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

                         RIGHT TIME, RIGHT PLACE, RIGHT
                        TREATMENT WITH VA COMMUNITY CARE

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

                                    HEARING

                                  BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED NINETEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                             TUESDAY, JULY 15, 2025

                                   __________

                               Serial No. 119-30

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                        Available via http://govinfo.gov

                                    __________

                       U.S. GOVERNMENT PUBLISHING OFFICE
    61-357                     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 HEALTH

                   MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

    JACK BERGMAN, Michigan               JULIA BROWNLEY, California,
    GREGORY F. MURPHY, North Carolina        Ranking Member
    DERRICK VAN ORDEN, Wisconsin         SHEILA CHERFILUS-MCCORMICK,
    JEN KIGGANS, Virginia                    Florida
    ABE HAMADEH, Arizona                 MAXINE DEXTER, Oregon
    KIMBERLYN KING-HINDS, Northern       HERB CONAWAY, New Jersey
        Mariana Islands                  KELLY MORRISON, Minnesota

    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

                                  ----------

                             TUESDAY, JULY 15, 2025

                                                                       Page

                               OPENING STATEMENTS

    The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
    The Honorable Julia Brownley, Ranking Member.....................     3

                                   WITNESSES
                                    Panel I

    Ms. Dallas Knight, Founder & President, Operation Juliet, Army
      Combat Veteran.................................................     6

    Dr. Meaghan Mobbs, Ph.D., Director, Center for American Safety
      and Security, Independent Women's Forum........................     8

    Ms. Amanda Newman, Chief Executive Officer, Western Illinois Home
      Health Care....................................................    10

    Ms. Kristina Keenan, Director of National Legislative Service,
      Veterans of Foreign Wars of the United States..................    11

    Dr. Kyleanne Hunter, Ph.D., Chief Executive Officer, Iraq and
      Afghanistan Veterans of America................................    13

                                    APPENDIX
                        Prepared Statements Of Witnesses

    Ms. Dallas Knight Prepared Statement.............................    35
    Dr. Meaghan Mobbs, Ph.D. Prepared Statement......................   107
    Ms. Amanda Newman Prepared Statement.............................   111
    Ms. Kristina Keenan Prepared Statement...........................   116
    Dr. Kyleanne Hunter, Ph.D. Prepared Statement....................   121

                            Statement For The Record

    Cohen Veterans Network Prepared Statement........................   139

        RIGHT TIME, RIGHT PLACE, RIGHT TREATMENT WITH VA COMMUNITY CARE

                                  ----------

                             TUESDAY, JULY 15, 2025

                        Subcommittee on Health,
                        Committee on Veterans' Affairs,
                                 U.S. House of Representatives,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 2:43 p.m., in
    room 360, Cannon House Office Building, Hon. Mariannette
    Miller-Meek [chairwoman of the subcommittee] presiding.
        Present: Representatives Miller-Meek, Murphy, King-Hinds,
    Brownley, Cherfilus-McCormick, Dexter, Conaway, and Morrison.

       OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

        Ms. Miller-Meeks. Good afternoon. This legislative hearing
    of the Subcommittee on Health will now come to order. I would
    like to welcome all the members and witnesses to today's
    hearing. During this hearing, witnesses will share with us how
    U.S. Department of Veterans Affairs (VA) works hand-in-hand
    with private doctors and providers to meet veterans' specialty
    care needs throughout the VA Community Care Program.
        Data show that veterans like and want community care just
    as they like and want their VA healthcare system. Polling has
    shown that Americans want veterans to be able to access shorter
    wait times and drive times to get their healthcare. Through the
    John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA
    Maintaining Internal Systems and Strengthening Integrated
    Outside Networks (MISSION) Act, Congress has closed the gap
    that was crippling the delivery of care by the VA and
    oftentimes leaving veterans behind, stuck in line and waiting
    for an appointment. This was especially true for specialty
    care. By virtue of being in the community, these providers are
    closer to veterans and their homes than a brick-and-mortar VA
    facility. That can mean shorter wait times and drive times for
    veterans.
        Through the MISSION Act, the VA Community Care Program
    created new opportunities for more resources than ever to serve
    veterans. Veterans enjoy shorter wait times and drive times for
    specialty care appointments because VA is allowed to cover
    specialty care in the community. Veterans have more specialty
    care through VA because of community care, not less.
        Three key indicators today and on the horizon show that the
    VA will continue to rely on providers in the community to meet
    the moment for specialty care for veterans. First, demand will
    increase for all specialty care needs as more women use the VA
    for healthcare. By 2040, the VA estimates that women will make
    up 18 percent of all veterans. More women veterans means not
    just an increase in female-specific care, but an increase in
    specialty care services overall.
        Second, VA's workforce challenges mirror those of the
    healthcare industry as a whole. There is a national shortage of
    healthcare professionals, especially for physicians and nurses.
    The VA recently identified shortages for clinical roles like
    psychologist, medical technologist, diagnostic radiologic
    technologist, which is the same in the private sector. This is
    true across all VA facilities, even though this committee and
    the Veterans' Affairs Committee has increased pay to providers
    within the VA healthcare system. All of these roles play a part
    in, if not directly provide, specialty care for veterans. The
    higher the ratio between veterans and healthcare staff, the
    more veterans will need community providers for VA-covered
    specialty care.
        Third, and finally, the VA expects significant changes in
    demand for care in general, including specialty care. The VA
    projects major shifts in physical space demands for hospital
    operations by about 2030. Estimates range from an 850,000
    decrease in needed square feet in New Orleans, Louisiana, to a
    2,500,000 increase in needed square feet in Orlando, Florida.
    Having facilities where they are needed in accordance with the
    demographic shifts of the country, sometimes we are far behind
    where that movement occurs. These are but two of the many
    estimates projecting dramatic increases and decreases in demand
    for physical space across the country and one of the reasons we
    introduced the Communities Helping Invest through Property and
    Improvements Needed for Veterans (CHIP IN) Act in this
    committee, as well as increases for funding infrastructure
    within the VA.
        The VA also projects highly variable demand in different
    facilities across different types of care. I hope you will bear
    with me as I explain the numbers which paint a compelling
    picture of the veterans' healthcare needs.
        The VA expects a 50 percent growth nationwide in outpatient
    primary and specialty care combined. Relatedly, the VA also
    expects a 13 percent decrease in inpatient acute medicine and
    surgery nationwide. This, too, mirrors what we see in all
    healthcare sector. The VA expects an increase for inpatient
    acute mental health. That means more demand for psychiatric
    services at a hospital for severe mental health crisis. As we
    know from hearings here in this room, the VA did not consider
    residential mental healthcare or residential substance abuse
    part of the MISSION Act. That is a lot of variation.
        Even within these numbers, the VA expects significant
    differences in demand from region to region. For example, with
    inpatient acute mental healthcare, the VA projects a 6 percent
    decrease nationally in demand for inpatient acute mental
    health. When we dig another layer deeper, we see that the VA
    expects anywhere between a 19 percent decrease to a 14 percent
    increase across different regions of the country.
        I care deeply about mental health resources for veterans. I
    know that the VA will continue to provide valuable in-house
    care to veterans who need it. With so many variables, the VA
    cannot expect in-house care alone to meet different demands
    from different communities. Veterans need inpatient mental
    healthcare when they need it and when they are in crisis.
    Veterans need specialty care when they need it. A condition in
    need of treatment does not wait for the facilitary
    infrastructure to be built and to catch up. As a physician, I
    know this reality firsthand.
        A veteran should not wait for treatment when community
    providers are already available to meet a need. To best serve
    veterans, the VA should pursue whatever gets quality care to
    veterans when they need it. The VA serves all veterans when it
    opens the door to community providers equipped to care for
    veterans at the right time, at the right place, with the right
    treatment. As a 24-year Army veteran and physician, I am
    focused on working in lockstep with the administration to
    ensure that this happens. The future of veterans' healthcare
    depends on it.
        I now yield to Ranking Member Brownley for any opening
    remarks she may have.

          OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

        Ms. Brownley. Thank you, Chairwoman Miller-Meeks. At the
    outset of today's hearing, I would like to set the scene a bit
    by describing the situation in which veterans and the VA
    currently find themselves.
        First, veterans across the country are losing access to VA
    healthcare due to numerous actions taken by the Trump
    administration. Why is this happening? With each passing day,
    VA is becoming a less and less desirable place to work. Upon
    taking office, President Trump ordered a governmentwide hiring
    freeze. The haphazard implementation at VA meant the essential
    occupations initially were not exempted from the freeze. Job
    offers for key employees who were already in the onboarding
    process were rescinded, then reinstated, a flip-flopping that
    led many would-be hires to run the other way.
        Less than a month after that, VA terminated nearly 2,400
    probationary employees. While some have since been rehired,
    they may be terminated again after pending lawsuits have
    resolved. Many opted not to return after being offered their
    jobs back.
        Then as a result of the Trump administration's returning to
    office policy, tens of thousands of VA employees who had been
    hired into fully remote positions were directed to report to
    offices that were ill-equipped and ill-suited to accommodate
    them, with little consideration for the effect it would have on
    their productivity or the quality of care delivery.
        We heard a week ago that while VA is no longer planning to
    pursue a large-scale reduction in force, or RIF, it still
    anticipates losing nearly 30,000 employees by September 30th.
    That is about 6 percent of VA's overall workforce. This is
    happening through DRP, the Deferred Resignation Buyout Program,
    and VERA, the Voluntary Early Retirement Authority, as well as
    employees choosing to resign or retire without any incentives.
        As this chart shows behind me here, as of May 31, 2025,
    nearly 22,000 employees had separated from the Veterans Health
    Administration (VHA). While about half have been replaced, as a
    whole VHA has lost 10,310 more employees than it had hired so
    far this fiscal year. The Secretary has repeatedly claimed that
    veterans will not lose access to healthcare as a result of the
    Department's ongoing restructuring process.
        Maybe you are thinking that these losses are mostly
    nonessential occupations at VHA, but that is just simply not
    true. Losses of essential frontline employees are occurring at
    VA medical facilities nationwide.
        As the second chart shows VHA is currently operating at a
    loss of nearly 3,000 mission-critical employees since the start
    of this fiscal year. This is after making significant gains in
    the overall number of frontline employees during the same
    period last fiscal year. Those new hires were helping VA
    deliver record numbers of appointments and serve the influx of
    new enrollees that are coming into VA as a result of the The
    Sergeant First Class Heath Robinson Honoring our Promise to
    Address Comprehensive Toxics (PACT) Act.
        Where are the losses of essential employees most
    significant? Custodial workers, food service workers, nurses,
    physicians, social workers, employees that VA medical
    facilities simply cannot do without.
        At the Community-Based Outpatient Clinic (CBOC) that serves
    my constituents in Ventura, California, 7 out of 12 mental
    health providers have left. This is driving up wait times for
    mental health appointments. As of Friday, the new patient wait
    time for a mental health appointment was 101 days.
        Now, maybe you are thinking to yourself those veterans are
    eligible for community care and while that is true, they need
    VA staff to coordinate their care in the community. As this
    chart refers to, it shows that we are down more than 1,147
    medical support assistants nationwide since the start of the
    fiscal year. Those are the staff who help veterans find
    community providers and schedule their appointments.
        It does not matter that so-called mission critical VHA
    staff were not eligible for the DRP and VERA separation
    incentives. They are leaving anyway because VA has become a
    toxic, unpredictable, and hostile place to work. We are kidding
    ourselves if we think no RIF is the end of it and that the loss
    of employees will stop at 30,000 folks. These losses will
    continue to grow. As long as VA's workforce continues to
    suffer, all aspects of VA care, including community care, will
    suffer.
        Second, on July Fourth, President Trump signed the One Big
    Beautiful Betrayal Bill into law. By most analysis, this law
    and its 1 trillion cut to Medicaid will have a wide-ranging
    impact on the healthcare landscape in the United States.
    Researchers at the University of North Carolina have identified
    338 rural hospitals that are already at risk for closure.
    Future loss of Medicaid coverage will elevate the risk of
    financial distress for hospitals, long-term care facilities,
    and other providers, further reducing veterans' access to care.
        We cannot have a conversation about specialty care in the
    community without acknowledging both the strain that is
    currently being placed on VA's healthcare system and the strain
    that is about to be placed on non-VA providers. We should be
    shoring up VA care and making sure that there is capacity in
    the community when veterans need specialty care in the
    community. Instead, under this administration we are seeing a
    chaotic approach to delivering veterans' healthcare that
    undercuts VA's internal capacity, shifts more and more care to
    the community, and leaves veterans and VA employees in the
    lurch. Insisting that those actions will not impact veterans'
    healthcare does not make it so, and ignoring the unforeseen
    consequences of this administration's actions will not make
    them go away.
        As I have always acknowledged, VA will always need to offer
    some level of community care because they cannot do it all.
    However, for many veterans, VA is the right place for them to
    receive care. They know their provider understands their
    military service and what it means to have served their
    country. They know they will receive world-class healthcare
    backed up by world-class research. They know they will not have
    to explain to their VA provider what a presumptive condition is
    or their experience with Military Sexual Trauma (MST) or how
    their service impacted their mental health.
        We also lack oversight of the care that veterans receive in
    the community. We know wait times for VA appointments because
    VA publishes them. Community providers are not required to
    report their wait times or how long it will actually take a
    veteran to be seen.
        We know that VA providers have received training on
    military cultural competencies, suicide prevention practices,
    opioid safety, and many others because VA requires them to
    receive such trainings and report how they have completed them.
    Community providers are not required to take all of these
    trainings and veterans are not informed about whether their
    community providers have voluntarily taken such trainings.
        Based on the testimony from our witnesses, I think we can
    all agree that the administration of VA's Community Care
    Program needs reform. Unfortunately, we find ourselves convened
    for an oversight hearing where there are no VA officials
    present to respond to questions about the barriers and
    challenges highlighted by our witnesses. I think that does them
    a disservice and I would respectfully ask the chairwoman to
    invite Department witnesses to future oversight hearings so
    that we can have a more robust discussion about what is working
    well, what is not, and how to fix it.
        With that, Madam Chair, I yield back.
        Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
        Before I introduce our witnesses, I just want to be clear,
    our colleagues have spent the past 6 months yelling from the
    sidelines and should have held their criticism of potential
    plans until a plan was actually in place. It is public
    knowledge that the VHA loses about 9 percent of its workforce
    annually through regular attrition, or about 38,000 employees
    based on its current workforce. Those were the same statistics
    during the Biden administration and are the same statistics
    today. We also know the status quo is not working and will
    continue to cut through the nonsense and restore common sense
    at the VA to put veterans first.
        Additionally, during the past 4 years, the funding to the
    VA has dramatically increased. The numbers of employees
    increased by 80,000, yet the number of veterans applying for
    care had remained level nationwide. Most VA employees come to
    work and proudly serve our veterans. However, poor performing
    VA employees must be held accountable when they are not putting
    veterans first, and we will ensure that that message is clear.
        Chairman Bost, House Republicans, and myself have full
    confidence in Secretary Collins and the Trump administration to
    bring needed change to the VA. That is what we are focused on.
    I look forward to continuing to work with Ranking Member
    Brownley and those on the other side of the aisle so that we
    can affect real change for veterans that the VA serves.
        Testifying before us today, as I would now like to
    introduce our witnesses, Dallas Knight, founder and president
    of Operation Juliet. She is an Army combat veteran. Meaghan
    Mobbs, director of the Center for American Safety and Security
    at Independent Women's Forum. She is a clinical psychologist
    and also an Army combat veteran. Amanda Newman, Chief Executive
    Officer (CEO) of Western Illinois Home Health Care. Western
    Illinois has operations close to my district. Kristina Keenan,
    legislative director at Veterans of Foreign Wars (VFW) and an
    Army veteran as well. Kyleanne ``Kai'' Hunter, CEO of Iraq and
    Afghanistan Veterans of America and Marine Corps combat
    veteran.
        Ms. Knight, you are now recognized for 5 minutes to present
    your testimony.

                       STATEMENT OF DALLAS KNIGHT

        Ms. Knight. Chairwoman, Ranking Member, and members of the
    subcommittee, my name is Dallas Knight. I am an Army combat
    veteran and the founder of Operation Juliet, a nonprofit
    serving female veterans.
        I joined the Army just 2 months before 9-11, intending to
    gain experience and work for the Drug Enforcement
    Administration (DEA). I had no idea how real that experience
    would become. I deployed to Iraq in 2003, and returned a year
    later with invisible wounds far worse than the physical ones. I
    avoided the VA after learning Post-Traumatic Stress Disorder
    (PTSD) diagnoses would revoke your security clearance, My
    entire career plan. I stuffed it down, I stayed silent, and I
    told myself I was fine for 17 years. Eventually, the weight of
    what I saw, felt, and endured caught up with me.
        Finally, after enrolling in VA Healthcare, I walked into
    the Billings clinic for my first appointment and was asked if
    my husband needed help. Apparently, I did not look like a
    veteran. That first appointment stuck with me. When I was asked
    if I had suicidal ideations, I said not recently. The provider
    responded by lecturing me on how selfish it would be to leave
    my children without a mother. Then, when I disclosed military
    sexual trauma, I was referred to a psychologist and handed a
    stack of prescriptions. No conversation about healing, just a
    follow-up call from a man temporarily filling in as the State
    MST coordinator, notifying me I would be receiving a pamphlet
    in the mail.
        At a neurology appointment, I was asked for graphic,
    unnecessary details about my Traumatic Brain Injury (TBI)
    trauma. It felt more like an interrogation, questioning my
    integrity, rather than a consultation, only stopping when the
    doctor noticed my visible discomfort. Despite our encyclopedia-
    sized files, we are expected to rehash and relive the very
    traumas we are trying to escape. I do not believe these VA
    providers intended harm, but they were clearly undertrained and
    unequipped to treat trauma. That is when I realized there must
    be better care available.
        Because no one explained trauma-informed therapy, no one
    told me about community care and other options, those options
    were only discovered from other veterans, helping me to
    navigate the system, a lifeline passed from veteran to veteran.
    Requests for alternative therapies often took weeks, sometimes
    months for a response. I have hung up on my boss, my son, and
    walked out of meetings just to answer the VA's call, afraid of
    missing a rare chance at care. As I scrambled to choose a
    provider from a rushed list, no context, no ratings, no
    reviews, I hung up relieved just to have an appointment at all.
        I am not alone in my frustrations and disappointments. I
    told my community I would be standing before you here today and
    within days, nearly 600 women veterans responded, eager and
    desperate to be heard, hundreds of female veterans describing
    waiting months, sometimes over a year, for critical referrals,
    specialty care or community-based treatment. These delays often
    compounded existing mental and physical health issues, leaving
    veterans to suffer in silence.
        Veterans living in rural or underserved areas detailed the
    near impossibility of accessing timely and appropriate care.
    Many faced multi-hour drives, limited provider options, and a
    lack of female clinicians or trauma-informed specialists. For
    these women, geographic isolation added another barrier to
    healing, making community care feel like a broken promise.
        Veterans who bravely disclosed histories of military sexual
    trauma shared disturbing accounts of re-traumatization within
    the VA system. Common themes included being forced to recount
    trauma repeatedly, being assigned male providers despite
    requests for female clinicians, and being denied or delayed
    access to mental health support. The lack of MST-sensitive
    pathways reflects a systemic failure to prioritize survivor
    safety and dignity.
        I have hundreds of stories but only 5 minutes to speak, so
    I ask that you take the time to read their stories that I have
    submitted to you. There is one story that I carry most heavily
    with me today. Lynessa Van Kirk was born February 21, 1989;
    Army Military Police (MP) sergeant, daughter, sister, friend,
    hero. I never met Lynessa, but I know her through her mother,
    now living every parent's worst nightmare. Lynessa served her
    country with honor. She asked for help repeatedly, but she was
    denied, delayed, ignored, and even sexually assaulted at a VA
    inpatient treatment facility. The VA failed her repeatedly. On
    April 30, 2022, at just 33 years old, Lynessa died from the
    long-term effects of untreated PTSD and trauma, left in a
    hospital bed with hematomas, liver failure, and no more
    chances.
        Today, I am not just asking you to hear me. I am asking you
    to hear all of us. Hear the hundreds of women who have come
    forward. Hear Lynessa. Female veterans are not invisible. We
    are not dramatic or broken. We are warriors, leaders. We are
    asking boldly, urgently for a system that sees us, hears us,
    and serves us with dignity.
        Thank you for your time.

        [The Prepared Statement Of Dallas Knight Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Ms. Knight.
        Ms. Mobbs, you are now recognized for 5 minutes to present
    your testimony.

                       STATEMENT OF MEAGHAN MOBBS

        Dr. Mobbs. Chairwoman Miller-Meeks, Ranking Member
    Brownley, and members of the subcommittee, thank you for the
    opportunity to testify today. My name is Dr. Meaghan Mobbs and
    I am the director for the Center of American Safety and
    Security at Independent Women. I am a combat veteran, former
    Army officer, and clinical psychologist who specialized in
    trauma, transition stress, and post-military reintegration. I
    trained in the VA system and currently teach through the
    Veterans Mental Health Primary Care Training Initiative for the
    New York State Psychiatric Association, helping civilian
    physicians better recognize and treat veterans.
        I have been on all sides of the system: soldier, clinician,
    educator, and advocate. I have walked beside fellow veterans
    struggling to navigate the very bureaucracy designed to serve
    them. In 2018, when President Trump signed the bipartisan VA
    MISSION Act, it was more than legislation. It was a solemn
    promise that what happened to the Phoenix VA, where veterans
    died waiting for care, would never happen again. The Community
    Care Program was created to fulfill that promise. It
    acknowledged that while the VA is indispensable, it is not
    omnipresent. Too often, bureaucracy stood where medical support
    should have.
        This program was never meant to be a replacement, but it
    was a direct response to institutional failure. It intended to
    put outcomes over promises and patients over paperwork. We have
    not yet fulfilled that promise. Let me place it in some
    context.
        In 2001, the VA's hospital administration budget was 20.9
    billion. At that time, we were tragically losing about 16.5
    veterans a day to suicide. In 2024, after decades of war and
    exponential growth in funding, now approximately 121 billion,
    we are still losing 17.6 veterans a day to suicide. What faces
    us is not a funding problem. It is a function problem and a
    failure to adapt and decentralize to meet veterans where they
    are.
        Veterans are still waiting weeks or driving hours for care
    they should receive promptly and locally. Medical decisions are
    too often driven by bureaucrats and not doctors. Community Care
    was created to fix this. Today it provides nearly 40 percent of
    all VA delivered care, and it is working. Veterans use it. They
    are satisfied with it, especially in rural areas it has become
    a lifeline. Instead of expanding it, some VA administrators
    have undermined it.
        We have heard the stories. Last year, a Portland VA
    official admitted they were intentionally keeping care in-
    house, even where referrals were warranted. In Buffalo, a
    veteran with cancer had his radiation therapy referrals denied
    and then canceled, and he died in pain. To move forward, we
    need a Community Care Program rooted in four principles:
    flexibility, accessibility, rapidity, and accountability.
        First, flexibility. Veterans live in rural towns, suburbs,
    and cities. They raise families, hold jobs, and carry injuries
    both visible and invisible. They deserve a care system that
    reflects that complexity. Community care gives them access when
    the VA is too far, too slow, or lacks the right specialists.
    That flexibility is especially crucial for women veterans.
    Seventy percent prefer female providers for woman-specific care
    and 50 percent even for general care. Recently, a VA facility
    went 2 years without a full-time gynecologist.
        Second, accessibility. Only 55 percent of veterans live
    within 40 miles of a VA facility and just 26 percent live near
    specialty care. Community care reduces the physical and
    financial burden of long-distance travel, and that improves
    health outcomes and trust and adherence. With women expected to
    make up nearly 20 percent of the veteran population by 2040,
    many from minority backgrounds, we need a system that reflects
    today's demographics, not those from 50 years ago.
        Third, rapidity. Delayed care is denied care. Veterans do
    not need treatment eventually, they need it now. Today's
    eligibility thresholds are arbitrary. I have personally worked
    with veterans denied mental health services because they were
    not sick enough or were forced into treatment that they did not
    want. Whether it is PTSD, chronic pain, or substance use, every
    delay or denial feels like administrative cruelty, and it is
    costing lives.
        Fourth, accountability. Since 2018, the U.S. Government
    Accountability Officer (GAO) has issued 27 recommendations to
    approve the Community Care Program and, as of this year, only 9
    have been fully implemented. The lack of enforceable standards,
    inconsistent referral coordination, and inadequate oversight
    does undermine the program. We need to measure timely access
    and continuity of care. Otherwise, we are building a system
    that is blind to its own failures.
        I want to commend Secretary Collins for accelerating the
    implementation of the Senator Elizabeth Dole 21st Century
    Veterans Healthcare and Benefits Improvement Act and it is a
    meaningful step forward. Let me be clear, it is not enough to
    offer a door. We must ensure that door is open, functional, and
    that it leads somewhere worth going.
        I believe deeply in the VA. I trained there. I have
    referred patients there, but no single system can meet every
    need in every place at every time for every veteran. Community
    care is not an indictment. It is just an extension of the
    promise we made. Veterans do not need more bureaucracy. They
    need choice, they need speed, and they need a system built to
    serve them, not the other way around.
        Thank you and I look forward to your questions.

        [The Prepared Statement Of Meaghan Mobbs Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Ms. Mobbs.
        Ms. Newman, you are now recognized for 5 minutes to present
    your testimony.

                       STATEMENT OF AMANDA NEWMAN

        Ms. Newman. Thank you, Chairwoman Miller-Meeks, Ranking
    Member Brownley, and the members of the committee for the
    opportunity to speak on the critical topic of the VA's
    Community Care Program. Thank you for the important legislation
    that you have successfully led through the legislative process
    to support veterans. I am honored to speak on behalf of the 121
    Illinois veterans that we serve in our agency and on behalf of
    veterans served by Home Care Association of America members
    across the Nation.
        I am the second generation running a family owned home care
    agency in West Central Illinois. We cover a 10-county, mostly
    rural area and have worked with the VA for over 30 years. We
    currently do so as a contracted provider in the VA Community
    Care Network operated by Optum.
        Community care is not an alternative to the VA, it is an
    extension of it. For many veterans, especially those living in
    rural areas, community care represents a vital lifeline. These
    veterans often face long travel times or limited services at
    local VA facilities, making care in the home a necessary
    option. The success of community care hinges on a shared
    commitment to veteran-centered, team-based care where VA and
    community providers work in partnership, not in competition.
        Over our 30 years working with the VA, we have always had
    good relationships with the Veterans Integrated Service Network
    (VISN) 23 Veteran Affairs Medical Center in Iowa City and our
    local VA outpatient clinic in Galesburg, Illinois, working
    together to meet veteran needs. Our experience has been that
    process changes within the VA in the last year have created
    barriers to veteran access and care. These changes do not
    appear to be in line with the spirit of the MISSION Act.
        Three key barriers to veteran access that I have seen are
    the VA reducing or eliminating community care services for many
    veterans who have qualified for and relied on these services
    for years; harming care stability and consistency for veterans
    by reducing authorization periods from the prior standard of 12
    months to 6 months or less, creating uncertainty for the
    veteran and an overwhelming workload for the VA staff who
    process authorizations; in the 2025 nonbundled fee schedule,
    reducing rates to a point where veterans, especially in rural
    areas, are at risk of losing critical services because the fee
    schedule does not provide adequate reimbursement given the
    travel involved.
        I would like to tell you about two of our veterans who
    asked me to share their story. One veteran we care for is 79
    years old. He lives alone in a small rural town and has
    difficulty controlling his diabetes. He cannot cook for himself
    or safely navigate the stairs in his home to do laundry. He was
    denied homemaker services. When we requested Physical Therapy
    (PT) to help him safely ambulate, this was also denied.
    Instead, they required him to drive 53 miles each way in the
    winter twice a week to go to the VA clinic for PT.
        We serve an 85-year-old veteran who has difficulty
    ambulating. He uses a cane due to a stroke and cannot stand for
    long. He was denied home health aid services because he
    reported on the phone that he can shave his beard. However, the
    VA team failed to take into account his ability to perform
    other activities of daily living, such as bathing, ambulating,
    or dressing.
        Community care enhances access, expands capacity, and
    supports choice for veterans without replacing the foundational
    role of the VA. Community care is not a workaround. It is a
    necessary part of a comprehensive veteran first healthcare
    system. When community providers and the VA work together,
    veterans benefit from timely, compassionate, and coordinated
    care delivered wherever they are, whenever they need it.
        We have an opportunity and a responsibility to ensure that
    every veteran receives care that is timely, high quality,
    coordinated, and close to home. By strengthening community care
    as a complement to VA services, investing in home care and
    rural access, and ensuring providers are supported through fair
    reimbursement, we can fulfill the VA's sacred mission to those
    who have served.
        I thank you for your time and for your continued commitment
    to the health and dignity of America's veterans.

        [The Prepared Statement Of Amanda Newman Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Ms. Newman.
        Ms. Keenan, you are now recognized for 5 minutes to present
    your testimony.

                      STATEMENT OF KRISTINA KEENAN

        Ms. Keenan. Chairwoman Miller-Meeks, Ranking Member
    Brownley, and members of the subcommittee, on behalf of the men
    and women of the Veterans of Foreign Wars of the United States
    and its auxiliary, thank you for the opportunity to provide the
    VFW's remarks and my personal story on the topic of community
    care.
        VA's Community Care Program and its network of providers
    are a vital component of VA healthcare, particularly for
    specialized care that VA does not provide. Community providers
    are force multipliers, allowing VA to offer the world-class
    care that veterans prefer while also ensuring they have access
    to a range of services when they need them. When used
    appropriately, community care can save lives and improve health
    outcomes.
        However, problems with the coordination of that care can
    drive veterans away from VA altogether. VFW members have
    identified several coordination issues, including delays in VA
    paying for community care in a timely manner. VA referrals can
    also be unclear, especially understanding the types of care
    that are authorized, including lab work and procedures.
    Scheduling appointments for community care is also a reported
    point of confusion for our members. Not every VA medical center
    informs veterans when they have the option to use community
    care, nor when the veterans should set up the appointments or
    --and if and when VA will schedule them.
        I have personally experienced these issues as nearly all of
    my woman-specific care has been in the community. The first
    time I had a mammogram, it took VA 6 months to pay the $700
    bill. I had to call both VA and the community provider several
    times and began receiving collections notices until the bill
    was paid.
        I have also used community care for maternity care, a type
    of specialized care that VA does not provide at all through its
    direct care. The coordination of that care has been a source of
    frustration and stress at times. I actually had a pregnancy
    last year which sadly ended in miscarriage. My VA maternity
    care coordinator twice received incorrect information from my
    community provider and called me to ask me why I was trying to
    terminate my pregnancy. She called me at a later date and asked
    why I had proceeded with a termination procedure not approved
    by VA. In both instances, I had to tell her that her
    information was incorrect and then explain and re-explain that
    my pregnancy had not been viable. This is an example of poor
    record-sharing between community providers and VA, resulting in
    painful conversations made with an administrator and not even
    my primary care physician.
        I am currently using VA-coordinated maternity care again as
    I became pregnant this spring and have successfully made it
    into my second trimester. I am currently struggling with the
    bureaucracy of having genetic tests conducted by my community
    provider. Because of my age, the provider finds them especially
    necessary. After exchanging several secure messages with VA
    about billing codes, I was told that two of the tests should be
    covered by VA, but that I should also confirm with the lab,
    likely LabCorp, to verify with them that the tests are indeed
    covered by VA's insurance provider, Optum. This does not feel
    like VA has approved these tests if I have to discuss the
    billing codes myself with the non-VA provider, a subject with
    which I have no familiarity. If I accept a test that VA does
    not cover, that could be thousands of dollars that I have to
    pay out of pocket.
        Despite these and other coordination issues mentioned in my
    written statements, I am very happy with the quality of care
    that I have received in the community and I like that I have
    had the choice of my providers. We must find ways to improve
    the coordination of community care.
        The VFW supports Chairman Bost's H.R. 740, the Veterans
    Access Act of 2025, as it represents a critical step forward in
    enhancing access to community care for veterans. Additional
    legislative measures should also be considered to address the
    issues that I and VFW members have mentioned. While veterans
    consistently report to us that they prefer direct care at VA,
    when needed community care should be coordinated appropriately
    and not create additional bureaucratic frustrations for
    veterans.
        Chairwoman Miller-Meeks, Ranking Member Brownley, this
    concludes my testimony. I am prepared to take any questions you
    or the subcommittee members may have. Thank you.

        [The Prepared Statement Of Kristina Keenan Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Ms. Keenan.
        Ms. Hunter, you are now recognized for 5 minutes to present
    your testimony.

                      STATEMENT OF KYLEANNE HUNTER

        Dr. Hunter. Chairwoman Miller-Meeks, Ranking Member
    Brownley, and members of the committee, thank you for the
    opportunity to testify today. I am the CEO of Iraq and
    Afghanistan Veterans of America, but I am also a public policy
    researcher and a service-connected disabled veteran who
    utilizes VA services.
        I am honored to represent the post 9-11 veteran community.
    This is a diverse population with unique healthcare needs,
    which includes illnesses and injuries that are a result of
    cumulative and compound exposures, latent impacts of blast-
    related injuries, and the interaction of several physical and
    mental healthcare issues. Community care is a vital part of
    overall veterans' healthcare, but especially as we consider
    rising costs, we need to be clear that the evidence does not
    bear out that community care is a meaningful replacement for
    all direct VA care. For a detailed discussion of the research
    underlying this, I ask that you please reference my written
    testimony that has been submitted for the record.
        Community care does play a critical role for some patients
    and this is most evident for veterans who live in rural or
    remote areas for whom it would be time prohibitive to travel
    for direct care or for those who need specialty care that has a
    narrow focus or serves a small population and it would not be
    efficient or effective for the VA to maintain these services.
    However, the evidence is also clear that VA direct care
    provides better health outcomes for the majority of veterans.
        First, direct care does have lower wait times than
    community care and wait times are not about convenience or
    hassle, but about health and well-being. Prolonged wait times
    are associated with deteriorating health outcomes among
    multiple dimensions. When compared to community care, direct
    care has markedly better health outcomes, such as a
    significantly lower postsurgical 28-day mortality rate, lower
    hospital readmission rates, and quicker hospitalization return
    to work rates.
        For our most vulnerable veterans, the disparity of outcomes
    is even more stark. For suicide rates, veterans who receive
    community care have a 25 percent higher suicide rate than those
    enrolled in VA direct mental healthcare, and too many of our
    post 9-11 veterans are falling into this category.
        VA direct care also has more positive outcomes related to
    toxic screenings for veterans with compound exposures, which
    include environmental toxins, traumatic brain injuries, acute
    injuries, and mental health conditions. Evidence from PACT Act
    implementation, a process many of our veterans have benefited
    from, shows that VA direct care providers were able to identify
    exposure-related illnesses at a faster and more accurate rate
    than community care providers.
        VA direct care does not just provide better patient
    outcomes, it provides cost savings to the U.S. Government. In
    side-by-side comparisons with community care, VA patients have
    a 24 percent year over year primary and preventive care cost
    savings. More contributing to the cost savings, veterans
    receiving direct care experienced 43 percent fewer
    hospitalizations, 58 percent fewer days when they were in a
    hospital, and 43 percent outpatient surgical procedures. As
    more patients are being seen by the VA, we will see more cost
    savings.
        Between fiscal years 2023 and 2024, the VA saw 14 million
    additional episodes of care. This upward trend is indicative of
    both the expanded population that is seeking VA care and the
    conditions most common in post 9-11 veterans that require well-
    coordinated and integrated care, which leads to the fact that
    the VA is unique in its ability to coordinate care between
    primary and specialty care providers through its patient-
    aligned care teams. This reduces the burden on the veteran for
    scheduling and managing their own care, and ensures that
    veterans do not receive unnecessary medical treatment. Many
    recent studies have found that community care providers too
    frequently administered high-cost and medically unnecessary
    procedures to veterans without coordinating with their care
    teams, thereby exposing veterans to unnecessary treatment
    without medical benefit.
        VA-run community-based outpatient clinics also provide a
    necessary direct care service in many areas that there is not
    one of the 170 VA medical centers. These should be expanded
    upon and invested in at this time. In my written testimony I
    detail the importance of investing in CBOCs in four key areas
    that align with the Veterans Service Organization (VSO)
    independent budget recommendations. By focusing on targeted
    expansions and improvements, CBOCs can more fully realize their
    designated purpose.
        Community care is best used when originally intended, to
    meet the needs of those patients in rural and remote areas and
    for particular specialty care. For the majority of veterans'
    healthcare needs, the evidence presented just indicates that VA
    care is better care.
        Thank you and I look forward to your questions.

        [The Prepared Statement Of Kyleanne Hunter Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Ms. Hunter.
        I just want to take a moment to, this is I think a little
    unusual, but thank our witnesses for their service. Four of our
    witnesses have served, so thank you for your service.
        As is my typical practice, I will reserve my time until all
    of the members have had a chance to ask their questions. I now
    recognize Ranking Member Brownley for 5 minutes for any
    questions she may have.
        Ms. Brownley. Thank you, Madam Chair. I, too, want to thank
    all of you for your service to our Nation's veterans. We
    appreciate it very, very much.
        Dr. Hunter, I appreciate that in your testimony you
    highlighted the importance of military cultural competency and
    training. Can you expand on why VA providers are so uniquely
    positioned to care for veterans and what it means for your
    members that their providers understand their unique needs?
        Dr. Hunter. Thank you so much. VA providers are required to
    undergo extensive training on military cultural competency.
    This includes things like multiple compound exposures, whether
    it is toxins, the interaction between mental and physical
    healthcare, as well as emerging research on some of our
    technologies. Additionally, VA providers, some of which are
    actually cleared to be able to access classified medical
    records and so they can understand environmental exposures that
    were there.
        For myself, this was life-saving. At a regular, routine
    optometry appointment that I had where I was experiencing
    vision changes, and I thought it was because maybe I was just
    over the age of 40, my VA optometrist was able to connect
    symptoms I was experiencing to exposures from my service time
    and get me screened for ocular melanoma. Turned out I had it.
    We caught it super early at this case, but in every single
    community care optometry appointment I had, not once had I been
    asked about my time in military service, where might I have
    been, the type of exposures that I would have seen.
        If we look at the post 9-11 generation and we look at what
    was found in the PACT Act, the ideas of presumptive connections
    for things like toxic exposures, but we are seeing more and
    more aviation equipment, the time around fueling, as well as
    the compound traumas with military sexual trauma and PTSD, it
    is essential that our veterans are seen by providers who
    understand that. In the community, while the MISSION Act says
    they should have training, we actually have no idea what sort
    of training they are getting. We do not have oversight on that
    in a real and meaningful way, the way we do have oversight on
    the types of training that VA providers have.
        Ms. Brownley. Thank you for that. I think in reading Dr.
    Mobbs' testimony, she cited a RAND's article --excuse me, a
    Research and Development (RAND) article stating that or at
    least making the assertion that VA providers are not trained. I
    know that you have previously worked at RAND. Are you familiar
    with this article at all?
        Dr. Hunter. Yes, I was one of the contributing authors to
    that study.
        Ms. Brownley. Is that true what the conclusion of that
    article said?
        Dr. Hunter. No, the article said that we are aware of the
    training that VA providers received. We do not have oversight
    on the training that community care providers received.
        Ms. Brownley. Thank you for that. Another thing I
    appreciate about your testimony was that you included extensive
    citations throughout to articles in academic journals, to
    studies from nonpartisan entities, like RAND, GAO, and the
    Congressional Budget Office (CBO). One thing that worries me
    about the way legislation sometimes comes together is that it
    is informed by anecdotes and the experiences of perhaps a vocal
    minority voice rather than by the true evidence. What does the
    evidence say about where veterans prefer to receive their care
    and where the quality and outcomes are better?
        Dr. Hunter. The preponderance of the evidence shows that
    veterans prefer VA care. When we look at some of the very, very
    tragic stories that we see and the antidotes that we hear, we
    need to take every single one of them seriously and look into
    what has happened. The VA does have significant measures to
    actually address providers that provide subpar care. We also
    need to be reminded, as I was often in my doctoral studies,
    that the plural of antidote is not data. If we look at the
    preponderance of the data, the data lead us to VA care
    providing better care. In surveys of our own members, only 14
    percent express any confidence in community care being able to
    address and coordinate their complex medical needs.
        Ms. Brownley. Thanks for that. You know, do you have any
    suggestions on really how we help veterans, the public for that
    matter, to better understand the evidence and overcome this
    perception that the VA care is not as good as community care?
        Dr. Hunter. I think it is very incumbent upon VSOs to take
    an educating role on what the VA is and also incumbent on
    Members of Congress to continue to engage with VA providers to
    ensure that we have appropriate oversight and engagement to
    understand the quality of care that exists.
        Ms. Brownley. Thank you for that. I yield back.
        Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
        I now recognize Dr. Murphy for 5 minutes for any questions
    he may have.
        Mr. Murphy. Thank you, Madam Chairman. Thank each of you
    for your service and the work that you are doing to try to make
    our care for our veterans as best as possible, regardless of
    where it comes from.
        You know, I wish this was not an either/or kind of
    situation. This needs to be an and/yes, a yes/and situation,
    because the VA cannot handle all the healthcare that it needs
    to handle for our veterans, period. There are not the
    resources, some of which is negligence, on the behalf of the
    medical education system of the United States. We simply do not
    have the doctors. We simply do not have the doctors. It just
    kind of hurts me that people want to say this is better, that
    is better, and against one care or the other.
        Dr. Hunter, since you brought it up, if you do not mind, I
    am going to ask you about your ocular melanoma. Are you saying
    that the VA doctor picked that up because they knew you might
    be exposed to something or are you saying your optometrist out
    in the community missed it?
        Dr. Hunter. I had had a appointment with a optometrist out
    in the community who did miss it. Six months later, I had an
    appointment with an optometrist at the VA who was able to
    recognize it.
        Mr. Murphy. Did the optometrist do an ocular examination?
    Did he look in your eye and look all around your quadrants?
        Dr. Hunter. Yes.
        Mr. Murphy. Did you, by any chance, get films from them
    before then? Because they always make films.
        Dr. Hunter. My ----
        Mr. Murphy. Because ocular melanomas can happen in 6
    months.
        Dr. Hunter. Yes, yes, there were films. It was present in
    the films when my VA provider had reviewed them later on, and
    it was not discussed or addressed ----
        Mr. Murphy. I would just submit that that is a difference
    between two physicians. It does not matter where they are
    coming from, whether you could flip them the other way itself.
    To say one is better just because of the place where they work,
    I think is just not being correct.
        Also, delving into some of your comments about
    postoperative care, can you give me a breakdown of the type of
    patients that are referred out to community care for surgery
    versus those that are kept in-house?
        Dr. Hunter. I can take that question for the record and get
    you the breakdown.
        Mr. Murphy. I can tell you what it is. You do not refer
    things out to the VA unless it is specialty care. I am a
    specialty surgeon. I get specialty referrals for specialty care
    that cannot be happened within the hospital. By definition,
    those are more costly because they are more time-effective,
    they are more specialty-oriented, and their risk rates are
    higher. Doing, actually, a risk ratio would be factual to this
    rather than just saying postoperative care is better at the VA,
    the outcomes are better than they are in the community, because
    they are two entirely different populations. You refer people
    out who need specialty care, who, by definition, have greater
    needs than they do.
        I just do not like the tenor that we are putting, they were
    battling against, you know, saying that community care doctors,
    of which I am one, are better or are worse. I do not think that
    is fair. That is not fair to our veterans. Then what are you
    saying to them? Anybody who gets referred out, well, we are
    saying we are sending you out for inferior care? That is not
    fair. I do not think that is fair.
        Ms. Knight, let me ask you this. You know, and there are
    questions about, which has bothered me since I have been on
    this committee, about our electronic medical record, which I
    think is just derelict in the VA through how many
    administrations that we have been going through. I still
    cannot. I had a patient last week who was a VA and I said, did
    you bring your records? He said, no, they said you would have
    them. Of course, they never sent them, and I cannot get access
    to them. Can you explain to me how just the community care has
    helped you to access more or less --excuse me, giving you more
    or less access to VA-covered healthcare?
        Ms. Knight. I have more options. I live in Montana, so the
    biggest city in Montana at 150,000 people, so it is quite
    small, actually. There are not a lot of providers, let alone
    specialty providers, from within the VA. I see a chiropractor
    and an acupuncturist to help with my chronic migraines, of
    which neither are available within the VA. As I have shared in
    my testimony, I have had pretty horrid stories and experiences
    within the VA and good experiences within the community.
        My chiropractor, who is a male, actually took the time to
    review what information was passed to him from the VA with my
    referral and asked me on my preference on whether or not I
    wanted a man or a woman physician, which was the first time I
    have ever been asked as a proactive manner on my preference,
    given my military sexual trauma.
        Mr. Murphy. There are good experiences or bad experiences,
    really, probably within both systems?
        Ms. Knight. Absolutely. I would ask to just have more
    control and choice over where I want to go. As I also mentioned
    in my testimony, most times the gatekeeper within the VA calls
    and says, here is your list of providers. Where do you want to
    go? I feel like I am on this ticking time bomb and of making a
    decision while, you know, momentarily taking a time out of my
    workplace, because it is usually Monday through Friday, 9 to 5.
    In that effort, my typical question is, well, what is closest
    to me as a convenience for me? Not necessarily are they man?
    Are they woman? Do they have good reviews? Can I do research on
    them? I would ask to better understand what my options are, so
    that I can make a more informed and educated decision for
    myself.
        Mr. Murphy. Thank you. You know, Dr. Mobbs, it hurt my
    heart to hear that somebody in administration would withhold
    care because they would not have the compassion, much less the
    medical competence, to send somebody out to the community and
    withhold care. I hope that person, I do not want to say
    disciplined, I hope they got shown the door because what an
    absolute disservice it would be to whoever veteran, sadly
    enough, if they die in pain because they did not get their
    radiation. That is horrible. That is a horrible story.
        Ms. Keenan, in your opinion, if you will, where does
    community care fit in?
        Am I already over? I am sorry, I have been yakking too
    much. I apologize. I will yield back.
        Ms. Miller-Meeks. Thank you, Dr. Murphy.
        The chair now recognizes Dr. Morrison for 5 minutes for any
    questions she may have.
        Ms. Morrison. Thank you very much, Madam Chair. I want to
    thank the witnesses for your testimony and thank you for your
    service to our Nation and thank you for sharing your very
    personal stories today. That is not easy to do and I know we
    are all to going grateful, so thank you for that.
        Today's hearing really touches on struggles and
    frustrations that are all too familiar to me as a physician.
    One of the reasons that compelled me to serve in Congress was
    my firsthand experience with how difficult navigating the
    healthcare system in our country can be at times. Patients and
    physicians have no shortage of exceedingly valid frustrations
    with navigating healthcare in the United States. A Gallup poll
    actually earlier this year found that one in four Americans
    ranked improving healthcare access and affordability as their
    highest priority. Over half of Americans ranked healthcare
    among their top three priorities for government leaders. There
    is no question that Americans are looking to their elected
    leaders to act on the issue of healthcare.
        The testimony from today's witnesses highlights the reality
    that like the majority of their fellow Americans, far too many
    veterans are facing barriers that prevent them from accessing
    the healthcare we made a commitment to provide. They are asking
    Congress to make meaningful progress toward improving their
    quality of care and making sure we are delivering on the
    promises we made to those who have served our country.
        Today's hearing title includes ``Right Time, Right Place,''
    and ``Right Treatment,'' and I could not agree more that
    pursuing improvements to healthcare at the VA does require
    considering time, place, and treatment. We should absolutely be
    evaluating whether veterans are receiving the care they need in
    a timely manner. We should absolutely be focusing on fostering
    and preserving the specialized care that research continuously
    demonstrates is critical to veteran health outcomes. We should
    absolutely be committed to reviewing cutting-edge scientific
    evidence and research to bring novel treatments to veterans
    without delay.
        However, if we attempt to pursue all of those goals without
    considering the present circumstances of the VA or preserving a
    commitment to evidence-based treatments and rigorous standards,
    then we cannot in good faith claim to be delivering on what
    veterans have asked of us. Losing an estimated 30,000 staff in
    less than 12 months will move veterans seeking direct VA care
    and coordinated community care away from the ``right time.''
    Devastating Medicaid cuts from the so-called One Big Beautiful
    Bill that President Trump signed into law threaten rural
    hospitals and access to community care, costing veterans the
    potential ``right places'' across areas that need it them most.
    I worry that if we are not vigilant, the pace at which
    community care funds are growing will strain VA research and
    direct care that is indispensable to getting to the ``right
    treatment.''
        Dr. Hunter, with that in mind, in your testimony you
    emphasize the importance of following the data. What does the
    data tell us about how to improve access to timely quality care
    at the VA?
        Dr. Hunter. Thank you so much for that. We share your
    concern and commitment for having the right care at the right
    time.
        The biggest thing that the data are telling us is the
    importance of investing in the patient-centered care teams that
    exist. Far too often these care teams are cut out of the loop.
    They are often sometimes the first employees to get cut or
    deemed nonessential. What we know is that they are the most
    essential.
        The other aspect that is incredibly important, as the data
    said, is to hold community care to some of the same rigorous
    standards and information sharing, so that the patient-aligned
    care team can effectively create an entire course of treatment.
    In our conversations with medical directors at the VA, what we
    are finding too often is that community care providers are not
    required to provide back the full course of treatment that they
    are engaging in with the patients, which makes it more
    difficult and adds time to having to understand what the
    patient is going through, and often leads to patients having to
    relive horrible stories and events time and time and again
    because there is not that coordination.
        Keeping that patient-aligned care team coordination as the
    center, investing in it, and strengthening the resources for
    that team is what is absolutely essential to get the right care
    to our veterans at the right time.
        Ms. Morrison. Thank you, Dr. Hunter. I agree. VA direct
    care is vital to meeting unique veteran health needs. There is
    no question that there are circumstances in which community
    care is appropriate and essential. This committee cannot claim
    a serious commitment to either while advancing legislation and
    cosigning leadership decisions that undermine VA's stability
    and capacity to deliver on its core missions.
        Thank you, Madam Chair. With that, I yield back.
        Ms. Miller-Meeks. Thank you. The chair now recognizes
    Representative King-Hinds for 5 minutes.
        Ms. King-Hinds. First of all, thank you to all of you for
    appearing before us today. Thank you for your service. I just
    have to say, man, go women power, because just phenomenal women
    appearing before this committee.
        I come from the Northern Marianas, where access to service
    is very limited. We do not have a CBOC. I think people are
    going to get sick of me saying that because I am going to say
    it over and over again until we actually do get access to care,
    which is why, you know, looking at community care programs is
    very important to me because of that reason.
        Now, one of the things that I am hearing from all of you is
    that things could be better with regards to the way we deliver
    those programs. There are gaps.
        Dr. Mobbs, is it ``Mobs''? You spoke of, in your written
    testimony that you submitted, you talked about a comprehensive
    metrics system that needs to be put in place. Can you just kind
    of dive into that a little bit? Because I am looking for
    opportunities to improve --to ensure that some of these
    challenges and gaps that we are talking about and hearing about
    today are actually addressed in the legislation and that we can
    improve the system.
        Dr. Mobbs. Thank you very much for that question. I think
    this is critically important. I am certainly a advocate for the
    --not the either/or, but the and. We have to have both a strong
    VA and strong community care.
        As part of that, the GAO has provided extensive
    recommendations regarding the opportunity to improve oversight
    and accountability around community care. In particular, some
    of the things that have been mentioned here do need to be
    improved upon. The ability to track scheduling performance, for
    example; metrics aligned with those timeframes are imperative;
    meaningful accountability around those metrics. Then, for
    example, the VA's referral coordination initiative, which was
    meant to streamline specialty care, has suffered from somewhat
    inconsistent implementation, unclear guidance about its use,
    and inadequate performance metrics.
        I would simply say that the work has been done around
    assessing VA Community Care opportunities for improvement. I
    would just say that we should be looking very extensively at
    the recommendations provided by GAO in order to enhance them.
        Ms. King-Hinds. Thank you for that.
        This is a question to you, Dr. Hunter, because I do agree.
    I am an attorney by practice, and, you know, when you appear in
    front of a jury, you have to submit data evidence. Right?
    Sometimes the anecdote does win. Too often, as a matter of
    fact, in the community that I come from, these stories are what
    I hear every single time I meet with constituents. For as long
    as I have sat in this committee, in this last 7 months, these
    are the stories that we hear.
        You know, you spoke of some of the gaps to include
    accessibility to recordkeeping and being able to have a more
    seamless process whereby there is a little bit more
    accountability with regards to the program itself. Can you give
    us suggestions as to how we can improve the current situation?
        Dr. Hunter. Thank you so much for that. Because, you know,
    again, we understand that this is not a either/or. That is not
    how this should be characterized. It is a yes/and. We really
    need to improve the coordination side of community care, so it
    is held to some of the same standards that VA care is.
        If we are thinking about the coordination piece, there are
    a few things that can be done. One is there needs to be some
    more deliberate looking into some of the VA modernization and
    the enterprise systems that are being rolled out. This work is
    sort of early on, preliminary. We are really excited to work
    with the committee to better understand and ensure that the
    electronic healthcare record system is being rolled out in an
    appropriate manner that allows for better coordination.
        Because right now, what we are seeing far too often is that
    the VA, where there are very well-coordinated records kept, is
    not able to communicate well with community providers, and
    things are falling through the cracks. We are not getting full
    care plans. We are not able to ensure that veterans are
    receiving the same standard and quality of care. First, making
    sure that process is going well, as well as ensuring oversight
    and enforcement of the quality standards and training that are
    required of our community care providers.
        You know, the MISSION Act said that needed to happen, but
    according to multiple independent medical associations, there
    is not yet a published transparent standard for what community
    care needs to meet or what sort of records need to be provided
    back to the VA care teams to ensure the comprehensive
    continuity of care. In those two areas, I think there is a lot
    of room to be done, and I think this committee is primed to be
    able to engage in that sort of oversight.
        Ms. King-Hinds. Thank you. I am out of time. I yield my
    time. I yield back.
        Ms. Miller-Meeks. Thank you very much, Representative King-
    Hinds.
        The chair now recognizes Dr. Conaway for 5 minutes for any
    questions he may have.
        Mr. Conaway. Thank you, Madam Chair. Thank you, ladies, for
    your service and your commitment to veterans and their
    healthcare. I want to make a few comments and observations.
        Since both sitting on this committee and what I have heard
    today, I hope there is consensus on this committee and across
    the House, across the government, that we need to have a strong
    VA healthcare system and that we need community providers
    because we know the VA does not exist everywhere, particularly
    in rural areas. We know this partnership needs to exist.
        One of the problems, as a physician, practicing physician
    for 30 years myself, worked on an Air Force base in New Jersey
    taking care of veterans and in the community and private
    practice, what my experience tells me and what I have read
    about and what the research shows and what we all know with the
    problems with our information system is that there is not
    coordination across those systems. Once you move outside of a
    system, even within hospitals in my own little State of New
    Jersey, getting records to move from hospital to hospital, if
    they are not on the same platform, is a very difficult thing to
    achieve. You will have, and particularly --and so you are going
    to have patients, if they move to different locales, having to
    repeat their stories. It is terrible when it involves things
    like trauma.
        When you are in a teaching institution, a resident might
    see you, might be a medical student, then a resident, then the
    attending. This is part of the teaching process in teaching
    institutions. Unfortunately, we will hear stories about people
    being re-traumatized as this information is collected. That
    iterative process in teaching institutions is part of driving
    great outcomes.
        I would also say that, you know, we have to rely on data,
    as you mentioned, and the data has been consistent over many
    years and repeated that VA care for veterans provides great
    outcomes. Veterans want the care there. If you think a moment
    about the different exposures, the experience in the military,
    where they have been, the experience of people taking care of
    numbers of veterans over the years that is unlikely to be
    replicated in most communities, it does not surprise me that
    outcomes are better in the VA system.
        Our problem is that it is hard --well, maybe I should speak
    for myself, but I think I am speaking for a lot of others, too.
    When we understand that the administration is cutting tens of
    thousands of people out of a system that is already stressed,
    it is hard to imagine that you can achieve the kind of outcome
    standards that you could achieve if those people were not out
    of the system.
        Now, reform, looking at how things are done, making sure
    training is correct, maybe having a special access for women
    who are having particular problems, whether it be reproductive
    healthcare or sexual trauma in the service, those things are
    important to put in a system. I think you are more likely to
    get that in the VA than very often you are in the community, by
    the way away, because of the sensitivities in the VA system for
    this, I suspect. As I look at the numbers we have about the
    people who have been --who are leaving the service now, as I
    look at the numbers, two-thirds of them are clinical staff:
    physicians, nurses, support staff.
        If we were to decide to bring in or try to recruit more
    women to deal with sexual trauma in the service, I cannot
    imagine how that would not be decried as a Diversity, Equity,
    and Inclusion (DEI) program within the government. You cannot
    even recognize women who have served, you know, honorably
    overseas because it is, you know, recognizing women, never mind
    people of color.
        I want to ask this question of you, Ms. Newman, because you
    work in a rural area and we know now that there are a number of
    studies that are coming out showing that these Medicaid cuts
    are going to be particularly devastating in rural areas where
    Medicaid might make up 40 to 50 percent of their revenue. We
    heard 338 hospitals at risk. You live and others on this panel
    live and get care in rural areas. Describe how the loss of
    hospitals in the community is going to impact access to care,
    the access that we know veterans need.
        Ms. Newman. Thank you for the question. Yes, I do live in a
    rural area. In my particular area, we already have lost access
    to hospitals. We are an independent home care agency. These
    cuts are not going to, in particular, impact our agency, but
    our --people in our area, they are already used to traveling to
    receive care.
        Mr. Conaway. Just reclaiming my time because I am running
    out of time. Thank you for that. I think it is obvious that if
    hospitals close, there is going to be an access to care
    problem.
        I asked Secretary Collins at a hearing just like this one
    about whether or not cuts to Medicare and food assistance is
    going to impact veterans. He says, I do not foresee that
    happening now. Well, now it has happened. We know as a result
    of that big, ugly bill that we are going to see, really, quite
    devastating dislocation across the land, and particularly in
    rural areas and also impacting veterans. That is a shame, given
    the commitment this country needs to keep to our veteran
    community.
        Thank you, Madam Chair. I yield back.
        Ms. Miller-Meeks. Thank you, Dr. Conaway.
        The chair now recognizes Representative Cherfilus-McCormick
    for 5 minutes for any questions she may have.
        Ms. Cherfilus-McCormick. Thank you so much, Chairwoman, and
    thank you so much for your testimony. It is truly an honor to
    be here listening to your testimony.
        I do have a background in home health, also. I am second
    generation and I kind of miss being in there and finding
    solutions to these problems. I do believe also that community
    care is imperative to serving our veterans. However, we do need
    to have bipartisan legislation that can help us fill in those
    gaps. I was very delighted when I heard what Dr. Hunter was
    talking about. The need for standardization as far as to make
    sure that we have accessibility, but also communicating what is
    going on with the community care doctors, specifically getting
    on-time or real-time information for our patients, which even
    in the private side and community care, we are still trying to
    get up to date.
        I wanted to talk to Dr. Hunter a little bit more about
    that. What recommendations would you put in place so we can
    actually bridge that gap, specifically when it comes to
    community care and our veterans' offices?
        Dr. Hunter. Thank you so much for that question. As we
    said, we know community care is vital, but we know there needs
    to be better direct communication so that patients are
    receiving that same quality, integrated, coordinated VA care
    that leads to better outcomes.
        If we look at recommendations that can improve this, one is
    having the same types of care standards that are required for
    community care providers as for VA healthcare providers. This
    is seen very clearly in the mental health area, where when a
    patient is seen internally to VA direct care, VA direct care
    mental health providers are required to set a evidence-based
    course of care for that patient that hits very significant
    benchmarks that are there.
        When they are referred out to the community, they were
    referred out for a time-based episodes of care. 6 months, 12
    months, and then it is reevaluated. Right now there is not a
    requirement to actually share back with the patient care team
    what the decided course of care is. In fact, all that is
    required is a yes, this patient showed up for an appointment
    and it is either improving or not improving.
        First and foremost, to strengthen this is to set the same
    standards for evidence-based care for VA care and community
    care and require that transparency, so that all providers
    within the VA system know what the course of treatment is
    across all sorts of specialty care that are provided. This is
    one very specific example for mental healthcare, but we see
    this happen in other forms of care as well.
        Ms. Cherfilus-McCormick. Now, you touched upon the problems
    that we are having with electronic medical records. My other
    subcommittee is Technology and Modernization. I really hope
    that we can have a joint hearing so we can be discussing this
    together. I know we already have strains in even getting the
    VA's system up to task and up to snuff. I know it will be
    challenging for us to do that with community care. Do you have
    any recommendations that you can give us when it comes to
    electronic medical records?
        Dr. Hunter. I think we do need to take a very close look at
    the current implementation of electronic health records within
    the VA. We know it is plagued with problems from the get-go.
    This is an area that I am new in this seat. I have been a CEO
    here for a month, but it is one of the things that I have
    really wanted to dive into to be able to provide those better
    recommendations to you all as to how we can effectively
    modernize the VA and create better synergies and more seamless
    communication between VA and community care, and would love to
    work with your office to do just that.
        Ms. Cherfilus-McCormick. Thank you. I want to pivot a
    little bit over back to our home health issues that are
    happening. When I was the CEO of a healthcare company, what we
    did, we also had rural areas, Clewiston, Belle Glade, and we
    were servicing there. We had huge issues when it came to
    recruiting healthcare professionals to get out there. Also, we
    did have a good number of Medicaid recipients.
        Now, do you have any Medicaid recipients who are actually
    with your organization?
        Ms. Newman. We have very little in our particular
    organization. We are a standalone home care agency.
        Ms. Cherfilus-McCormick. Right now we are looking at $1
    trillion in cuts when it comes to Medicaid. I have deep
    concerns about the compound effects with the cuts that we have
    in the VA combined with the $1 trillion in Medicaid cuts and
    how we are going to keep organizations like yourself, who play
    such an imperative role in making sure that our veterans can
    actually retire at home with dignity, with their family, but
    still get their services. Could you touch on some of those
    effects for your organization's other home healthcare agencies
    that will be servicing our Medicaid patients and our veterans?
        Ms. Newman. Sure. Of course, as I stated, our particular
    payer mix, we have very little of the Medicaid and so for us,
    personally, it will not have a large impact. What we do is, as
    with any other agency, is we try to meet everybody's needs. In
    our particular area, we are not hearing feedback.
        Ms. Cherfilus-McCormick. Well, I have a few more seconds
    and I just wanted to ask you this one question. One of the
    things I am hearing from home care agencies is that they have
    real concerns about the people who are going to be kicked off
    of Medicaid. They cannot abandon those patients. How do you
    transition that person who is homebound, cannot get up, cannot
    take care of themselves, how do you rip their insurance, and
    how do you leave them there?
        Have you guys thought about that transition process? Are we
    just going to abandon these patients to leave them to
    themselves?
        Ms. Newman. Well, if I can circle it back to the VA, we are
    actually actively seeing that now with our veterans, where on
    the VA services, where they have lost homemaker services, home
    health aide services due to internal cuts within the VA. We are
    seeing that they have lost access to care. I think it is
    already happening within the VA, but this started a year ago
    based off of decisions within the VA.
        Ms. Cherfilus-McCormick. So the compound ----
        Ms. Miller-Meeks. Thank you very much. Your time has
    expired.
        Ms. Cherfilus-McCormick. Thank you.
        Ms. Miller-Meeks. The chair now recognizes Dr. Dexter for 5
    minutes for any questions she may have.
        Ms. Dexter. Thank you, Madam Chair, and thank you all again
    for your service and for being here today. Really, really
    appreciate it.
        One thing that struck me listening to all of you, that I
    continue to struggle with being new here in Congress and coming
    here as a physician, is what feels like a binary choice between
    community care and in-VA care. I know nobody here is advocating
    necessarily for one versus the other, but I think that is how
    it feels in this committee at times. One quote that one of you
    shared was community care is not an alternative to the VA. It
    is an extension of it. That should be what it is, but it is not
    what it ends up being because this is a fixed pie that when we
    take money out of the VA direct care services and get it out to
    the community, it is a loss from being able to buildup the VA
    care to the quality that we know.
        Dr. Hunter, you spoke to, when we get it to our veterans,
    it is better quality care and they are more satisfied. The
    problem is, as Ms. Keenan and so many people have talked to, it
    is getting them that care and having them available or be able
    to get availability.
        One thing that I would like us to try to center, it is
    truly a bipartisan endeavor, I believe, is to get our veterans
    at the center of what we are trying to do and make sure that
    their needs and their access and quality are what drives our
    decisions rather than protecting community care, protecting the
    VA system in district care.
        Ms. Hunter and several of you have talked about the data,
    and I wonder what kind of data would be most compelling for you
    as a veteran? I will start with you, Dr. Hunter. What would be
    the most compelling data for you as an advocate for veterans,
    especially our women veterans who are underserved in so many
    ways? I do not want to be disproportionately focused on that.
    What would you want to see? What would help you make decisions
    about advocating for community care versus in the VA system
    care, direct care?
        Dr. Hunter. Thank you so much for that question. When we
    look about where the compelling data is, I will put my
    researcher hat on, I look at outcomes. Right? Outcomes matter
    and we know that patient-centered outcomes are better when with
    VA care because of the coordination, which does not mean that
    community care cannot get there, but the coordination needs to
    get there.
        One thing you noted that I really want to touch on is some
    of the concerns that are coming from the fixed budget. What we
    are seeing more and more is mandatory spending being directed
    toward mandatory spending for community care, which
    necessitates making cuts at the VA. We are hearing from several
    VA providers that that results in not being able to fill
    positions, not being able to actually hire the people they need
    to hire, which creates an unfortunate cycle of demonization of
    the VA because we have lower morale, lower staff, which leads
    to longer wait times and sometimes worse outcomes. Again,
    centering the patient in the outcomes is absolutely essential
    there.
        I think as we are looking at this and we are talking about
    choice in all of this, and choice is essential, but we need to
    ensure that we do not remove the ability of veterans to choose
    VA and to choose a provider at the VA as a one-stop shop for
    their care.
        Ms. Dexter. No, I appreciate that. I think what I certainly
    am interested in working across the aisle and with this
    subcommittee on is centering how do we get the data that we
    need to make the decisions that really do deliver the quality,
    access, and service to our veterans that they deserve? It may
    be that it is wound care in the community is the most effective
    way, especially in rural areas. Let us have the data so that we
    understand how long it takes to get for a wound care
    appointment and how far you have to drive, and then let the
    patients have a choice.
        I do think making clear at the VA that patients or veterans
    have a choice is important. I heard several of you speak to
    that, that we should not be trying to deter people from getting
    care at the VA, but we should not shield them from a choice,
    but making that choice tangible. I hope that everyone on this
    committee consider that. I look forward to working with you all
    on how we get policy amendments, however it looks, so that we
    can get the right outcomes for our veterans.
        Because again, I do not want to be shielding Optum and
    TRICARE and trying to get them dollars. I want to get those
    dollars to the VA and to our veterans.
        Okay, thank you. With that, I yield back.
        Ms. Miller-Meeks. Thank you very much, Dr. Dexter.
        The chair now recognizes herself for 5 minutes.
        Ms. Hunter, you mentioned several times about the
    challenges of information and training and whether VA-specific
    providers had specific types of training that did not happen in
    community care. Is not that a failing of the VA?
        Dr. Hunter. If we think about the training, it could be a
    failing of the VA.
        Ms. Miller-Meeks. Yes.
        Dr. Hunter. Could be a failing.
        Ms. Miller-Meeks. I have got 5 minutes.
        Dr. Hunter. Yes. It could be a VA. We just ----
        Ms. Miller-Meeks. I just want a simple yes and no question.
    It is a failing of the VA, agree, disagree?
        Dr. Hunter. We do not have the data, so we cannot say where
    the failure is.
        Ms. Miller-Meeks. Okay. Is not the VA responsible for that?
    The VA can set the standards for community care.
        Dr. Hunter. They can.
        Ms. Miller-Meeks. Ms. Mobbs, can the VA set the standards
    for community care?
        Dr. Mobbs. They absolutely can. That is correct.
        Ms. Miller-Meeks. You mentioned the training. You also
    mentioned the Red Report. I think perhaps you might have some
    comments you wanted to make on testimony, so I am going to give
    you an opportunity to clarify that.
        Dr. Mobbs. Thank you, Chairwoman. First off, I never said
    that they do not receive training. That that is an inaccurate
    characterization of what I said.
        I think it is really important if we are talking about
    specifically data here, and I am going to go where I am an
    expert in, which is mental health. In the VA system, for
    example, we prioritized two performance metrics-based, data-
    driven therapies for post-traumatic stress disorder: prolonged
    exposure, combat processing therapy. Unfortunately, because
    that was a trauma-centered therapy, the majority of veterans
    left after 2.4 sessions, therefore wanting a different type of
    therapy that they were not allowed to receive in the VA because
    they were given a PTSD diagnosis and qualification.
    Unfortunately, other evidence-based cares like interpersonal
    therapy, community care providers are trained in, were unable
    to see those veterans and they dropped out and then we could
    not follow them.
        All that to say just because there is training in the VA
    does not always mean it is the right training. To the
    chairwoman's point, you can absolutely receive care in the
    community set by the VA to ensure that they are evidence-based
    therapies to provide for veterans.
        Ms. Miller-Meeks. I admit that as a community care
    provider, as an ophthalmologist, I am given a specific type of
    treatment for a specific disorder I am supposed to address.
    There were questions that may have been asked of other type of
    conditions that I did not need training from the VA for.
        Ms. Knight, I am going to ask you to comment because you
    mentioned receiving care at the VA and care in the community,
    and you have heard how this specific training better equips VA
    physicians to handle either PTSD or the variety of issues. I
    did not hear that in your testimony. Can you comment upon
    whether you thought that this training uniquely qualified VA
    physicians, and did you receive better treatment at the VA
    versus in community care?
        Ms. Knight. My answer would be no, Chairwoman. No, I had
    three different accounts of VA providers, one of whom was a
    veteran herself. All three, again, I felt more like I was
    interrogated at times, questioned and validated on my combat
    service and what I had endured, and drilled.
        I would also add that so many of our community providers
    out there deal with other patients who are similar in trauma
    exposure, such as our police and firefighters. There are an
    array of providers, both in the VA and outside of the VA that
    are more than qualified to meet the standards. I just feel very
    strongly that, again, one, they need to ask the questions, but
    that can be resolved by the patient, by understanding and being
    educated on who the providers are, whether that is ratings or
    reviews or anything of that nature. Right now, we are not given
    that choice. We are not giving that option. We are told where
    to go. It is more or less being in the military.
        If I may, if we are going to talk technology, I would love
    to see the transition of documentation from U.S. Department of
    Defense (DOD) to VA fixed first.
        Ms. Miller-Meeks. Kudos. As an Army veteran, I will say
    kudos to that. We have been asking for that.
        Ms. Newman, have you noticed any decrease in community care
    referrals for home care services?
        Ms. Newman. Yes. In 2024, we noticed a marked decrease,
    both within our agency and members across the Nation.
        Ms. Miller-Meeks. Have you heard what the reason for the
    decrease in referrals would be?
        Ms. Newman. In our particular VISN, there was an extra
    layer of oversight and bureaucracy where their intent was to
    find reasons to reduce the amount of care authorized.
        Ms. Miller-Meeks. I can tell you from my exposure, my talks
    with veterans, it was felt that they were encouraged not to
    send patients into the community. As a community care provider,
    it can be extraordinarily challenging dealing with the VA, even
    when someone is 60 miles away from a center that could give
    them care.
        I think veterans do appreciate and like the care that they
    receive at the VA. There is a reason why the MISSION Act and
    Community Care exist. The reason was because people were dying
    waiting for care at the VA.
        Ms. Hunter, do you know how much the budget for the VA has
    increased in the past 4 years?
        Dr. Hunter. Yes, I have that data right here.
        Ms. Miller-Meeks. Is it flat?
        Dr. Hunter. No, the budget has continued to increase.
        Ms. Miller-Meeks. The budget has continued to increase. We
    know community care is comprised in about 40 percent of care
    now within the VA, but we also know they do it at about 25
    percent of the cost to the regular VA. I am just going to say
    that, you know, implicating that community care is a downward
    spiral for the VA and taking money away from the direct care
    system, I am going to say that does not bear out by the facts
    when you look at the budget and you look where the spending
    goes.
        I also want to say that we keep talking about this as a
    fixed budget. If you have providers going to community care,
    they are not going to get direct care because the budget is the
    same and there is never any increase in funding. That is
    patently incorrect. I mean, there has been more appropriation
    dollars from Congress. This spring, Congress voted billions
    more into VA, VHA medical services, $75 billion to be exact. I
    think some of the arguments are poorly founded, although they
    sound very dramatic.
        With that, I yield back my time, as I, too, am over time.
        Thank everyone for their participation in today's hearing,
    for the discussions we have heard on the important topic. I am
    going to yield to Ms. Brownley if she has any closing comments.
        Ms. Brownley. I do have some closing comments. I wanted to
    just respond, Madam Chair, to what you just said about an
    increase in the VA budget. I agree, there has been an increase
    in that budget. There has also been an increase in the
    community care budget. The issue is the community care budget
    is increasing at a more rapid pace than the VA. I want to put
    that sort of fact out there.
        The way I want to kind of conclude today's comments is to
    respond to Dr. Murphy, and I think Dr. Dexter actually did a
    very good job of responding to some of the things that he was
    saying. He talked about he was tired of talking about an
    either/or scenario. He said we need to get to, I believe what
    he said was ``yes'' and ``and''. I agree with him, ``yes'' and
    ``and.''
        I think what Dr. Dexter was saying, you know, we should
    not, you know, we should not have a binary choice, an either/or
    choice, but the community care should be an extension of the VA
    care, which in my mind is the yes/and scenario. The point I am
    trying to make, and I think Dr. Dexter made the point with
    regards to, you know, one pot of resources can only go so far,
    and we have got to make those choices.
        The other issue I want to make here is, the chart is behind
    me, is this data that I have here is VA data. It is not anybody
    else's data. It comes directly from the VA. What it says is
    that from 2022 to 2023, there was a net gain of employees of a
    little bit more than 18,000 employees. The next bar chart is
    from 2023 to 2024, the net gain for employees was almost 14,000
    people. Excuse me. The last bar chart here is 2024 to 2025.
    This shows that there is a net loss of a little over 10,000
    employees. What I see here is a trajectory going in a direction
    that is not going to be good relative to what quality care
    looks like at the VA.
        I just believe that as the workforce at the VA continues to
    decline, I think as the data shows, and, again, this is VA
    data, it will absolutely begin to limit the choice a veteran
    should have, whether they want to get their care at the VA or
    whether they want to get their care in the community. We will
    get to a point, I am not saying we are going to get there today
    or tomorrow, but we could get there to a point where a veteran
    will only have one choice, and that will be to go to the
    community for their care.
        I think it is very clear, and the data is very clear about
    this, that veterans want to receive their care at the VA. Now,
    if you are a female veteran, you have got to go out to the
    community for --if you are pregnant and you have got to go out
    to the community to get your care, and you should have your
    choice of providers when you go to the community care.
    Generally, veterans want to get their care at the VA because
    they believe they have more quality time with the doctor, they
    believe that they understand the veteran better, et cetera.
    This is just the point that I am trying to make, that we do not
    want to go down this road.
        Secondarily, what is a concern with regards to community
    care is the impact of a $1 trillion cut to Medicaid. I
    mentioned in my opening comments, the University of North
    Carolina has identified 338 rural hospitals at risk for
    closure. One of the main reasons why we started the MISSION Act
    and moved toward community care was for rural areas. If these
    community hospitals are going to have to shut down because of
    lack of resources, there is not going to be a choice. The only
    choice then will be the VA. Then, yet, you know, people are
    resigning, people are retiring, people are leaving because it
    is just not a healthy place to work and they are not going to
    be able to provide the resources.
        This is what I am just --the point that I am trying to get
    across. The point, I think, we are trying to avoid a
    deterioration of the VA, and we do not want to deteriorate
    community care either. We have got, as I said so many times in
    these hearings, we have got to find the right balance here.
        I worry about this chart. I think the chairwoman said at
    the beginning, this is just normal attrition what is going on
    at the VA. This is not normal attrition.
        With that, I will yield back. Thank you, Madam Chair.
        Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
    Again, 9 percent of the workforce of VHA is lost annually
    through attrition. These are the VA's figures, about 38,000
    employees based on its current workforce. That is the VA
    numbers. Those are facts.
        For me, this is not an either/or. This should be that
    veterans have choice over where they receive care. I am a
    veteran. Neither my husband nor I desire to receive care at the
    VA hospital. We prefer to receive care in our community either
    through private health insurance or through Medicare. Would it
    save us money if we went to the VA hospital? Possibly. We would
    not have copays or deductibles, but we choose to receive our
    care in the community. We are asking for the same choice for
    all veterans and the veterans on this panel.
        There is a consensus in my mind that we want both community
    care and, and VA care. Why both? We are trying to serve
    veterans and serve veterans first and foremost. There would not
    be a need for community care had the VA been able to serve
    veterans, not keep them on waiting lists, not have veterans
    die, not have the big Public Relations (PR) nightmare of
    veterans waiting for care and dying waiting for care, a suicide
    rate that remains at 17 percent and has not gone down. A VA who
    here in this room in testimony admitted that they did not think
    that residential mental healthcare, the most critical of care,
    or residential substance use disorder care fell under the
    MISSION Act. If you were in a mental health crisis from the VA,
    it was okay if you waited 30 days or 60 days or 90 days or, by
    God, a year, or you can go to a VISN two VISNs away, 300 miles
    away.
        That is why we are having this conversation. If the VA was
    not actively trying to prevent people from going to community
    care, from my standpoint, it is not adversarial. Let us have
    the consensus that VA care is community care. That our goal is
    and always on this committee and in Congress is to serve our
    veterans.
        With that, I would like to thank everyone for their
    participation in today's hearing, for the discussions we have
    had on a critically important topic. The complete written
    statements of today's witnesses will be entered into the
    hearing record. I ask unanimous consent that all members have 5
    legislative days to revise and extend their remarks and include
    extraneous material.
        Hearing no objections, so ordered.
        I thank the members and the witnesses for their attendance
    and their participation today. This hearing is now adjourned.
        [Whereupon, at 4:19 p.m., the subcommittee was adjourned.]

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

                             A  P  P  E  N  D  I  X

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

                        Prepared Statements of Witnesses

                                  ----------

                      Prepared Statement of Dallas Knight
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                      Prepared Statement of Meaghan Mobbs

        Chairman Miller-Meeks, Ranking Member Brownley, and members of the
    subcommittee, thank you for the opportunity to testify today.
        It's an honor to speak on an issue that is both deeply personal and
    profoundly consequential.
        My name is Meaghan Mobbs, and I sit before you as the Director for
    the Center of American Safety and Security at Independent Women. I am a
    combat veteran and former Army officer, as well as a clinical
    psychologist whose research has focused on trauma, transition stress,
    and post-military reintegration. I completed my internship in the VA
    system and currently teach under the Veterans Mental Health-Primary
    Care Training Initiative through the New York State Psychiatric
    Association. That program trains physicians and hospital-based
    clinicians across New York State to identify, treat, and appropriately
    refer veterans in civilian care settings--because, too often, providers
    fail to recognize the cultural and clinical complexities that define
    military and post-military life.
        I've been on every side of this system: as a soldier, as a
    clinician, as an educator, and as someone who has walked beside my
    fellow veterans--men and women--struggling to navigate the bureaucracy
    meant to serve them.
        In 2018, when President Donald Trump signed the bipartisan VA
    MISSION Act, it wasn't just legislation, it was a solemn promise: that
    what happened at the Phoenix VA, where veterans died waiting for care,
    would never happen again.\1\
    ---------------------------------------------------------------------------
        \1\ Sen. Johnny Isakson. John S. McCain III, Daniel K. Akaka, and
    Samuel R. Johnson. ``VA Maintaining Internal Systems and Strengthening
    Integrated Outside Networks Act of 2018 (VA MISSION Act of 2018).''
    115th Congress, S. 2372. Introduced Feb. 5, 2018; enacted June 6, 2018
    (Public Law No. 115-182). https://www.Congress.gov/bill/115th-congress/
    senate-bill/2372/.
    ---------------------------------------------------------------------------
        The VA Community Care Program was born of that promise. It was
    built on the understanding that the VA, while indispensable, is not
    omnipresent.\2\ That in too many places, at too many times, bureaucracy
    has stood where medical support should have. The Community Care Program
    was designed to bridge that gap.
    ---------------------------------------------------------------------------
        \2\ Department of Veterans Affairs. ``VA Makes It Easier for
    Veterans to Use Community Care.'' Wilmington VA Medical Center, May 19,
    2025.https://www.va.gov/wilmington-health-care/news-releases/va-makes-
    it-easier-for-veterans-to-use-comm unity-care/.
    ---------------------------------------------------------------------------
        It was a direct response to bureaucratic failure, not a detour
    around it. It put the focus where it belongs: on outcomes, not process;
    on veterans, not institutions.
        The VA Community Care Program is not just helpful, it is essential.
    It is a critical tool that helps us uphold our moral and national
    obligation to veterans.
        But that promise has not been fully realized.

    The Reality We Face

        In 2001, as America entered the Global War on Terror, the VA
    Hospital Administration received $20.9 billion in funding.\3\ That same
    year, we lost 16.5 veterans a day to suicide.
    ---------------------------------------------------------------------------
        \3\ Department of Veterans Affairs. ``Administration Seeks Record
    VA Budget Increase.'' VA News, Feb. 7, 2000. https://news.va.gov/press-
    room/administration-seeks-record-va-budget-increase/.
    ---------------------------------------------------------------------------
        In 2024, after nearly two decades of war and massive Federal
    investment, the VA now receives $121 billion, a 479 percent increase.
        And yet, at the end of last year, the VA reported the suicide rate
    at 17.6 veterans a day.\4\ Of note, this figure is from 2022, as there
    is a significant data lag in veteran suicide statistics reporting.
    ---------------------------------------------------------------------------
        \4\ Department of Veterans Affairs. ``VA Releases 2024 National
    Veteran Suicide Prevention Annual Report.'' VA News, Dec. 19, 2024.
    https://news.va.gov/137221/va-2024-suicide-prevention-annual-report/.
    ---------------------------------------------------------------------------
        But these figures are more than just numbers. They serve as a stark
    reminder that money alone doesn't solve structural failure. It is
    increasingly apparent, we do not have a funding problem; we have a
    function problem. It is a system-design problem and a failure to adapt,
    to decentralize, and to meet veterans where they are.
        It is a system that, despite its scale and sincerity, continues to
    force veterans to wait weeks or drive hours for care that should be
    available promptly and locally. And it's a system where decisions about
    who gets timely treatment are too often made by bureaucrats with a
    budget, not doctors with a diagnosis.
        The Community Care Program was created to address that failure. It
    offers veterans an alternative path to care when the VA cannot meet
    their needs in a timely or appropriate manner. It is the answer to wait
    lists, distance barriers, specialty gaps, and overwhelmed facilities.
        Today, roughly 40 percent of VA health care is delivered through
    community care.\5\ Veterans are using it. They're satisfied with it.
    It's mostly working.
    ---------------------------------------------------------------------------
        \5\ Petra Rasmussen and Carrie M Farmer.. ``The Promise and
    Challenges of VA Community Care: Veterans' Issues in Focus.'' Rand
    Health Quarterly, Jun. 16, 2023, Vol 10(3):9. https://
    pmc.ncbi.nlm.nih.gov/articles/PMC10273892/.
    ---------------------------------------------------------------------------
        Community providers have stepped up, filling critical gaps in
    mental health, oncology, pain management, women's health, and substance
    use treatment. And in rural areas, especially, where VA facilities may
    be hours away, community care has become a lifeline.
        But instead of expanding access, some VA administrators have worked
    to restrict it, undermining the law, the intent of the MISSION Act, and
    the trust of the veterans they serve..
        Let me be specific. Last year at the Portland VA, a senior official
    admitted to oversight staff that they were deliberately trying to keep
    care ``in-house,'' even when referrals were warranted.\6\ In Buffalo, a
    veteran with cancer saw his radiation therapy referrals delayed, then
    canceled.\7\ He died in pain. That is not a system error. That is
    systemic negligence.
    ---------------------------------------------------------------------------
        \6\ Oregon Public Broadcasting. ``Wyden: Roseburg VA Officials
    Admitted To `Inappropriate Admissions' System.'' OPB News, Jun. 24,
    2025.https://www.opb.org/news/article/roseburg-va-admissions-system-
    ron-wyden/
        \7\  Office of Healthcare Inspection. ``Leaders Failed to Address
    Community Care Consult Delays Despite Staff's Advocacy Efforts at
    VA...'' Department of Veterans Affairs Office of Inspector General,
    Audit Report No. 23-03679-262. Sept. 27, 2024.https://www.vaoig.gov/
    sites/default/files/reports/2024-09/vaoig-23-03679-262.pdf
    ---------------------------------------------------------------------------
        While VA has taken steps to improve the Veterans Community Care
    Program, key gaps in timeliness, oversight, and care coordination
    remain.
        If we are serious about honoring the promise made to every man and
    woman who has served, we must get this right. And that begins with
    clarity of mission, guided by four principles: flexibility,
    accessibility, rapidity, and accountability.

    Flexibility: Real Choice, Not Red Tape

        Veterans do not live neatly within institutional boundaries. They
    live in rural towns, sprawling suburbs, and city centers. They manage
    jobs, raise families, and carry injuries--both visible and invisible.
    And they deserve a care system that reflects that complexity.
        The Community Care Program allows them to seek care outside the VA
    when it is too far, too slow, or lacks the necessary capability. This
    is particularly critical for specialized services--such as orthopedics,
    trauma therapy, neurology, reproductive health, and substance use
    treatment.
        The system must respond to the reality of the modern veteran, a
    population that is younger, more diverse, geographically dispersed, and
    managing complex civilian and military transitions. When a VA system
    goes 2 years without a full-time gynecologist, as was documented in a
    2020 Inspector General report, that's not a scheduling issue; it's a
    failure of access and management.\8\ And with 70 percent of women
    veterans preferring female providers for women-specific care, and 50
    percent even for general care, flexibility becomes a clinical
    imperative.\9\
    ---------------------------------------------------------------------------
        \8\ Office of Healthcare Inspections. ``Comprehensive Healthcare
    Inspection of the Alaska VA Healthcare System, Anchorage, Alaska.''
    Department of Veterans Affairs Office of Inspector General, Audit
    Report No. 19-06378-73, Jan. 23, 2020.https://www.vaoig.gov/sites/
    default/files/reports/2020-01/VAOIG-19-06378-73.pdf.
        \9\ Kate L. Sheahan, Karen M. Golstein, Elizabeth M. Yano, et. al.
    ``Women Veterans' Healthcare Needs, Utilization, and Preferences in
    Veterans Affairs Primary Care Settings.'' Journal of General Internal
    Medicine, Aug. 30, 2022, Vol. 37(Suppl 3):791-798.https://
    link.springer.com/article/10.1007/s11606-022-07585-3

    ---------------------------------------------------------------------------
    Accessibility: Geography Should Not Determine Health Outcomes

        Let's be blunt: If a veteran has to drive 3 hours each way to get
    care, that's not access, that's denial of care.
        Only 55 percent of veterans live within 40 miles of a VA medical
    center. Just 26 percent live near a facility with full specialty
    care.\10\ These numbers are even more dismal for veterans in rural
    communities, many of whom are older, sicker, and less mobile.
    ---------------------------------------------------------------------------
        \10\ Petra Rasmussen and Carrie M Farmer.. ``The Promise and
    Challenges of VA Community Care: Veterans' Issues in Focus.'' Rand
    Health Quarterly, Jun. 16, 2023, Vol 10(3):9. https://
    pmc.ncbi.nlm.nih.gov/articles/PMC10273892/.
    ---------------------------------------------------------------------------
        Community Care helps correct that. It allows veterans to seek
    treatment locally, reducing both the physical and financial burden of
    long-distance travel. That doesn't just improve health outcomes. It
    improves trust, adherence, and it keeps veterans engaged.
        And with the veteran population shifting rapidly--2.2 million women
    veterans expected by 2025, nearly 18 percent of the total veteran
    population by 2040, and 43 percent of women VA users in 2020 from
    racial or ethnic minority backgrounds--it's no longer acceptable to
    offer a model built for the demographics of 50 years ago.\11\
    ---------------------------------------------------------------------------
        \11\  U.S. Department of Veterans Affairs, Office of Women's
    Health. ``Facts and Statistics.'' Women Veterans Health Care, accessed
    Jul. 10, 2025.https://www.womenshealth.va.gov/materials-and-resources/
    facts-and-statistics.asp.
    ---------------------------------------------------------------------------
        Veterans deserve care where they live, not just where we've
    historically placed facilities.

    Rapidity: Delayed Care is Denied Care

        In that regard, veterans don't need care eventually, they need care
    now.
        VA outpatient satisfaction ratings reached 91.8 percent in 2024,
    that is a number to be celebrated, but it also runs the risk of masking
    regional and categorical disparities.\12\ It does not speak to the
    veteran experiencing PTSD symptoms today. It does not help the veteran
    with worsening chronic pain who's told to wait 28 days before seeing a
    specialist.
    ---------------------------------------------------------------------------
        \12\ Department of Veterans Affairs. ``Trust in VA Among Veteran
    Patients Rises to 91.8 percent, Up 6 percent Since 2018.'' Wilmington
    VA Medical Center Press Release, Apr. 17, 2024.https://www.va.gov/
    wilmington-health-care/news-releases/trust-in-va-among-veteran-
    patients-rises-to-918-up-6-since-2018/
    ---------------------------------------------------------------------------
        Under current rules, veterans are often forced to endure arbitrary
    thresholds before becoming eligible for Community Care--20-day waits
    and 60-minute drive times. These are numbers written on paper, not
    reflections of actual urgency.
        I've worked with veterans denied certain types of mental health
    treatment or experienced significant delay in access to specialty
    mental health care. Others were turned away because they weren't sick
    enough. Still others were forced to partake in a type of therapeutic
    intervention at odds with their preferred course of treatment.
        Many times these decisions were not meant to be negligent, but
    hyper process-oriented. Irrespective of intent, such moments are often
    perceived as administrative cruelty and institutional malaise. And it
    is costing well-being and lives.

    Accountability: Structure Must Serve the Mission

        I believe in oversight. And I believe that no system--public or
    private--should operate without guardrails. But accountability should
    be about ensuring quality and responsiveness, not erecting barriers
    that keep veterans out.
        Despite ongoing efforts to improve the Veterans Community Care
    Program, the Department of Veterans Affairs continues to fall short in
    fully addressing longstanding structural and operational deficiencies.
        These reforms are designed to ensure veterans can more easily
    obtain the health care that best fits their needs, whether within VA
    facilities or through qualified community providers.
        Since 2018, the Government Accountability Office (GAO) has issued
    27 recommendations to strengthen the program's performance,
    particularly in the areas of appointment scheduling, wait time
    monitoring, contract oversight, and network adequacy. As of early 2025,
    only nine of these recommendations have been fully implemented.\13\
    This sluggish pace of reform has tangible consequences for veterans who
    rely on community care when timely services are not available within
    the VA system.
    ---------------------------------------------------------------------------
        \13\ Sharon M. Silas. ``Veterans Health Care: Opportunities to
    Improve Access to Care Through the Veterans Community Care Program.''
    U.S. Government Accountability Office, Feb. 12, 2025. https://
    files.gao.gov/reports/GAO-25-108101/index.html.
    ---------------------------------------------------------------------------
        A central and unresolved issue remains the lack of a clearly
    defined, enforceable standard for how quickly veterans must receive
    community care appointments. While the VA has implemented some
    mechanisms to track scheduling performance, it has not yet established
    comprehensive metrics aligned with those timeframes, leaving the system
    without meaningful accountability.
        The VA's Referral Coordination Initiative, intended to streamline
    specialty care referrals, has likewise suffered from inconsistent
    implementation, unclear guidance, and inadequate performance metrics.
    These shortcomings create variability in veteran experience and
    undermine trust in the VA's ability to deliver timely, coordinated care
    across its network.
        Equally concerning is the state of contract oversight and provider
    network adequacy. Although the VA has taken steps to improve data
    systems and oversight processes, critical vulnerabilities remain. The
    current methodology for assessing whether provider networks are
    adequate, particularly in the realm of specialty and mental health
    care, risks obscuring the extent to which veterans have real access to
    services. Without reforms to oversight processes and more accurate
    measurement tools, the VA risks misallocating resources and failing to
    ensure that community networks meet veterans' needs.
        Finally, as the use of community care continues to grow, especially
    in behavioral health, the VA must prioritize seamless coordination
    between VA facilities and outside providers. Preliminary findings show
    that the majority of veterans who seek mental health services in the
    community continue to rely on the VA for ongoing care. This underscores
    the urgent need for standardized, reliable systems to ensure timely
    medical documentation exchange and continuity of treatment.
        In light of all of these critical issues, I want to commend
    Secretary Collins on his recent announcement that the VA will expedite
    the implementation of the Senator Elizabeth Dole 21st Century Veterans
    Healthcare and Benefits Improvement Act--enacted earlier this year--
    which addresses some of these concerns and includes critical provisions
    to expand and streamline veterans' access to the Community Care
    program.
        Because let's be clear: It is not enough to offer a door, we must
    ensure that the door is open, functional, and leads somewhere worth
    going.

    Conclusion

        I completed my training in the VA system. I've referred patients
    there. I believe deeply in the VA and the essential mission it fulfills
    for our veterans. But no system, no matter how well-intentioned, can
    serve every need, in every place, for every veteran.
        That's why Community Care matters. It's not an indictment of the
    VA, it's an extension of the promise made. A veteran's health outcomes
    should not depend on geography, paperwork, or luck. They should depend
    on whether we've built a system that puts their needs first.
        Veterans don't need more bureaucracy--they need choice, speed, and
    accountability.
        Thank you for your time, your leadership, and your continued
    commitment to those who've served. I welcome your questions.

                      Prepared Statement of Amanda Newman
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                     Prepared Statement of Kristina Keenan

        Chairwoman Miller-Meeks, Ranking Member Brownley, and members of
    the subcommittee, on behalf of the men and women of the Veterans of
    Foreign Wars of the United States (VFW) and its Auxiliary, thank you
    for the opportunity to provide the VFW's and my personal remarks on
    this important topic.
        The VFW believes the Department of Veterans Affairs (VA) community
    care program and its Community Care Network (CCN) of providers are a
    vital component of VA health care as it delivers the care and services
    that VA hospitals and community-based outpatient clinics either cannot
    or do not provide. Since no institution can be everything for
    everybody, community care providers are force multipliers, allowing VA
    to continue providing the world-class care that veterans prefer,
    deserve, and have earned, while also ensuring they have access to the
    range of services they may need throughout their lives.
        When appropriately used, community care can save lives and improve
    the health outcomes for countless veterans, but the problems that arise
    can drive people away from the care they have earned. We have also
    called on VA to rely on its third-party administrators to ensure
    consistent delivery of community care to eligible veterans. The VFW has
    been unequivocal that community care must be a part of VA care since
    the 2014 Phoenix crisis. It always has been. However, veterans expect
    consistency. When 23 Veterans Integrated Services Networks interpret
    the VA MISSION Act of 2018 in 23 different ways, veterans are
    overlooked, as the VA Inspector General pointed out last year in
    Buffalo, New York.

    Background

        VA provided fee-based care through non-VA providers before 2014,
    under limited circumstances, to veterans residing in rural areas who
    could not access a VA facility, and for services that the local VA
    facility could not provide. Following the VA wait-time scandal in
    Phoenix, the Veterans Access, Choice, and Accountability Act of 2014,
    called the Choice Act, was passed to establish the Veterans Choice
    Program (VCP). The Choice Act enabled eligibility for community care
    for those living far from a VA facility or facing excessive wait times,
    which was overseen by third-party administrators managing provider
    networks. In 2018, VCP was replaced with the more unified and permanent
    Veterans Community Care Program (VCCP) through the passage of the VA
    MISSION Act of 2018. This change provided community care if VA services
    were not available in a timely manner, were not readily accessible,
    were in the veteran's best medical interest, or if the veteran and
    provider agreed that community care was the best option. Currently,
    VCCP eligibility is determined based on clinical need, rather than
    distance or wait time. It is coordinated through VA Care Teams, which
    include urgent care, primary care, specialty care, and mental health
    services. Third-party administrators manage community care networks,
    such as Optum Serve (East Region) and TriWest Healthcare Alliance (West
    Region).

    Specialty Care

        VCCP provides a wide range of specialty care services to ensure
    that veterans can access medical care that may not be immediately
    available in VA facilities. These may include cardiology, audiology,
    otolaryngology, gastroenterology, dental and oral surgery, mental
    health and behavioral services, and women's health, among others.
        As the number of women serving in the military has increased, so
    has the women veteran population. For these VA patients, community care
    has become essential, particularly for their gender-specific services
    like mammograms, fertility treatment, and maternity care. Veterans
    living in rural and underserved areas that are greater distances from
    VA medical facilities rely heavily on this option. Additionally,
    veterans experiencing mental health crises who require inpatient care
    may need to be referred to community care providers for specialized
    treatment. All veterans must receive timely, high-quality, and
    consistent care that meets their individual needs and preferences.

    My Story

        I use VA for all my health care except dental care, which is not
    currently covered for veterans without a dental-related service-
    connected disability. The specialty care that I have received as part
    of VA's community care program includes mammograms and maternity care.
        The care I have received through VA's community care providers has
    been high quality and has met my needs and preferences. VA coordinated
    my care during a pregnancy last year, which sadly ended in miscarriage.
    I became pregnant again this spring, and VA is again coordinating my
    maternity care in the community. In both instances when I became
    pregnant, a VA maternity care coordinator sent me a list of 27 medical
    facilities for covered maternity care within the Washington, DC. metro
    area. I was able to select both the facility and provider of my choice
    based on availability. I selected a hospital five miles from my home
    (which is 30 minutes of city driving time), and that is next to my VA
    medical center. I was pleasantly surprised to learn that I could even
    select midwifery services at my hospital of choice, which was my top
    preference for maternity care. I appreciated the exceptional compassion
    and bedside manner of my providers, especially during the difficulties
    of my first pregnancy. In both cases, VA processed my community care
    referrals in a timely manner, and I received communications both
    electronically and by phone about my health care through a maternity
    care coordinator.
        While I have had very positive experiences with community care, I
    have also encountered several challenges along the way in how that care
    was coordinated by VA. First, for my mammogram screening, I received a
    bill for nearly $700 that VA failed to pay even though it made the
    appointment for that care. Each time I received a bill, I called the
    community care provider and gave my VA referral information. As I
    continued to receive bills and saw the threatening words in red letters
    that I could face collections if I failed to pay, I would call again
    and was always told it would be taken care of. After approximately 6
    months of receiving bills and calling to try to remedy the situation,
    the bills finally stopped.
        Second, the process to set up my initial appointments during my
    maternity care was quite confusing. It was unclear to me if VA was
    going to set up the first community care appointment or if I needed to
    call providers from the approved VA list. The first time, I was told to
    wait for VA to call me to schedule the appointment. Then, after a
    couple of weeks, I was told that I could make the appointment myself.
    Once I received the VA referral, I made an appointment with the
    approved provider, but at the same time VA made an appointment with
    that same provider though my name was misspelled. When I tried to
    cancel the VA-scheduled appointment, which was weeks later than the
    appointment I had scheduled, the CCN provider could not locate it
    because of the misspelling. When I called the VA appointment phone
    number, I was told that VA was obligated to keep the scheduled
    appointment even if I did not attend it, so there was no way for me to
    cancel or change that appointment.
        Third, also during my maternity care, my CCN provider attempted to
    send a prescription to my VA pharmacy for me to pick up since this was
    the only way that VA would cover the cost of the medication. I asked
    for a written prescription to hand carry to the pharmacy, but my
    provider said that prescriptions could only be sent electronically. I
    walked over to the VA medical center, across the street from my
    community care facility and waited for it to be filled. Once it was
    clear that VA never received the request, I walked back to the CCN
    provider, but by then it was late in the afternoon on a Friday and
    already closed. I walked back to the VA pharmacy and was told I should
    have requested a paper prescription or had the provider send it by fax.
    None of this information was provided to me or the CCN provider, nor
    was it on my VA referral documents. Frustrated with the situation, the
    pharmacist advised me to walk to the VA women's clinic and attempt to
    speak with my primary care physician. I spoke with a nurse, and she was
    able to relay a message to my doctor. When the nurse returned, she said
    that my doctor had put in an electronic prescription request for the
    same medication at the VA pharmacy. I was grateful that the staff at my
    VA facility were there to help me before the facility closed for the
    weekend. This could have been avoided with better information sharing
    between VA and the CCN provider.
        Fourth, during my first pregnancy, which ceased to be viable after
    the first few weeks, I received a phone call from my VA maternity care
    coordinator. She said that she had been informed that I wanted to
    terminate my pregnancy. I had the impression that she was calling to
    tell me that VA could not cover the termination. She said she thought I
    was happy to have become pregnant. The information she received was
    incredibly hurtful and completely incorrect. I informed her that my
    pregnancy was likely not viable and that I may need additional care to
    manage the miscarriage. She apologized and reassured me that my care
    would be covered. I learned later that the care I opted for did in fact
    need VA approvals. My coordinator called me again to ask why I had
    received a certain procedure related to my miscarriage that was not
    normally approved by VA. Again, she had been misinformed because I had
    not had any procedures at that point. Accurate information sharing
    between VA and community care providers is absolutely critical to
    ensure providers have all the information needed to provide high-
    quality continuity of care. The need for accuracy of medical records
    cannot be understated. Additionally, when veterans receive care within
    VA, there is never a worry about insurance or coverage because VA
    providers can be clear about what they can and cannot provide. Using
    community care exposes veterans to confusing insurance coverage and
    required approvals that can cause delays and frustration.
        Last, during my current pregnancy, my community care provider
    indicated that I should have three genetic tests performed to rule out
    certain conditions that may affect my baby. She said that because of my
    age, these tests were critical and, depending on the results, could
    require me to take additional medications or treatments during my
    pregnancy to lower the risks of negative outcomes for my child. My VA
    referral document simply states that it covers ``Laboratory and
    pathology services to include screening and testing as clinically
    indicated and relevant...Also includes medically indicated genetic
    testing.'' Since the referral did not list any specific tests, I have
    not scheduled any yet, but contacted my VA maternity coordinator to
    inquire if they are covered. The coordinator asked me what the billing
    codes are for the recommended tests. She also sent me a list of 173
    billing codes, some of which were accompanied by the text ``Pre-
    Certification Required.'' At my next appointment 2 weeks later, I asked
    my CCN provider about the billing codes for the recommended tests. She
    said they can be found online simply by using Google. I sent my VA
    coordinator a follow-up message with the codes that I researched myself
    for the three recommended tests. Even though all three of the billing
    codes were on the VA list of approved screenings, two of them required
    pre-certification. This means that I need to wait until my next monthly
    appointment with my CCN provider so they can fill out a VA Form 10-
    10172, Request for Additional Services (RFS). After several secure
    messages and a follow-up phone call with my maternity coordinator, it
    was explained to me that I would have to send these VA forms back to
    her and she would then forward them to both my VA primary care
    physician and the VA community care office for approval. If approved,
    she advised me to ensure that when I received the screenings, likely at
    a Labcorp office, I should also be sure that the tests are indeed
    covered by VA's insurance provider, Optum Serve.
        The problem with these challenges in the coordination of my
    specialty care in the community is that it would have been easier to
    disregard the tests or pay my prescriptions out of pocket, rather than
    experience the extensive amount of bureaucracy. In these cases the
    costs have been high, so I have been extra vigilant to ensure VA will
    cover the expenses. I have had VA deny medical bills, even for urgent
    care that was coordinated by VA, so I am being particularly careful
    with potentially costly maternity care.
        Despite the fact that I have had wonderful care in the community,
    the coordination of that care has been particularly stressful. As a
    woman veteran who cannot receive any of these services within VA
    itself, it is disappointing that I must manage these challenges at a
    time when additional stress is detrimental to my health and that of my
    baby. Issues with scheduling, pharmacy, screenings, coverage,
    information sharing, and billing need to improve before VA sends more
    veterans to community care providers.

    Issues Reported by VFW Members

        Billing issues and confusing VA referrals related to community care
    have also affected veterans and VFW members nationwide. One problem is
    the lack of communication regarding the appropriate procedures veterans
    must follow when receiving care in the community, including whether a
    referral is involved, as well as who to contact for assistance.
        Consider the case of an 88-year-old veteran in Pennsylvania who
    collapsed in a VA parking lot a few years ago. He was transported by
    ambulance to a civilian hospital for treatment. Instead of billing
    Medicare first, the civilian hospital billed VA. VA authorized and paid
    for the service, but then billed the veteran more than 2 years after
    the incident. This delayed billing occurred beyond any timeframe for
    disputing charges with either VA or the civilian facility. Despite the
    veteran having settled all debts, he continues to receive additional
    bills for this care. Upon reviewing the situation, it became clear that
    the veteran was not at fault. The initial error arose from the civilian
    facility's decision to bill VA before Medicare, and VA's subsequent
    coverage of those costs. Unfortunately, VA took several years to bill
    the veteran due to an internal processing issue. As a result, the
    veteran is being held financially responsible despite not being at
    fault. This situation is causing significant financial stress and
    creating barriers to accessing care. Further review also revealed that
    the veteran has been paying copayments that he should not have had to
    cover.
        In a separate case in Washington, DC, veterans were approved to
    visit urgent care facilities. However, the urgent care institution
    faced difficulties processing the billing under VA authorization and
    reached out to VA for assistance, but received no response. VA
    instructed the veterans to pay out of pocket for the care, which they
    did. This situation arose from an authorization and billing issue that
    required submission for upfront VA coverage, but VA was unable to
    assist. If VA authorized the care, why was it unable to provide the
    appropriate billing codes? Veterans should not be burdened with costs
    due to VA's inability to provide accurate billing information to CCN
    providers.
        A veteran from Virginia received a referral for CCN dental care,
    however, when the dentist determined that surgery was necessary, the
    veteran had to wait for VA approval. This required a further evaluation
    by a VA dentist to get the needed procedure approved. As a result,
    previous referrals for preventive dental care were canceled.
        In California, veterans have experienced issues with referral
    approvals, possibly linked to TriWest Healthcare Alliance system
    problems, resulting in inconsistent care appointments. One veteran has
    had an active referral for 12 specialty service sessions scheduled
    between April 1, 2025, and September 30, 2025. Unfortunately, no
    further care was provided after the initial appointment. The veteran
    reported that VA instructed the CCN provider to hold off on care. The
    reason is unknown.
        Several veterans received letters from both VA and their CCN
    providers stating that the CCN provider could no longer offer the
    specified care and that they would begin receiving services through VA
    instead. This change required veterans to travel excessive distances
    for appointments, sometimes multiple times a week, which significantly
    impacted their ability to work and manage other responsibilities.
        In Texas, a veteran was referred to community care for vision care
    but was informed by the CCN provider that surgery was required. Both
    the CCN provider and the veteran notified VA, which then scheduled the
    veteran for a VA follow up to determine the next steps. The veteran is
    currently frustrated about having to wait beyond the required
    timeframes to be seen by VA, especially after being referred to CCN due
    to long wait times for his vision care.

    Solutions

        VA's community care program is plagued with numerous challenges
    that require thoughtful solutions. Care in the community is necessary
    for some veterans, but if given the choice, our members routinely tell
    us they prefer VA direct care. Negative experiences with the community
    care coordination process contribute to that sentiment. We must fix
    those issues because our veterans have earned quality care regardless
    of who provides it.
        The VFW supports H.R. 740, Veterans' ACCESS Act of 2025, as it
    represents a critical step forward in enhancing access to care for
    veterans, particularly in ensuring timely, effective, and consistent
    health care options through the CCN to streamline care, reduce
    bureaucratic obstacles, and expand access to care. Key provisions
    include codifying community care access standards based on wait times
    and driving distance, notifications regarding available services and
    provider preferences, transparency about denials of community care
    services and appeals rights, extensions for billing deadlines, and
    expedited access to mental health services.
        The VFW appreciates the provision to improve the policies and
    processes that govern access to VA's Mental Health Residential
    Rehabilitation Treatment Program (MH RRTP) as we recognize it needs
    serious attention. We would ask that the standards for accessing these
    programs be thoughtfully considered due to their different nature.
    Priority admission standards should be developed differently than
    routine admission standards because many of these programs, whether VA-
    provided or in the CCN, are typically not local to veterans.
        Additional legislative measures should also be considered to
    improve VA's community care program. Sharing health records and care
    integration must be addressed and improved between VA and community
    care providers. We urge the committee to prioritize not only the
    improvement of community care coordination but also the continuous
    support and enhancement of VA direct care services. This approach will
    help prevent over reliance on the community care system and ensure that
    veterans receive the comprehensive care they rightfully deserve. We owe
    it to our veterans to ensure that their access to care is not hindered
    by bureaucracy or geographical limitations. Expanding and integrating
    community care options is not just a policy choice; it is a moral
    obligation to those who have served.
        Chairwoman Miller-Meeks, Ranking Member Brownley, this concludes my
    testimony. I welcome any questions from you or members of the
    subcommittee.
    Information Required by Rule XI2(g)(4) of the House of Representatives

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

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

                     Prepared Statement of Kyleanne Hunter
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                            Statement for the Record

                                  ----------

                  Prepared Statement of Cohen Veterans Network

        As the committee examines the best ways to ensure our Nation's
    veterans have access to the highest quality care, particularly as it
    relates to mental health, I wanted to provide some background for you
    on how Cohen Veterans Network (CVN) is working with the Department of
    Veterans Affairs (VA) to provide mental health services to Veterans and
    their families. Our clinics strive to be the ``right time, right place,
    right treatment'' model for community care that the committee seeks to
    strengthen for veterans and their families.
        CVN is a not-for-profit philanthropic organization founded in 2016
    that serves veterans, service members, and military families through a
    nationwide system of mental health clinics. CVN operates 22 clinics
    that provide care across 20 states, including telehealth services. Our
    clinics provide treatment for depression, anxiety, adjustment issues,
    substance misuse, anger, PTSD, grief and loss, family issues,
    transition challenges, sleep problems, relationship problems, and
    children's behavioral problems. We also provide comprehensive case
    management services to address social drivers of health issues,
    including unemployment, food insecurity, finances, housing, and more.
        While the VA has invested heavily in expanding mental health
    services, significant challenges remain in the Community Care program
    and the suicide epidemic persists. Veterans often face long delays,
    limited local access, and administrative hurdles that discourage them
    from pursuing care when they need it most. CVN helps relieve this
    pressure by serving the whole family (as defined by the veteran or
    service member) and providing barrier-free, high-quality outpatient
    treatment in trusted community settings. CVN does not turn veterans
    away based on discharge status or insurance.
        Since its inception in 2016, CVN has served nearly 90,000 clients
    in almost 800,000 clinical sessions and provided more than 440,000
    telehealth sessions. More than 56 percent of the clients served have
    been veterans and service members. Approximately 29 percent have been
    non-veteran adult family members and 15 percent of family members were
    children. 31 percent of our veteran clients to date are female
    veterans.
        Over the past decade, the demand for high-quality, accessible
    mental health care for veteran and military families has only grown.
    Through public-private partnerships, CVN has worked to fill gaps where
    and when they exist. Our care model is focused on being military
    culturally competent and is based on both data analytics and
    operational research.
        Our clinicians are trained in evidence-based practices and deliver
    measurable outcomes. As part of our mission to continually improve and
    enhance care, we track satisfaction and clinical improvement across all
    clinics. According to our metrics, over 90 percent of our clients would
    recommend CVN services to others.
        CVN is proud to complement the VA's mission and extend its reach in
    the community. To strengthen and scale this kind of work, we support
    pending legislation like the RECOVER Act (H.R. 2283), which would
    establish a pilot grant program to support non-profit clinics
    delivering culturally competent, evidence-based mental health care at
    no cost to the veteran. By encouraging public-private partnerships, the
    RECOVER Act can help close access gaps, especially in underserved
    areas, and provide a lifeline to family members who are too often left
    out of the traditional VA system.
        A recent study entitled Experiences With VA-Purchased Community
    Care for US Veterans With Mental Health Conditions (JAMA Network Open,
    21 May 25) observed, ``These findings underscore the challenges
    vulnerable veterans experience when navigating and receiving community
    care and highlight an opportunity for targeted quality and care
    coordination strategies. (p.9). CVN strongly agrees.
        Community care for veterans is a critical resource and mechanism
    for filling gaps in care and improving access. To fully address the
    need, the VA and Community Care must continue to function as
    complementary elements with each providing vital resources which
    jointly offer improved access and options for veterans while
    maintaining an appropriate standard of care.
        CVN stands ready to continue supporting these efforts and pledges
    to work with the committee and administration to help veteran and
    military families. Thank you for your leadership and for advancing
    solutions that meet the full scope of veterans' mental health needs,
    including their families.

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