[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.
[all]