sept. 30, 2024
https://www.vaoig.gov/sites/default/files/document/2024-11/
semiannual_report_to_congress_issue_92.pdf.
\7\ Department of Veteran Office of Inspector General, September
2024 Highlights (Sept. 24, 2024) https://www.vaoig.gov/sites/default/
files/document/2024-10/monthly_highlights_september_2024.pdf.
\8\ See e.g., @SenatorTester, X (Feb. 16, 2022, 5:47 PM), https://
x.com/SenatorTester/status/1494081013940641793; Press Release, Boozman,
Hassan Introduce Bipartisan Legislation Requiring Mandatory
Whistleblower Training for VA Employees, Office of Senator John Boozman
(July 23, 2021) https://www.boozman.senate.gov/public/index.cfm/2021/7/
boozman-hassan-introduce-bipartisan-legislation-requiring-mandatory-
whistleblower-training-for-va-employees; @SenCapito, X (July 31, 2020,
1:32 PM), https://x.com/SenCapito/status/1289252668695748609; and Press
Release, Inspector General to Investigate Reports of ``Wait Lists'' at
Colorado VA Facility, Senate HSGAC (Oct. 16, 2020), https://
www.hsgac.senate.gov/media/reps/inspector-general-to-investigate-
reports-of-wait-lists-at-colorado-v a-facility/.
\9\ Leo Shane III, VA, DOD oversight questioned after Trump
inspector general firings, Military Times (Jan. 27, 2025), https://
www.militarytimes.com/news/pentagon-congress/2025/01/27/va-dod-
oversight-questioned-after-trump-inspector-general-firings/.
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Despite that staggering impact, Mr. Missal is not here today to
testify about his oversight of the VA OIG during President Biden's
tenure because President Trump unceremoniously fired him last month
along with more than a dozen other independent agency inspectors
general.\10\ The firing of IG Missal came just days after Chairman of
the Senate Committee on Veterans' Affairs Jerry Moran stated: ``We work
closely with the inspector general at VA... I find him valuable both to
me and to this committee, and he should be valuable to the Department
of Veterans Affairs.'' \11\
---------------------------------------------------------------------------
\10\ Id.
\11\ Id.
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Although it is beyond my expertise to opine on the state of VA's
mission-specific operations, the mere existence of these reports
highlights the value of robust oversight to ensure accountability at
the VA. Without the work of the inspector general and the cooperation
of past administrations, the waste, fraud, abuse and operational
challenges identified in some of these reports and recommendations may
never have come to light. And the efforts that administrations have
taken to implement and correct these recommendations to better support
our nation's veterans and military families likely would never have
been possible. That includes efforts to address over 266,000 reports of
potential wrongdoing, waste, abuse or inefficiencies received through
the VA OIG hotline over the last eight fiscal years covering the Trump
and Biden administrations.\12\ During the first Trump and Biden
administrations combined, the VA OIG's work resulted in cost savings
with an estimated total monetary impact of over $40 billion.\13\
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\12\ These figures were calculated by CREW using reports available
at ``All Reports,'' Department of Veterans Affairs Office of Inspector
General, https://www.vaoig.gov/reports/all.
\13\ Id.
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Inspectors general are critical to improving government agencies'
efficiency in serving the American public and investigating fraud. In
the nearly 50 years since the first inspector general positions were
established, these officials have provided critical independent
oversight that improved the integrity of our government. Crucially,
inspector general terms were not designed to be tied to that of the
president, because they provide oversight and accountability regardless
of political party or who sits in the Oval Office. I am proud to have
worked cooperatively with inspectors general and their staff during my
tenure in the House, Senate and executive branch. At a time when there
is a low global trust in government, the role of inspectors general is
more important than ever to rebuild and strengthen that public
trust.\14\ Under both Presidents Trump and Biden, CREW has consistently
pressed for Inspector General vacancies to be filled and advocated for
strong independent oversight of federal departments and agencies.\15\
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\14\ OECD Survey on Drivers of Trust in Public Institutions - 2024
Results: Building Trust in a Complex Policy Environment, OECD, July 12,
2024, https://doi.org/10.1787/9a20554b-en.
\15\ President Biden should fill vacant inspector general and
ethics roles, CREW (Aug. 7, 2024), https://www.citizensforethics.org/
legal-action/letters/president-biden-should-fill-vacant-inspector-
general-an d-ethics-roles/; Donald K. Sherman, 12 Federal agencies
still do not have permanent inspectors general, CREW (Sept. 23, 2020,
https://www.citizensforethics.org/reports-investigations/crew-
investigations/12-inspector-general-vacancies/.
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During President Trump's first term, my organization identified at
least 25 actions taken by him to undermine the inspector general
community, including firing two permanent IGs, removing three acting
IGs without any clear justification and appointing four IGs to dual
roles thus limiting their ability operate independently - a critical
aspect of the IG role.\16\ During his first term, President Trump also
suggested that he would prevent the Special Inspector General for
Pandemic Recovery from communicating with Congress about administration
misconduct and obstruction, thus attempting to stifle Congress'
constitutional oversight role.\17\ These attempts to politicize IG
offices undermined their independence, thus hindering their ability to
identify waste, fraud and abuse. They were rightfully condemned by
lawmakers on both sides of the aisle.\18\
---------------------------------------------------------------------------
\16\ Donald K. Sherman, Trump's war on watchdogs and what Congress
can do about it, Citizens for Responsibility and Ethics In Washington
(June 15, 2020), https://www.citizensforethics.org/reports-
investigations/crew-reports/trumps-war-on-watchdogs-and-what-congress-
can-do-about-it/.
\17\ Charlie Savage, Trump Suggests He Can Gag Inspector General
for Stimulus Bailout Program, The New York Times (Mar. 27, 2020),
https://www.nytimes.com/2020/03/27/us/trump-signing-statement-
coronavirus.html.
\18\ Press Release, Grassley Leads Bipartisan Call to Safeguard
Inspector General Independence Following ICIG Removal (Apr. 8,
2020),https://www.grassley.senate.gov/news/news-releases/grassley-
leads-bipartisan-call-safeguard-inspector-general-independence-
following; Alexander Bolton and Laura Kelly, Senate Republicans demand
answers from Trump on IG firing, The Hill (May 18, 2020), https://
thehill.com/homenews/senate/498425-senate-republicans-demand-answers-
from-trump-on-ig-firing/.
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Also critical to the mission of providing excellent care for our
nation's veterans is the support of a strong, well-trained and
experienced civil service to carry out the important mission of the
department. Supporting veterans through the implementation of federal
programs requires agencies to be staffed by individuals with a thorough
understanding of statutory and regulatory schemes, institutional
knowledge of the history of the programs, familiarity with relevant
stakeholders inside and outside government, and substantial technical
expertise. That is what the career civil service provides. Sometimes
lost in the discussion about the civil service is that veterans make up
30% of the federal civilian workforce,\19\ 53% of whom are
disabled.\20\ Attacks on the federal civil service is an attack on
veterans. Right now, veteran unemployment stands at 2.8%, but that
number could rise with efforts to weaken civil service protections and
reduce the size of the federal workforce.\21\
---------------------------------------------------------------------------
\19\ Office of Personnel Management, Employment of Veterans in the
Federal Executive Branch (Fiscal Year 2021), https://www.opm.gov/
fedshirevets/hiring-officials/ved-fy21.pdf.
\20\ Id.
\21\ Department of Labor, Veteran Unemployment Rates (Jan. 10,
2025), https://www.dol.gov/agencies/vets/latest-numbers.
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Our merit-based system is critical to the government's ability to
continue operating effectively, and is thus crucial to the protection
of the health and welfare of America's veterans. The merit-based civil
service system was created to replace its predecessor, the spoils
system, under which, politicians would put in place political cronies
\22\ who often lacked the knowledge or expertise to fulfill their jobs
in positions of power.
---------------------------------------------------------------------------
\22\ See ``Spoils System,'' Encyclopedia.com; Machine Politics,
PBS, https://www.pbs.org/wgbh/americanexperience/features/presidents-
unity-garfield/; Gabe Lezra and Diamond Brown, FAQ: The conservative
attack on the merit-based civil service, CREW (Jan. 25, 2024), https://
www.citizensforethics.org/news/analysis/faq-the-conservative-attack-on-
the-merit-based-civil-service/.
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The first Trump administration sought to upend the merit-based
civil service by implementing an executive order referred to as
``Schedule F,'' which would have stripped employment protections away
from thousands of career civil servants. Had Schedule F not been
rescinded, independent civil servants could have been replaced with
political loyalists who likely would have prioritized blind obedience
over following the law, leading to a government more prone to
corruption.
During President Trump's first term in office, the VA was
specifically targeted by efforts to upend the civil service. In 2017,
President Trump signed the VA Accountability and Whistleblower
Protection Act into law.\23\ Although the bill was ostensibly aimed at
making it easier to remove government managers, in actuality the law
was used to target low-level workers and retaliate against
whistleblowers.\24\ Between June 2017 (the month the bill was passed)
and March 2018, 1,700 low level VA employees were removed from their
positions, including housekeepers and food service workers, many of
whom may have been veterans themselves.\25\ An investigation by
ProPublica found that whistleblowers and people who had filed
discrimination complaints were among those fired. In 2018, the VA OIG
reported significant staff shortages in the Veterans Health
Administration, with high staff turnover being one of the top causes of
the shortages.\26\ These firings were so egregious that the VA paid
roughly $134 million to the 1,700 former VA employees who had been
wrongfully fired as part of a settlement it reached with the American
Federation of Government Employees.\27\ Yet, despite this successful
legal challenge, the Trump administration and its allies indicated that
the VA's system should be replicated across all federal agencies.\28\
---------------------------------------------------------------------------
\23\ S. 1094, 115th Cong. (2017), https://www.Congress.gov/bill/
115th-congress/senate-bill/1094.
\24\ Jasper Craven, At the VA, a Law Meant to Discipline Executives
is Being Used to Fire Low-Level Workers, The Nation (May 10,
2018),https://www.thenation.com/article/archive/at-the-va-a-law-meant-
to-discipline-executives-is-being-used-to-fi re-low-level-workers/;
Department of Veterans Affairs Office of Inspector General, Failures
Implementing Aspects of the VA Accountability and Whistleblower
Protection Act of 2017 (Oct. 24, 2019), https://www.vaoig.gov/sites/
default/files/reports/2019-10/VAOIG-18-04968-249.pdf .
\25\ Jory Heckman, VA reinstated 100 employees fired under widely
challenged law, paid $134M to hundreds more, Federal News Network (Oct.
29, 2024),https://Federalnewsnetwork.com/workforce/2024/10/va-
reinstated-100-employees-fired-under-widely challenged-law-paid-134m-
to-hundreds-more/; Isaac Arnsdorf, The Trump Administration's Campaign
to Weaken Civil Service Ramps Up at the VA, ProPublica (Mar. 12,
2018),https://www.propublica.org/article/veterans-affairs-the-trump-
administration-campaign-to-weaken-civil-service-ramps-up; Craven, Supra
note 24.
\26\ Department of Veterans Affairs Office of Inspector General,
OIG Determination of Veterans Health Administration's Occupational
Staffing Shortages (FY2018), https://www.vaoig.gov/sites/default/files/
reports/2018-06/VAOIG-18-01693-196.pdf.
\27\ Heckman, supra note 25.
\28\ Arnsdorf, supra note 25.
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As unprecedented, damaging, and in some cases illegal, as President
Trump's actions were toward inspectors general and the civil service
during his first term, what we have seen unfold in recent days is on an
entirely different scale. If these attacks continue, they will harm all
Americans, including our veterans.
On the day President Trump was sworn in, he signed a series of
executive orders, including one essentially reinstating Schedule F.\29\
In a separate executive order, President Trump implemented an immediate
and broad hiring freeze across the government,\30\ reportedly causing
chaos for certain vacancies at the VA.\31\ VA employees and applicants
rightfully questioned the impact of the hiring freeze on vital care and
services provided by the VA.\32\
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\29\ Office of Personnel Management, Memorandum from Acting
Director Charles Ezell to Heads and Acting Heads of Departments and
Agencies on Guidance on Implementing President Trump's Executive Order,
Restoring Accountability To Policy-Influencing Positions Within the
Federal Workforce (Jan. 27, 2025), https://www.opm.gov/policy-data-
oversight/latest-memos/guidance-on-implementing-president-trump-s-
executive-order-titled-restoring-accountability-to-policy-influencing-
positions-within-the-federal-workforce.pdf
\30\ The White House, Executive Order entitled Hiring Freeze (Jan.
20, 2025), https://www.whitehouse.gov/presidential-actions/2025/01/
hiring-freeze/.
\31\ Jory Heckman, VA reinstates job offers to health care hires,
but some still in limbo amid hiring freeze, Federal News Network (Jan.
27, 2025),https://federalnewsnetwork.com/veterans-affairs/2025/01/va-
reinstates-job-offers-to-health-care-hires-but-some-still-in-limbo-
amid-hiring-freeze/.
\32\ Id.
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President Trump's broadside attack against the government hasn't
been limited to hiring - his administration is also taking aim at
across the board government funding, including funding for programs
that are designed to protect and support our veterans. Last week, the
Acting Director of the Office of Management and Budget issued a
memorandum, requiring every federal agency to pause ``all activities
related to obligation or disbursement of all Federal financial
assistance, and other relevant agency activities that may be implicated
by [President Trump's] executive orders.'' \33\ According to reports,
44 separate financial assistance programs related to veterans were
temporarily suspended while the department reviewed them to see if they
were in compliance with OMB's funding freeze.\34\ Although they were
exempted from the freeze after they were reviewed, those included
veterans' suicide prevention, homelessness, job training and nursing
home support programs.\35\ The memo, which was halted by two federal
court judges who heard legal challenges to the rule, was later
rescinded by the administration. In one of the judicial opinions, a
federal district court judge wrote, ``For many, the harms caused by the
freeze are non-speculative, impending, and potentially catastrophic.''
\36\
---------------------------------------------------------------------------
\33\ Memorandum from Matthew Vaeth to Heads of Executive
Departments and Agencies, Office of Management and Budget (Jan. 27,
2025),https://www.documentcloud.org/documents/25506361-omb-memo-on-
Federal-aid-freeze/.
\34\ Leo Shane III, VA benefits won't be halted under White House
funding freeze order, Military Times (Jan. 29, 2025), https://
www.militarytimes.com/news/pentagon-congress/2025/01/29/va-benefits-
wont-be-halted-under-white-house-funding-freeze-order/.
\35\ Id.
\36\ Lindsay Whitehurst, Judge in nation's capital extends block on
Trump administration federal funding freeze, AP News (Feb. 3,
2025),https://apnews.com/article/trump-federal-grants-loans-funding-
freeze-court-1bc457d8e333dd8a8f374572ea33 927c.
---------------------------------------------------------------------------
President Trump's actions aimed at the civil service have produced,
and will continue to cause, untold ripple effects across departments
and agencies which will likely lead to complications, waste and
opportunities for abuse. That is why oversight and accountability is
needed now more than ever. Yet, within his first week in office,
President Trump fired inspectors general and members of their staffs
across 17 different federal agencies, including VA Inspector General
Missal, who members of Congress from both sides of the aisle have
lauded for his oversight work during both Democratic and Republican
administrations.\37\
---------------------------------------------------------------------------
\37\ Campaign Legal Center., The Significance of Firing Inspectors
General: Explained (Jan.31, 2025) https://campaignlegal.org/update/
significance-firing-inspectors-general-explained; Leo Shane III, VA,
DOD oversight questioned after Trump inspector general firings,
Military Times (Jan. 27, 2025), https://www.militarytimes.com/news/
pentagon-congress/2025/01/27/va-dod-oversight-questioned-after-trump-
inspector-general-firings/; Fired Inspectors General Raise Alarms as
Trump Administration Moves to Finalize Purge, The New York Times (Jan.
27, 2025),https://www.nytimes.com/2025/01/27/us/politics/trump-
inspectors-general-fired.html); See e.g., VA, DOD oversight questioned
after Trump inspector general firings, Military Times (Jan. 27, 2025)
https://www.militarytimes.com/news/pentagon-congress/2025/01/27/va-dod-
oversight-questioned-after-trump-inspector-general-firings/; See e.g.,
House Committee on Veterans Affairs Minority, Press Release: Ranking
Member Takano's Statement on Trump's Late-Night Purge of 12 Inspectors
General (Jan. 25. 2025), https://democrats-veterans.house.gov/news/
press-releases/ranking-member-takanos-statement-on-trumps-late-night-
purge-of-12-inspectors-general.
---------------------------------------------------------------------------
President Trump defended the firing of the inspectors general,
saying that ``it's a very common thing to do.'' \38\ That is not the
truth. The only precedent for such a mass firing of IGs by an incoming
president after the passage of the Inspectors General Act of 1978 was
the firing of 15 IGs by President Ronald Reagan in 1981 - an act met by
strong disfavor, which was only eased when President Reagan renominated
several of the removed IGs.\39\
---------------------------------------------------------------------------
\38\ Manu Raju, Alayna Treene, Morgan Rimmer and Annie Grayer,
Trump fires inspectors general from more than a dozen federal agencies,
CNN (Jan. 25, 2025),https://www.cnn.com/2025/01/25/politics/trump-
fires-inspectors-general/index.html.
\39\ Congressional Research Service, Removal of Inspectors General:
Rules, Practice, and Considerations for Congress (Updated January 25,
2025) https://crsreports.congress.gov/product/pdf/IF/IF11546.
---------------------------------------------------------------------------
As Hannibal Ware, the Chairperson of the Council of the Inspectors
General on Integrity and Efficiency, publicly acknowledged, ``IGs are
not immune from removal. However, the law must be followed to protect
independent government oversight for America.'' \40\ Within the last 20
years, Congress has passed two laws with bipartisan support to prevent
the precise type of action President Trump just took.\41\ The Inspector
General Reform Act of 2008, which established a requirement that
Congress be notified in writing no later than 30 days before removal or
transfer of an IG,\42\ and the Securing Inspector General Independence
Act of 2022, provisions of which became law as part of the James M.
Inhofe National Defense Authorization Act for Fiscal Year 2023, added a
requirement that Congress be given a detailed account of the
justification for the removal of an inspector general and the inspector
general remain in place for 30 days while Congress considers that
justification.\43\
---------------------------------------------------------------------------
\40\ Council of the Inspectors General on Integrity and Efficiency
(CIGIE), Statement from Hon. Hannibal Ware, Chairperson of the Council
of the Inspectors General on Integrity and Efficiency (Jan. 25, 2025)
https://www.ignet.gov/sites/default/files/files/CIGIE%20Statement%20--
%201_25_2025.pdf
\41\ Roll Call 661 for Bill Number: H.R. 928 Inspector General
Reform Act of 2008 (Sept. 27, 2008) https://clerk.house.gov/Votes/
2008661 ; Cosponsors Securing Inspector General Independence Act of
2021 https://www.congress.gov/bill/117th-congress/senate-bill/587/
cosponsors.
\42\ Public Law No: 110-409 (Oct. 14, 2008).
\43\ Public Law No: 117-263 (Dec. 23, 2022).
---------------------------------------------------------------------------
The firings of the IGs by President Trump were made all the more
concerning because President Trump failed to follow the law and provide
the legally required 30-day notice and case-specific reasons for
removal, as Chairman Chuck Grassley and Ranking Member Dick Durbin of
the Senate Judiciary Committee recently noted in a letter to President
Trump.\44\ The fact that these inspectors general appear to have been
fired without cause suggests that they may have been fired to stifle
oversight of the new administration and raises questions about whether
the next inspector general will be a partisan loyalist or simply fired
on the president's political whim. Will anyone filling these posts
actually conduct robust oversight? How can a federal employee stripped
of their employment protections by Trump's executive orders feel
comfortable going to a potential Trump loyalist hand-picked to serve as
IG to blow the whistle on waste, fraud or abuse? These are important
questions that I urge Congress to address.
---------------------------------------------------------------------------
\44\ Letter from Senate Judiciary Chairman Chuck Grassley and
Ranking Member Dick Durbin to President Donald J. Trump (Jan. 28,
2025),https://www.judiciary.senate.gov/press/rep/releases/grassley-
durbin-seek-presidential-explanation-for-ig-dismissals (citing Pub. L.
117-263 The ``President ``shall'' communicate to Congress in writing 30
days before removing or transferring an IG from office the
``substantive rationale, including detailed and case-specific reasons''
for the removal or transfer).
---------------------------------------------------------------------------
It is critical that the VA has a permanent IG that has the
expertise and institutional knowledge to provide continuity in the
oversight work directed at addressing critical long-term challenges at
the Department. For instance, the VA Office of Inspector General under
Missal, conducted in-depth work reviewing healthcare staffing
shortages, patient safety concerns, inadequate clinical care, as well
as veterans' suicide risk and prevention.\45\ It is important for
veterans and military families that IG oversight in these areas
continues unabated. Although VA Deputy IG David Case has been made
acting IG, having an acting IG is a far cry from having a properly
vetted and Senate-confirmed official serving in that role. As Senator
Grassley has noted, permanent IGs are critical because ``[e]ven the
best acting Inspector General lacks the standing to make lasting
changes needed to improve his or her office.'' \46\ Moreover, an acting
IG may not have the experience necessary, nor feel adequately
empowered, to take sensitive and problematic issues to the Secretary or
Congress as Inspector General Missal did when he confronted then-VA
Secretary David Shulkin, in 2018, with allegations of the Secretary's
own unethical conduct, including the improper acceptance of gifts and
the misuse of agency resources.\47\ Or like Mr. Missal's office did in
May 2024 when it issued a report finding that the Biden VA erroneously
awarded $10.8 million in recruitment and retention bonuses to senior
executives, leading to an effort by then-Secretary McDonough to recoup
those funds.\48\
---------------------------------------------------------------------------
\45\ See e.g., Department of Veterans Affairs Office of Inspector
General, Deficiencies in Inpatient Mental Health Suicide Risk
Assessment, Mental Health Treatment Coordinator Processes, and
Discharge Care Coordination (Dec. 18, 2024),https://www.vaoig.gov/
reports/national-healthcare-review/deficiencies-inpatient-mental-
health-suicide-risk-assessment; Department of Veterans Affairs Office
of Inspector General, Inadequate Staff Training and Lack of Oversight
Contribute to the Veterans Health Administration's Suicide Risk
Screening and Evaluation Deficiencies (Dec. 18, 2024), https://
www.vaoig.gov/reports/national-healthcare-review/inadequate-staff-
training-and-lack-oversight-contribute-veterans; Department of Veterans
Affairs Office of Inspector General, Mismanaged Surgical Privileging
Actions and Deficient Surgical Service Quality Management Processes at
the Hampton VA Medical Center in Virginia (July 23, 2024),https://
www.vaoig.gov/reports/hotline-healthcare-inspection/mismanaged-
surgical-privileging-actions-and-deficient.
\46\ Andrew Ackerman,Maloney Named Interim SEC Inspector General,
Wall Street Journal (Jan. 27 2012), https://www.wsj.com/articles/
SB10001424052970204573704577187443078314650.
\47\ Department of Veterans Affairs Office of Inspector General,
Administrative Investigation - VA Secretary and Delegation Travel to
Europe (Feb. 14, 2018),https://www.vaoig.gov/sites/default/files/
reports/2018-02/VAOIG-17-05909-106.pdf.
\48\ Department of Veterans Affairs Office of Inspector General, VA
Improperly Awarded $10.8 Million in Incentives to Central Office Senior
Executives (May 9, 2024), https://www.vaoig.gov/reports/administrative-
investigation/va-improperly-awarded-108-million-incentives-central-
office; Eric Katz, Lawmakers blast VA over executive bonus scandal, but
secretary declines to offer any heads, Government Executive (June 4,
2024), https://www.govexec.com/pay-benefits/2024/06/lawmakers-blast-va-
over-executive-bonus-scandal-secretary-declines-offer-any-heads/
397095/.
---------------------------------------------------------------------------
To an administration that claims to value monetary efficiency in
government, I would argue that firing inspectors general actually
hinders efficiency and results in monetary waste. Mr. Missal's ouster
certainly did not benefit any veterans or military families. Instead,
attacking the IG and the civil service does a disservice to veterans
and makes the VA more susceptible to waste, fraud and abuse.
Thank you. I am happy to answer your questions on ways to foster
accountability at the VA and ensure our veterans and military families
can get the help, care and support they deserve.
Statements for the Record
----------
Prepared Statement of Government Accountability Project
MR. CHAIRMAN:
Thank you for the opportunity to submit written testimony on the
Department of Veterans Affairs (VA)'s Office of Accountability and
Whistleblower Protection (OAWP). I serve as Legal Director of the
Government Accountability Project (GAP), a non-profit, non-partisan
whistleblower support and advocacy organization. I hope this testimony
will provide additional context for matters not considered in the
February 6 hearing. summarizes issues Government Accountability Project
previously testified on four times in the previous hearings by this
Committee.
GAP has engaged in aggressive oversight of whistleblower rights at
the Department of Veterans Affairs (DVA) during the last two
administrations. When I first testified in 2019, 10 DVA whistleblowers
were 40% of my 25-client reprisal docket. The worst offender was the
agency's whistleblower protection office, the Office of Accountability
and Whistleblower Protection. During the Biden administration, the new
OAWP chief resolved all the OAWP reprisal cases in an even-handed
manner, and administratively instituted significant reforms that this
Committee unanimously sought to institutionalize in the H.R. 8510, the
Strengthening Whistleblower Protection at the Department of Veterans
Affairs Act. At the end of this testimony, we recommend that this
committee try again to codify the key reforms it approved previously.
HISTORY OF WHISTLEBLOWER RETALIATION
The DVA long has been the Executive branch's worst agency with
respect to whistleblower retaliation. GAP's 40% rate of DVA
whistleblowers compared to the rest of the government is consistent
with that of the U.S. Office of Special Counsel. To illustrate from our
clients, misconduct that whistleblowers were retaliated against for
exposing included----
gross mismanagement that led to multi-year waiting lists
for patients who needed immediate care for life threatening conditions;
lying to patients that they would receive timely care
while concealing the secret waiting lists;
sabotaging corrective action for waiting lists through
unqualified, buddy system contracts;
breakdown of the suicide prevention program;
breakdown of the program to treat spinal cord injuries;
and
bribery that led to contamination of the water supply at
a facility.
These examples are representative of a DVA pattern of betraying its
mission to promote its own self-interest. It was encouraging, however,
that whistleblower reprisal complaints to GAP dropped sharply during
the last Administration.
THE OFFICE OF ACCOUNTABILITY AND WHISTLEBLOWER PROTECTION
The OAWP had a disastrous birth, with GAP receiving more
whistleblowing disclosures and retaliation complaints from its staff
than the rest of the Department. The Office was not producing results,
as all the cases summarized above sought and failed to receive help. In
particular, OAWP employees blew the whistle on mission breakdowns such
as----
gagging its own employees despite being a whistleblower
protection agency;
lacking enforcement authority due to veto authority for
the agency General Counsel to veto actions;
canceling its effective mentoring mediations program; and
canceling counseling services that had assisted over
1,000 DVA employees.
Again, we were encouraged that the recent OAWP chief, Mary Donohue,
had significant success turning the agency around. All the
whistleblower retaliation complaints were resolved on fair terms. OAWP
obtained its own counsel. The mentoring and counseling programs were
restored.
While the progress was welcome, our organization and others have
advocated that the improved practices be institutionalized through
statutory requirements. We recommend that any further remedial
legislation include the following:
1. Independent Counsel for OAWP:
By statute, OAWP must have independent legal counsel free from VA
Officer of General Counsel (OGC) oversight. While OAWP attorneys now
exercise significant autonomy, OGC retains control over disciplinary
decisions. True structural independence must be codified.
2. Transfer of Investigative Authority to the Office of Special
Counsel (OSC):
OAWP lacks enforcement power. Unlike OSC, it cannot litigate to
enforce corrective action. Instead, it can only make recommendations VA
officials routinely ignore. If OAWP retains investigative authority,
Congress must grant it enforcement power to ensure real consequences
for retaliation.
3. Protection Against Retaliatory Licensing Board Referrals:
DVA officials often circumvent whistleblower protections by
referring employees to state licensing boards, effectively blocklisting
them from their profession. This practice must be explicitly prohibited
to prevent career-ending retaliation.
4. Increased Transparency in OAWP Oversight:
OAWP has improved its public reporting, but gaps remain. Unlike
OSC, OAWP does not disclose its assessments of agency corrective
actions. Congress should require parity with OSC's transparency
standards, ensuring full oversight and public accountability.
5. Mandatory Whistleblower Navigators:
An early administration eliminated whistleblower counseling
services, leaving employees to navigate a complex system alone. OAWP
has reinstated a navigator function, but Congress should codify this as
a permanent, mandatory service.
6. Institutionalized Alternative Dispute Resolution (ADR):
A prior OAWP mediation program successfully resolved whistleblower
disputes without litigation. However, this initiative was discontinued.
Congress should restore and mandate a no-fault ADR program to provide
an alternative to prolonged legal battles.
7. Tracking and Reporting Compliance with Recommendations:
OAWP claims that 95% of its recommendations are accepted, but there
is no data on whether they are implemented. Agencies frequently accept
recommendations without acting on them. Congress should require annual
reports on compliance and enforcement actions.
These reforms are necessary to ensure that OAWP serves its intended
purpose: protecting whistleblowers and upholding accountability at the
VA. While recent leadership changes have improved the agency's
responsiveness, structural safeguards are essential to prevent
regression.
Government Accountability Project remains committed to supporting
these efforts and is on call however we can be helpful. Thank you for
your time and attention to this matter.
______
Prepared Statement of American Federation of Government Employees, AFL-
CIO
Chairman Kiggans, Ranking Member Ramirez, and Members of the
Subcommittee:
The American Federation of Government Employees, AFL-CIO (AFGE) and
its National Veterans Affairs Council (NVAC) appreciate the opportunity
to submit a statement for the record on today's hearing titled ``VA
First, Veteran Second: The Biden-Harris Legacy.'' AFGE represents more
than 750,000 federal and District of Columbia government employees,
310,000 of whom are proud, dedicated Department of Veterans Affairs
(VA) employees. These include front-line providers at the Veterans
Health Administration (VHA) who provide exemplary specialized medical
and mental health care to veterans, the Veterans Benefits
Administration (VBA) workforce responsible for the processing veterans'
claims, the Board of Veterans' Appeals (Board) employees who shepherd
veterans' appeals, and the National Cemetery Administration Employees
(NCA) who honor the memory of the nation's fallen veterans every day.
With this firsthand and front-line perspective, we offer our
observations on the problems the Department of Veterans Affairs
Accountability and Whistleblower Protection Act of 2017 has caused
front-line VA Employees. Specially, AFGE has long objected to the VA's
use of 38 U.S.C. 714 (Sec. 714) of the law and how it has harmed
hardworking and dedicated employees. Additionally, through this
experience AFGE is also aware of the failure of VA leadership to hold
managers accountable under other provisions of the law. AFGE has
supported efforts to amend the law to restore fairness to VA employees
and encourages the committee to restore basic fairness to the VA
workforce.
Background
Public Law 115-41, the Department of Veterans Affairs
Accountability and Whistleblower Protection Act (Accountability Act or
Act), was signed into law on June 23, 2017. At the time of its passage,
supporters claimed the Act was intended to simplify and expedite the
disciplinary process at VA so that it could better hold bad employees
accountable. The Act is divided into two parts, Title I, which
established the Office of Accountability and Whistleblower Protections
(OAWP) and Title II, which governs Accountability and Adverse Actions
for Senior Executives, VA Employees, and Supervisors disciplinary
procedures. Within Title II, the bill enacted 38 U.S.C. Sec. 714 which
changed the following disciplinary procedures for bargaining unit
employees (38 U.S.C. Sec. 713 is for managers):
Required management to make a final decision within 15
business days of proposing an adverse action (i.e., suspension of more
than 14 days, demotion, or removal);
Reduced the time period for an employee to respond to
proposed adverse action to 7 business days;
Reduced the time period for an employee to appeal the
final adverse action;
Lowered the standard of proof necessary to sustain an
adverse action before a third party, such as arbitrators and the Merit
Systems Protection Board (MSPB), from preponderance of the evidence to
substantial evidence;
Prevented third part adjudicators from mitigating the
penalties assigned by VA.
Oversight
Since the Act's enactment, there has been robust oversight over the
Act's implementation, and its effect on the workforce in multiple
venues:
Congressional Oversight
The House Veterans' Affairs Committee held an oversight hearing in
July 2018 before the Committee on Veterans' Affairs entitled ``The VA
Accountability and Whistleblower Protection Act: One Year Later.'' \1\
The committee's goal was to address problems caused by the VA's
implementation of the Act. In his opening statement, then-Ranking
Member Mark Takano addressed the VA's penchant to use the Act to
disproportionately discipline rank and file employees as opposed to
supervisors and other management officials stating: \2\
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\1\ The VA Accountability and Whistleblower Protection Act: One
Year Later: Before the H. Comm. On Veterans Affairs, 115th Congr.
(2018), https://republicans-veterans.house.gov/calendar/
eventsingle.aspx?EventID=2212.
\2\ The VA Accountability and Whistleblower Protection Act: One
Year Later: Before the H. Comm. On Veterans Affairs, 115th Congr.
(2018) (statement of Mark Takano, ranking member), https://republicans-
veterans.house.gov/calendar/eventsingle.aspx?EventID=2212.
``[Of] the 1,086 removals during the first five months of 2018,
the majority of those fired were housekeeping aides...I also
find it hard to believe that there are large numbers of
housekeeping aides whose performance is so poor that it cannot
be addressed. If that is truly the case, then it stands to
reason that there are also management issues behind their poor
performance. But of those 1,096 removals, only fifteen were
supervisors which is less than 1.4%. Firing rank and file
employees does nothing to resolve persistent management
issues.'' He continued ``it is not possible to fire your way to
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excellence.''
AFGE also testified at this hearing citing how the law
disproportionately harmed lower paid federal workers and not the
managers who supervised them, and also further explained many of the
structural problems with the law that continue to exist today.\3\ AFGE
has also commented on the Accountability Act and Whistleblower at other
House Veterans' Affairs Committee hearings including before this
subcommittee on May 19, 2021 at hearing titled ``Protecting
Whistleblowers and Promoting Accountability: is VA Making Progress?''
\4\ citing the problems with the current law and the need to pass
reforms. AFGE also submitted a statement for the record before this
subcommittee on March 9, 2023 discussing the problems with the 2017
accountability statute at a hearing titled ``Accountability at VA:
Leadership Decisions Impacting its Employees and Veterans.''
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\3\ The VA Accountability and Whistleblower Protection Act: One
Year Later: Before the H. Comm. On Veterans Affairs, 115th Congr.
(2018) (statement of AFGE National President J. David Cox). https://
docs.house.gov/Committee/Calendar/ByEvent.aspx?EventID=108516.
\4\ Protecting Whistleblowers and Promoting Accountability: is VA
Making Progress? Before the H. Comm. On Veterans Affairs Subcommittee
on Oversight and Investigations, 117th Congr. (2021) (AFGE Statement
for the Record).
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Inspector General Investigation
In response to requests for an investigation from multiple
legislators, the Office of Inspector General (OIG) highlighted VA's
failure to properly implement the portion of the Act pertaining to
whistleblower protection. The OIG issued a report, which explained,
``in many instances, [OAWP] focused only on finding evidence sufficient
to substantiate the allegations without attempting to find exculpatory
or contradictory evidence.''
Further, while VA front-line employees were being disciplined more
often and more harshly under section 202 of the Accountability Act, the
OIG report found that VA ``struggled with implementing the Act's
authority to hold executives accountable.'' OIG explained that despite
statements from then-Secretary Shulkin, as of May 22, 2019, VA had only
removed one covered executive employee under 38 U.S.C. 713, which
addresses discipline for senior executives. Further, of thirty-five
cases involving executives, VA mitigated the discipline of thirty-two.
The OIG investigation revealed unlawful whistleblower retaliation
by OAWP itself, noting that after an OAWP employee made a whistleblower
complaint, Executive Director O'Rourke instructed a subordinate to
remove the employee. Finally, the OIG found that the VA did not comply
with reporting and training requirements of the Act and failed to
adequately report to Congress regarding the outcomes of disciplinary
actions.
Freedom of Information Act
In an attempt to learn more about the VA's use of its authorities
under the Accountability Act, on May 31, 2022, AFGE submitted a Freedom
of Information Act (FOIA) Request to the VA. This request asked the VA
to share, without violating the privacy of employees, the VA's use of
Section 204 of the Veterans Affairs Accountability and Whistleblower
Protection Act of 2017, 38 U.S.C. Sec. 721, which authorizes the
Secretary to issue an order, under certain circumstances, directing an
employee to repay an award or bonus paid to the employee. This request
covered the period from June 23, 2017, through May 31, 2022. In
response to the AFGE's request, the VA responded on June 2, 2022, and
stated that ``This is a recently enacted VA policy and there are no
responsive records.'' This is evidence that the VA has not utilized all
of the tools at its disposal to hold employees accountable, and that
the VA does not need additional tools for accountability.
Challenges in Federal Court
Since the enactment of the Accountability Act, the certain parts of
the law have been challenged in federal courts, relating to the
restrictions on the MSPB or third party adjudicators to mitigate a
penalty. In Sayers v. Dep't of Veterans Affairs, the U.S. Court of
Appeals for the Federal Circuit (Federal Circuit or Court) determined
that, contrary to VA's contentions, the MSPB was permitted to review
the penalty as well as the facts of a case under Sec. 714. The Court
explained that ``[d]eciding that an employee stole a paper clip is not
the same as deciding that the theft of a paper clip warranted the
employee's removal.'' It is clear that prior to Sayers, the Agency
promoted a limited review and harshly disciplined employees under
Sec. 714, often for similarly trivial acts.
The perceived inability to mitigate led judges to affirm decisions
where even a single charge was proven by substantial evidence. Where
the harshest available penalty, removal, was used liberally, this led
to a loss of employee resources for the smallest of infractions. VA's
rush to remove employees was clear in performance cases as well. As
Administrative Judges believed they could not mitigate penalties,
employees were removed for easily remedied performance failures.
Another key element of the law examined by the courts is the
elimination of the preponderance of the evidence standard, and the
implementation of the new substantial evidence standard. In Rodriguez
v. Dep't of Veterans Affairs, the Court held that the ``preponderance
of the evidence, rather than substantial evidence was the correct
standard for management to apply at the administrative level in conduct
cases under [Sec. ]714.'' \5\ The Court explained that when determining
whether conduct justified discipline under Sec. 714, preponderance of
the evidence was the correct evidentiary burden, and the MSPB's
standard of review should be substantial evidence. Consequently, the
Court found that VA had applied the wrong evidentiary standard in its
Sec. 714 conduct cases. The Court held in August 2021 that VA and MSPB
must apply the Douglas Factors in deciding and reviewing the imposed
penalty.\6\
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\5\ Ariel Rodriguez v. Department of Veterans Affairs, 8 F.4th 1290
(Fed. Cir.) (2021).
\6\ Stephen Connor v. Department of Veterans Affairs, 8 F.4th 1319
(Fed. Cir.) (2021).
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By subjecting management's decisions to additional scrutiny, the
Court demonstrated VA's overreach in its use of the Accountability Act.
The use of Sec. 714 has proven to have had its greatest impact on
lower-level employees, compounding a staffing crisis while doing little
to address systemic problems such as inadequate training and hostile
managers. Thus, while the reviewing arbitrators, Administrative Law
Judges, and Federal Circuit Judges have done much to curtail VA's broad
interpretation of the law, the law itself must be amended if it is to
accomplish its stated goal of improving systemic flaws in the Agency.
Furthermore, in the recent case Richardson v. Department of
Veterans Affairs, the MSPB further limited the applicability of the
law.\7\ In Richardson, the MSPB ruled that an employee appointed under
38 U.S.C 7401(3), a ``hybrid'' Title 38/Title 5 employee, could not be
terminated under Sec. 714 as the text of 38 U.S.C. 7403(f)(3) dictated
its reliance on ``the procedures'' of chapter 75 of Title 5.\8\
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\7\ Richardson v. Department of Veterans Affairs, Docket No. AT-
0714-21-0109-I-1 (MSPB) (2023).
\8\ Id.
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As a result of these and other legal rulings and determinations,
the VA announced on March 5, 2023, that the VA will prospectively
``cease using the provisions of 38 U.S.C. Sec. 714 to propose new
adverse actions against employees of the Department of Veterans Affairs
(VA), effective April 3, 2023.''
In the remaining 21 months of the Biden Administration, the VA
reverted to using standard and well understood Title 5 discipline for
employees covered by Sec. 714, which provided discipline, including
removal for VA employees, while simultaneously guarding the civil
service protections of the dedicated VA workforce.
Suggested Reforms
Irrespective of the possibility that future VA Secretaries could
reverse the Secretary's determination to cease using Sec. 714, AFGE
recommends two legislative changes to the Accountability Act:
Restore the Standard of Review to Preponderance of Evidence
38 U.S.C. Sec. 714 established by the Accountability Act mandates
that the MSPB uphold management's decision to remove, demote, or
suspend an employee if the decision is supported by substantial
evidence. While not defined in the law, management guidance defined
substantial evidence as ``relevant evidence that a reasonable person,
considering the record as a whole, might accept as adequate to support
a conclusion, even though other reasonable persons might disagree, or
evidence that a reasonable mind would accept as adequate to support a
conclusion.''
Prior to the implementation of Sec. 714, discipline based on
unacceptable performance was considered under Chapter 43. Disciplinary
actions to promote the efficiency of the service were considered under
Chapter 75 of Title 5 of the United States Code. Under those chapters,
a disciplinary action was upheld where substantial evidence
demonstrated that the unacceptable performance took place under Chapter
43, and where a preponderance of the evidence demonstrated that the
misconduct or performance took place under Chapter 75. The difference
in the burdens of proof aligned with the differences in penalties, as
Chapter 43 actions led to attempts to improve that performance whereas
harsher penalties, to include immediate removal, were available for
misconduct under Chapter 75.
As discussed in Rodriguez v. Dep't of Veterans Affairs, VA
improperly read Sec. 714 to mean that its burden of proof in justifying
discipline was lowered to the substantial evidence standard. The
Federal Circuit disagreed with the Agency's position, finding that the
Agency conflated burden of proof and standard of review. Consequently,
the Court found that the VA still had to meet the preponderance of the
evidence burden of proof in its decision to discipline for conduct.
Rodriguez clarified the difference between the burden of proof
required of management, a preponderance of the evidence for conduct
cases, and the standard of review by the MSPB, changed to substantial
evidence under Sec. 714. Even a proper reading of Sec. 714, however,
puts reviewers in a position they often have little choice but to
rubber stamp VA's harsh penalties. Changing the standard of review to
the preponderance of the evidence is necessary to ensure that VA
reassumes the burden of proving that the claimed action occurred. Where
an employee's job is on the line, VA's decisions should be held to a
higher degree of scrutiny.
Restore the Authority to Mitigate Unreasonable Penalties
Connor v. Department of Veterans Affairs, spoke to the issue of
mitigation. In that case, on appeal, the MSPB sustained only one of the
27 charges against the employee. On appeal to the Federal Circuit, the
Agency argued it need not consider the Douglas Factors in Sec. 714
proceedings.\9\
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\9\ Stephen Connor v. Department of Veterans Affairs, 8 F.4th 1319
(Fed. Cir.) (2021).
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Under current statute established by Sec. 714, the law provides
that where the Agency's decision is supported by substantial evidence,
the MSPB or an arbitrator may not mitigate the penalty. Thus, the MSPB
or an arbitrator could only reverse an Agency decision it determined
was unreasonable. MSPB had an extremely high rate of affirming Agency
decisions even before the enactment of the Accountability Act. MSPB's
affirmance rate of VA decisions was 83.7%, of the years recorded since,
2019 was the highest rate of affirmance at 89.44%. Few cases were
mitigated prior to 2017, however, mitigation was available to reviewing
entities, saving the time of sending back a case, causing needless
delay.
The Accountability Act was promoted as enabling management to
streamline the disciplinary process. VA's failure to use the right
evidentiary standard and MSPB's inability to mitigate discipline caused
many disciplinary cases to be returned to the Agency for time-consuming
work and increased the time it took to process discipline.
AFGE strongly supports restoring the standard of review applicable
to the Agency to the preponderance of the evidence and restoring the
ability of reviewing bodies to mitigate penalties under Sec. 714. Such
changes would ensure fair determinations and streamline the
disciplinary process.
Both of these recommendations would be enacted by passing H.R. 932,
the bi-partisan ``Protecting VA Employees Act.''
Conclusion
AFGE thanks the House Veterans' Affairs Committee for the
opportunity to submit a Statement for the Record for today's hearing.
AFGE stands ready to work with the committee and the VA to address the
workforce issues currently facing the department and find solutions
that will enable VA employees to better serve our nation's veterans.
______
Prepared Statement of Disabled American Veterans
Chairman Bost, Ranking Member Takano and Members of the Committee:
Thank you for inviting DAV (Disabled American Veterans) to submit
testimony for the record of this legislative hearing. As you know, DAV
is a congressionally chartered and Department of Veterans Affairs (VA)
accredited veterans service organization. We provide meaningful claims
support free of charge to more than 1 million veterans, family members,
caregivers and survivors. We are pleased to provide our views on the
bills under consideration by the Committee.
H.R. 472, the Restore VA Accountability Act of 2025
DAV has consistently advocated for a culture of accountability
within the VA, where VA employees are held to the highest standards of
performance and conduct. We applaud the committee for its efforts to
address longstanding issues within the VA and to ensure that federal
employees are responsible for their actions. We concur that bad
employees must be held accountable to ensure that the best federal
employees are serving veterans; however, accountability must include
due process principles, protecting the rights of employees, including
veterans, who make up nearly 30% of VA's workforce.
H.R. 472, the Restore VA Accountability Act of 2025, makes several
changes to the due process of appeals for employees at the VA. The Act
would allow for expedited disciplinary actions for certain categories
of VA employees based on substantial evidence of misconduct or poor
performance. Specifically, the bill would remove the Performance
Improvement Plan (PIP) requirement and the appellant's review by the
Merit Systems Protection Board (MSPB).
Although the goal of the Restore VA Accountability Act is to
increase accountability by streamlining the disciplinary process and
ensuring that VA employees who do not meet performance standards or
engage in misconduct can be held accountable more swiftly and
effectively, DAV asks the committee to give careful consideration to
our concerns, which may have an indirect impact on the high quality of
care and benefits services provided to veterans.
DAV's major concern is the exclusion of the MSPB from the appeals
process for federal employees. The MSPB has historically served as an
independent and impartial body that reviews agency decisions and
safeguards employees from arbitrary or unjust actions. By removing the
MSPB from the appeals process, we risk depriving employees of a crucial
avenue for redress and oversight.
Additionally, DAV has concerns with provisions that eliminate the
necessity for PIPs before any disciplinary measures are taken. PIPs
provide employees with a fair opportunity to address and correct
performance issues before facing more severe consequences. Eliminating
this critical step could lead to unjust disciplinary actions.
DAV wholeheartedly supports the Committee's commitment to
accountability within the VA. However, striking a balance between
holding civil servants accountable for their performance while
maintaining the VA as an employer of choice for the best and brightest
to ensure veterans receive the best care and timely services remains
our priority.
We firmly believe that due process must not be compromised in
pursuit of these goals, which has been reiterated within DAV's
Resolution No. 138 that notes any bill enacted by Congress should
include standards by which accountability can be measured while
ensuring due process and fairness for VA employees subject to such
standards.
H.R. 740, Veterans' ACCESS Act of 2025
The VA health care system is vital to millions of service-disabled
veterans, offering comprehensive primary care and specialized programs
tailored to their unique needs. While community care should be
available as a supplement when the VA cannot provide timely,
accessible, or high-quality care, it should not replace the VA's
primary role in delivering and coordinating integrated care for
enrolled veterans. The lack of expansion in the VA's capacity to meet
the increasing demand for care has led to an over-reliance on external
providers. The growing reliance on community care in recent years
presents significant challenges to this comprehensive, evidence-based
care model.
The VA MISSION Act of 2018 (P.L. 115-182) introduced a new process
for integrating community care with the VA's hospital care, medical
care, and extended care services, ensuring veterans receive the highest
standards of care regardless of limitations within the VA health care
system. The legislation aimed to expand access to non-VA care when
necessary while strengthening the VA direct care system to meet the
growing needs of enrolled veterans.
The Act established the Veterans Community Care Program (VCCP),
setting wait time and travel distance standards. The goal was to ensure
the VA maintained overall responsibility for veterans' care by
coordinating their treatment and requiring community providers to meet
the same quality standards as VA providers. Unfortunately, the VA has
yet to implement the intended quality standards for non-VA providers or
establish a robust care coordination program for veterans receiving
both VA and community care.
The Act also included provisions to enhance the VA's internal
capacity by improving the recruitment, hiring, and retention of
qualified clinicians and addressing the longstanding neglect of the
VA's aging health care infrastructure. Without sufficient
infrastructure and capacity to meet the rising needs of veterans, the
VA has turned increasingly to community care, which has seen more rapid
growth than VA services. Despite significant increases in the VA's
workforce over the past six years, the Department's health care
infrastructure remains critically under-funded.
H.R. 740, the Veterans' Assuring Critical Care Expansions to
Support Servicemembers (ACCESS) Act of 2025, aims to improve the
provision of care and services under the VCCP and enhance veterans'
health care with defined eligibility standards, mandatory notification
of eligibility and denial of requests, consideration of veterans' care
preferences, and extension of claim submission deadlines. It also seeks
to streamline specialized mental health treatment programs with a
standardized eligibility process and make improvements to the Mental
Health Residential Rehabilitation Treatment Program (RRTP). The
legislation also includes provisions to establish an interactive online
self-service module for care, change requirements for the Center for
Care and Payment Innovation (CCPI), and mandate pilot programs and
reports to ensure effective implementation.
The ACCESS Act stands to bring substantial changes to the VCCP,
potentially impacting the VA's mission of delivering timely, high-
quality, veteran-focused health care and services to enrolled veterans.
As we move forward with proposed program changes, we believe that it is
essential to appropriately balance the role community care plays in the
VA's provision of specialized health care and support to our nation's
ill and injured veterans.
The Independent Budget for fiscal year 2026-2027--coauthored by the
DAV, Veterans of Foreign Wars and Paralyzed Veterans of America, calls
on Congress to ensure that VA remains the primary provider and
coordinator of care for veterans and that community care is available
and accessible to veterans as needed to support and supplement VA care.
With this background and context, DAV offers the following comments and
recommendations regarding H.R. 740.
Section 101: Codification of Requirements for Eligibility Standards for
Access to Community Care from the Department of Veterans Affairs
Section 101 of the bill would codify the minimum access standards
for community care from the VA including all extended care services,
except for nursing home care and mandate the VA to review these
standards with an expanded stakeholder group and report to Congress
triennially. Provisions in this section would prohibit telehealth
appointments from fulfilling access standards if an in-person VA
appointment is unavailable within the standards. It would also require
that canceled VA appointments restart the wait time calculation from
the original request date, and any deviations in wait time or distance
agreed upon by a veteran and their provider must be documented and
provided to the veteran and apply to all VA care and patients, whether
new or established.
DAV has no concerns with codifying the eligibility standards for
access to community care from VHA, while emphasizing the need for
thorough and periodic reviews of these standards. However, we strongly
recommend amending the provision that the Secretary shall not take into
consideration the availability of telehealth appointments from the
Department when determining whether the VA is able to furnish such care
or services. We believe that a telehealth appointment should be
considered as an option if agreeable with a veteran. Additionally, if a
veteran is eligible and opts for an in-person community care
appointment because VA only had a telehealth appointment available,
that appointment in the community should be for an in-person
appointment only. Telehealth services would have already been offered
or provided by the VA under Section 105 of this act, which requires the
VA to discuss telehealth with veterans as an option for care, both in
the VA health care system and in the community, if telehealth is
available, appropriate, and acceptable to the veteran.
We endorse the mandate in this section of the bill to document
medical records and make them accessible to veterans through digital
platforms such as VA.gov, email, and mobile text, except where veterans
specifically request them and lack digital access.
Section 102: Requirement that Secretary Notify Veterans of Eligibility
for Care under Veterans Community Care Program
Section 102 mandates the VA to promptly notify veterans of their
eligibility for community care. To ensure clarity, we propose that the
two-day notification requirement includes digital methods, as
traditional mail may not meet the deadline. We recommend expeditious
deployment of the External Provider Scheduling (EPS) system within the
Community Care Network (CCN) to facilitate real-time scheduling when
the VA cannot provide direct care or meet access standards, thereby
enhancing more timely and effective communication and care coordination
for veterans.
Section 103: Consideration of Veteran Preference for Care, Continuity
of Care, and Need for Caregiver or Attendant
Section 103 of the Veterans ACCESS Act would require the VA to
consider various factors when determining if it is in the best medical
interest of a veteran to seek care in the community. These factors
include the veteran's preference for when, where, and how to receive
care, continuity of care, and the veteran's need or desire for a
caregiver or attendant to accompany them.
We have concerns with the definition of veterans' preference for
where, when, and how to seek hospital care, medical care, or extended
care services. While we want the veteran's preference to be considered
when determining the best option for care, the best medical interest
including the distance to care, the frequency of care, and the
availability of appointments, should be the primary factors considered,
as provided in the MISSION Act.
Section 104: Notification of Denial of Request for Care under Veterans
Community Care Program
Section 104 mandates that if the VA denies a veteran's request for
community care, it must provide the veteran with the reason for the
denial and instructions for appealing the decision through the Veterans
Health Administration's clinical appeals process. DAV has no concerns
with this section. In fact, our benefits advocates stand ready to
assist any veteran with filing a clinical appeal.
Section 106: Extension of Deadline for Submittal of Claims by
Healthcare Entities and Providers under Prompt Payment Standard
Section 106 extends the deadline for health care entities and
providers to submit claims for reimbursement for community care
services from the current 180 days to up to one year after service,
aligning with industry standards.
DAV has no concerns with this section, as it provides a more
flexible timeframe for providers without compromising the timely
processing of claims or the quality of care for veterans.
Section 202: Standardized Process to Determine Eligibility of Covered
Veterans for Participation in Certain Mental Health Treatment Programs
Section 202 would require the VA to establish a standardized
screening process to determine, based on clinical needs, whether a
covered veteran satisfies criteria for priority admission to a covered
residential rehabilitation treatment program (RRTP). As part of the
evaluation process a veteran must be screened and admitted into a
program within 48 hours if determined eligible for RRTP. Either a
veteran or relevant health care provider can make the request for
admission into a treatment program if they meet criteria for priority
admission.
We recommend that the language in this section be amended to
require that a VA clinician make the determination if the veteran meets
the eligibility criteria for priority admission within 48 hours of the
request.
We appreciate the provision in this section of the bill that
requires non-department RRTP facilities to be properly licensed by a
state and accredited by the Commission on Accreditation of
Rehabilitation Facilities (CARF) or the Joint Commission.
Section 203: Improvements to Department of Veterans Affairs Mental
Health Residential Rehabilitation Treatment Program
We appreciate that Section 203 includes requirements for the VA to
develop a process for assessing the quality of specialized RRTP care
delivered by both VA and non-VA providers, including the use of
evidence-based treatments, cultural competency, clinical outcomes and
oversight, and referral of billing practices.
The VA is advancing efforts to give veterans faster and simpler
access to its mental health RRTPs, which provide around-the-clock
support for substance use disorders, posttraumatic stress disorder,
depression, and other mental health conditions common among veterans.
Over 27,000 veterans were treated at VA RRTPs in fiscal year 2024, and
we urge the department to increase its bed capacity to expand these
critical services.
The VA's national RRTP conference in September 2024 underscored the
high priority the VA is giving to fostering more timely access for
veterans who need these programs. The VA is focused on implementing a
new centralized screening process for each region. However, there are
still limits to timely access to these specialized services, and we
want to ensure veterans do not have barriers to accessing this life-
changing care. Accountability and oversight are paramount to ensure
facilities meet the quality of care standards, include veteran-centric
programming, and demonstrate effective patient outcomes.
Section 301: Plan on Establishment of Interactive, Online Self-Service
Module for Care
Section 301 mandates the VA to create an interactive, online self-
service module to help veterans schedule appointments, track referrals,
appeal care denials, and receive reminders for both VA and community
care appointments.
DAV is supportive of this effort but suggests that alternative
methods and adequate support be provided to bridge the digital divide
and guarantee equitable access to care for all veterans, including
those living in rural and remote communities.
Section 302: Modification of Requirements for the Center for
Innovation for Care and Payment of the Department of Veterans Affairs
and Requirement for Pilot Program
Section 302 would require the VA to establish and report to
Congress on a three-year pilot program allowing enrolled veterans to
access outpatient mental health and/or substance use services through
community care network providers without referral or pre-authorization.
This pilot program would be conducted in areas with varying degrees of
urbanization, locations with high rates of veteran suicide, overdose
deaths, calls to the Veterans Crisis Line, and long wait times for VA
mental health and substance use disorder services. The VA would also be
required to develop a care coordination plan with appropriate oversight
and patient safety plans to monitor and support veterans participating
in the pilot.
The bill requires development of robust metrics and measures to
track and oversee the program's implementation, patient safety, and
patient outcomes. Annual reports would be required to the Committee on
Veterans' Affairs, detailing the number of participating veterans and
health care providers, program effectiveness, costs, and other relevant
matters.
We appreciate the intent behind the proposed pilot program aimed at
improving access to outpatient mental health and substance use services
for veterans. However, we have significant concerns about the bill's
lack of a requirement for clinical authorization for such care from the
VA.
While we fully support the goal of enhancing access to critical
mental health and substance use services, the absence of a clinical
authorization requirement raises serious questions about the quality
and coordination of care. Clinical authorization is a key element in
ensuring that veterans receive appropriate, evidence-based treatment
that is tailored to their individual needs. Without this oversight,
there is a risk of fragmented care, potential overuse or misuse of
services, and the potential for insufficient monitoring of treatment
outcomes.
The VA has a comprehensive understanding of veterans' unique health
care needs and a robust system for coordinating care across the system.
By bypassing clinical authorization, the bill may undermine the VA's
ability to properly manage and oversee the delivery of care
effectively. This could result in inconsistent treatment plans, gaps in
care continuity, and ultimately, negative impacts on veterans' health
outcomes.
We recommend that the bill be amended to include a requirement for
clinical authorization from the VA for all services provided under the
pilot program. This would ensure that veterans receive high-quality,
veteran-centric, coordinated care that aligns with best practices and
leverages the VA's expertise in managing veterans' health care and
these specialized services. Incorporating this requirement will
strengthen the program's effectiveness and safeguard the well-being of
our veterans.
In conclusion, while we understand and support the intent of the
pilot program, we urge the Committee to address the critical concern of
clinical authorization. Ensuring that the VA retains a central role in
authorizing and coordinating care will enhance the program's success
and better serve our nation's veterans. We appreciate the opportunity
to submit this statement and welcome further discussion on this
important matter.
H.R. 1041, the Veterans 2nd Amendment Protection Act
and
Discussion draft to prohibit the VA Secretary from transmitting certain
information to the Department of Justice for the NICS list.
The federal Gun Control Act of 1968, as amended, prohibits certain
classes of persons from purchasing or possessing firearms and
ammunition. One of the classes of prohibited persons are those who have
been ``adjudicated as a mental defective.'' A person may be
``adjudicated as a mental defective'' if a court, board, or commission
finds that they are a danger to themselves or others.
Under the provisions of the Brady Handgun Violence Prevention Act
of 1993, the Federal Bureau of Investigation (FBI) administers the
National Instant Criminal Background Check System (NICS) that allows
federally licensed firearms dealers to perform a required background
check on potential buyers to ensure they are not prohibited from
purchasing firearms and ammunition.
Historically, it has been the VA's policy to submit the names of
all beneficiaries determined to be incompetent to the Attorney General
for inclusion in NICS. However, incompetency within VA regulatory
provisions (38 C.F.R. 3.353) defines a mentally incompetent person as
someone who because of injury or disease lacks the mental capacity to
contract or to manage his or her own affairs, including disbursement of
funds without limitations. It does not address the requirement of a
finding that they are a danger to themselves and others.
On March 15, 2024, VA announced that through the remainder of
fiscal year 2024, VA would only report to the FBI NICS in instances
when VA was aware that a mentally incompetent beneficiary had been
found by a judicial authority to be a danger to themselves or others.
While VA implemented this change and updated its electronic reporting,
on March 11, 2024, VA stopped all weekly reporting to the NICS of
mentally incompetent beneficiaries.
These bills focus on two main provisions that are essential to
protecting veterans from unjust stigmatization and the loss of their
Second Amendment rights without proper due process:
The VA Secretary must notify the Attorney General that
the basis for transmitting personally identifiable information of a
beneficiary to the Department of Justice (DOJ) for use by NICS does not
apply, or no longer applies, if such transmittal was solely based on a
determination to pay benefits to a fiduciary.
The VA Secretary shall not treat a person as having been
adjudicated as a mental defective solely on the basis of requiring a
fiduciary.
Additionally, the draft bill would require notification of lack of
basis for the VA to have transmitted a veteran's information to the DOJ
on or after November 30, 1993, for placement on the NICS solely on the
basis of a determination by the VA to pay benefits to a fiduciary.
DAV supports these bills, to ensure that veterans are not unfairly
stigmatized or deprived of their Second Amendment rights based on VA
determinations without judicial oversight. Our veterans have dedicated
their lives to defending the freedoms we hold dear, and it is our
responsibility to safeguard their constitutional rights in return.
Discussion Draft, Student Veteran Benefit Restoration Act of 2025
Veterans have selflessly served our country, and it is our duty to
ensure they receive the benefits they have earned. Unfortunately, some
educational institutions have taken advantage of veterans, defrauding
them of their well-deserved educational assistance.
This draft bill, the Student Veteran Benefit Restoration Act of
2025, would restore educational entitlements of those veterans who have
fallen victim to fraudulent practices and would not be charged against
their benefit entitlements. This includes periods when the institution
was not approved or engaged in fraudulent activities. Additionally,
educational institutions found guilty of fraud would be required to
repay the VA Secretary any funds received fraudulently. This ensures
that the burden of fraud is placed on the institutions rather than the
veteran.
DAV supports this draft bill based on DAV Resolution No. 238, which
calls for legislation that reduces and removes barriers to a service-
disabled veteran continuing their education. We must ensure that we are
protecting veterans and their hard-earned education benefits from fraud
and deceptive acts.
Mr. Chairman, this concludes DAV's statement for the record.
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Prepared Statement of Concerned Veterans for America
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