    [Senate Hearing 119-7]
    [From the U.S. Government Publishing Office]

                                                              S. Hrg. 119-7

                           PROTECTING VETERAN CHOICE:
                     EXAMINING VA'S COMMUNITY CARE PROGRAM

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED NINETEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                JANUARY 28, 2025

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

     [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                                     __________

                       U.S. GOVERNMENT PUBLISHING OFFICE
    58-614 PDF                  WASHINGTON : 2025

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

                     SENATE COMMITTEE ON VETERANS' AFFAIRS

                         Jerry Moran, Kansas, Chairman
    John Boozman, Arkansas               Richard Blumenthal, Connecticut,
    Bill Cassidy, Louisiana                  Ranking Member
    Thom Tillis, North Carolina          Patty Murray, Washington
    Dan Sullivan, Alaska                 Bernard Sanders, Vermont
    Marsha Blackburn, Tennessee          Mazie K. Hirono, Hawaii
    Kevin Cramer, North Dakota           Margaret Wood Hassan, New
    Tommy Tuberville, Alabama                Hampshire
    Jim Banks, Indiana                   Angus S. King, Jr., Maine
    Tim Sheehy, Montana                  Tammy Duckworth, Illinois
                                         Ruben Gallego, Arizona
                                         Elissa Slotkin, Michigan

                         David Shearman, Staff Director
                    Tony McClain, Democratic Staff Director

                                C O N T E N T S

                                  ----------

                                January 28, 2025

                                    SENATORS

                                                                       Page
    Hon. Jerry Moran, Chairman, U.S. Senator from Kansas.............     1
    Hon. Richard Blumenthal, Ranking Member, U.S. Senator from
      Connecticut....................................................     2
    Hon. Bill Cassidy, U.S. Senator from Louisiana...................    16
    Hon. Ruben Gallego, U.S. Senator from Arizona....................    18
    Hon. Tommy Tuberville, U.S. Senator from Alabama.................    20
    Hon. Tammy Duckworth, U.S. Senator from Illinois.................    21
    Hon. Marsha Blackburn, U.S. Senator from Tennessee...............    23
    Hon. Angus S. King, Jr., U.S. Senator from Maine.................    24
    Hon. Kevin Cramer, U.S. Senator from North Dakota................    26
    Hon. Margaret Wood Hassan, U.S. Senator from New Hampshire.......    28
    Hon. Jim Banks, U.S. Senator from Indiana........................    29

                                   WITNESSES

    Eric Golnick, Veteran............................................     4
    Paige Marg, Veteran Spouse.......................................     6
    Jim Lorraine, President and Chief Executive Officer, America's
      Warrior Partnership............................................     8
    Naomi Mathis, Assistant National Legislative Director, Disabled
      American Veterans..............................................     9
    John Eaton, Vice President for Complex Care, Wounded Warrior
      Project........................................................    11

                                    APPENDIX
                              Prepared Statements

    Eric Golnick, Veteran............................................    39
    Paige Marg, Veteran Spouse.......................................    41
    Jim Lorraine, President and Chief Executive Officer, America's
      Warrior Partnership............................................    47
    Naomi Mathis, Assistant National Legislative Director, Disabled
      American Veterans..............................................    57
    John Eaton, Vice President for Complex Care, Wounded Warrior
      Project........................................................    65

                           Submission for the Record

    List of VA and Non-VA Programs and Grants Potentially Impacted by
      OMB Funding Pause..............................................    73

                            Questions for the Record

    America's Warrior Partnership response to questions submitted by:

      Hon. Dan Sullivan..............................................    77

                           Statements for the Record

    American Association of Nurse Anesthesiology (AANA), Janet
      Setnor, MSN, CRNA, Col. (Ret.), USAFR, NC, President...........    81
    Miramar Health, Tom Sauer, Founder and CEO.......................    89

      Attachment--Statement of Luis T., (West Los Angeles VA Medical
        Center Case Study)...........................................    91

    Paralyzed Veterans of America (PVA)..............................    97
    Statement from Independent Multi-Organizations...................   102

                           PROTECTING VETERAN CHOICE:
                                 EXAMINING VA'S
                             COMMUNITY CARE PROGRAM

                                  ----------

                           TUESDAY, JANUARY 28, 2025

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 10:30 a.m., in
    Room SR-418, Russell Senate Office Building, Hon. Jerry Moran,
    Chairman of the Committee, presiding.

        Present: Senators Moran, Boozman, Cassidy, Tillis,
    Sullivan, Blackburn, Cramer, Tuberville, Banks, Sheehy,
    Blumenthal, Hassan, King, Duckworth, Gallego, and Slotkin.

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

        Chairman Moran. The Senate Committee on Veteran's Affairs
    will come to order. We welcome our witnesses. We are here today
    to discuss what I consider hugely important, a hugely important
    role that community care plays in providing timely high-quality
    care to our Nation's veterans. I represent a rural state, and
    during my time as a Member of the House of Representatives, I
    represented a congressional district approximately the size of
    the State of Illinois. There was no, and is no VA hospital
    included in that geographic territory. And so, I bring this
    perspective of long distance and long amounts of time for
    veterans to access care.
        I've heard countless stories from veterans in Kansas and
    across the country who live in faraway places from the VA
    facilities about those challenges. In the absence of VA's
    community care program, these veterans would not be able to use
    the VA healthcare benefits they earned. The same can be said
    for veterans who face long wait times at the VA, veterans who
    require a service that the local VA doesn't offer, or veterans
    who have unique needs that are best served through community
    care.
        The MISSION Act was created so that the VA could more
    seamlessly care for those veterans. However, seven years after
    the MISSION Act was signed into law, it is still not fully
    living up to its promise. I have heard from veterans nationwide
    who've suffered as a result, especially over the last year, as
    VA acted to discourage and restrict the use of community care
    under the MISSION Act. Some of those veterans who've suffered
    the most are those with mental health conditions and addiction.
        This morning, we will hear from veterans' family members,
    we'll hear from veterans and advocates about how they
    encountered barriers at the VA, which limited veterans access
    to potentially lifesaving care and put their lives at risk. One
    of those veterans is Eric Golnick, who will testify today about
    waiting more than a year to be connected to a counselor after
    asking the VA for help in the midst of a personal crisis.
    Another one of those veterans is Paige Marg's husband, Charlie.
    Paige will testify today about how her and Charlie repeated
    requests for inpatient care were denied by the VA after Charlie
    attempted suicide in the parking lot of a VA clinic.
        VA leaders and advocates have repeatedly said that suicide
    prevention is one of their top VA's priorities. If that is
    indeed true, stories like the ones Eric and Paige will share,
    and the countless others that this Committee has heard from,
    veterans and their loved ones, should not be happening, and
    cannot be allowed to continue.
        As chair of this Committee, I'm committed to making certain
    that they do not. That is why I'm introducing legislation today
    with Chairman Bost, my counterpart in the House, to strengthen
    the MISSION Act and give veterans like Eric and Charlie an
    improved pathway to care in the VA's direct care system and in
    the community. And I hope this will be a bipartisan effort.
        The VA healthcare system is an invaluable resource for
    veterans, but it will only remain so if it stops failing those
    who need it the most. I yield to the Ranking Member, Senator
    Blumenthal, for his opening remarks.

             OPENING STATEMENT OF HON. RICHARD BLUMENTHAL,
             RANKING MEMBER, U.S. SENATOR FROM CONNECTICUT

        Senator Blumenthal. Thank you, Mr. Chairman. This cause
    must be bipartisan and it must be immediate. There is no
    question about the need to speed, streamline, and safeguard
    access to community care and referrals to the kind of providers
    that are necessary to prevent the tragedies or near tragedies
    such as your husband, Charlie, suffered, Ms. Marg.
        I believe, strongly, that these two systems, private and
    VA, must be complementary, not competitive. And overriding all
    of this debate is the need for more providers, more doctors,
    more nurses, more psychiatrists, and social workers who can
    provide the kind of care that our veterans need. And,
    obviously, the VA should not be in competition with communities
    for the numbers of scarce providers, skilled professionals who
    are necessary to provide this care.
        But we're here on a morning when all of these programs are
    in severe and urgent jeopardy. The Trump administration has
    announced, illegally, that it will freeze federal aid for
    programs that are immensely important to veterans. This freeze
    on federal aid will hurt veterans by pausing funding for
    critical programs that millions of veterans and their families
    rely on. We're talking about homeless veterans, funding for
    veterans' nursing homes across the country, suicide prevention
    programs, many of the programs that we will be discussing today
    and the efforts to streamline speed and safeguard access to
    community programs. Reimbursement for those providers who need
    it to make community care work, frozen.
        We are deterring and discouraging that kind of community
    care right now in real time, and I urge all the Members of the
    Committee, I urge my colleagues to oppose this measure to make
    their views known. I call on veterans and their organizations
    across the country to make their views known because these
    funds must be freed immediately or else veterans will be
    betrayed.
        There's nothing woke or Marxist about working to end
    veteran suicide or delivering our veterans the benefits they've
    earned and deserve. And I will put in the record later today a
    list of programs. It's going to be probably about two pages
    long. I have a tentative list here that will be adversely
    impacted by this freeze on funding.

        [The list referred to appears on page 73 of the Appendix.]

        It is also, by the way, unsustainable legally. It violates
    the Impoundment Act. These funds have been lawfully
    appropriated under bills passed by the Congress and signed by
    the President, and no member of the executive branch, including
    the President, has the lawful power to simply stop them.
        I am concerned also about the action to dismiss the
    Inspector General. I'm going to be circulating a letter to my
    colleagues that would in fact protest to the President, the
    firing of the VA's Inspector General, Mike Missal, who has
    worked for many years under both Republican and Democratic
    administrations to call out and stop waste, fraud, and abuse.
    He's done it in a very bipartisan, or actually, non-political
    way, aggressively and effectively.
        And the question for all of us is why this measure of
    firing the inspector general of the VA was done at this moment
    when, in fact, he has been the bulwark against waste, fraud,
    and abuse in the VA as have inspectors general across the
    executive branch.
        I believe strongly that the private sector healthcare
    system and the VA are complementary, and one route to care
    should never come at the expense of the other. I fear that's
    what's happening today. The erosion of VA direct care is a real
    threat. And I say erosion because it could happen gradually,
    not all of a sudden, but if it happens, it may well be
    irreparable.
        I am hopeful that we will restore the inspector general,
    that we will make sure that the funding for the VA system and
    other programs will be unfrozen, and that we will work together
    in a bipartisan way to speed and assure the referral system
    under the kind of legislation that the Chairman has proposed.
        There was an effort last session, and I supported it to
    legislate in this area. I'm hope hopeful that his measure is
    one that we can all support. I know last session he offered the
    Veterans' Health Act. I assume that this measure is similar to
    it. Senator Tester offered the Making Community Care Work for
    Veterans Act. I feel some combination of these measures is
    viable and achievable, and I'm hopeful that we can reach a
    bipartisan effort. Thank you, Mr. Chairman.
        Chairman Moran. Thank you, Senator Blumenthal. I would
    indicate just a couple of things for all of our Members. It's
    my understanding that the Department of Veterans Affairs
    leadership is meeting later this morning with OMB to learn
    details of this issue of impounding or withholding funding. And
    I would say that in both instances, both the inspector general
    and this issue, one of the best things that we can do is get
    Congressman Collins confirmed, and in a position to represent
    the Department of Veterans Affairs in these matters. And that
    is apparently taking place this week.
        I'll now call on our witness panel. Let me introduce them.
    Eric Golnick, a Navy veteran and an advocate for mental health
    and suicide prevention for veterans and first responders. Paige
    Marg, a veteran spouse with firsthand experience in navigating
    the VA healthcare system on behalf of her Air Force veteran
    husband, Charlie. Jim Lorraine, the President and Chief
    Executive Officer of America's Warrior Partnership. Naomi
    Mathis, the Assistant National Legislative Director for
    Disabled American Veterans, and John Eaton, the Vice President
    for Complex Care for the Wounded Warrior Project.
        Thank you-all for being here this morning. More
    importantly, thank you for all you do in care of veterans, and
    your care and concern for your loved ones. Mr. Golnick, we'll
    recognize you first, and you are recognized for five minutes.

                   STATEMENT OF ERIC GOLNICK, VETERAN

        Mr. Golnick. Chairman Moran, Ranking Member Blumenthal, and
    distinguished Members of the Senate Veterans' Affairs
    Committee. Thank you for the opportunity today to testify on
    the critical issues of improving access to care through the
    VA's Community Care Program. My name is Eric Golnick, I'm a
    U.S. Navy veteran and I've dedicated my life to supporting the
    health and well-being of veterans and first responders.
        The VA is an essential resource for millions of veterans.
    Community care under the MISSION Act is meant to complement,
    not replace the VA services, ensuring veterans receive the
    right care at the right time. I am going to begin by sharing a
    personal story to show you why this is so important to me.
        After leaving the military, I sought mental health care
    through the VA. I was fortunate to see a psychiatrist
    relatively quickly, but it took over a year to see a therapist.
    The lack of therapy meant I was only addressing part of the
    problem. This came to a head over the holidays a few years ago,
    and without the support of friends and fellow veterans, some of
    who are in this room, I may not be here today.
        For someone with a mental health or substance use disorder,
    the window to intervene is often just days. For veterans,
    timely access to this care is a matter of life and death. My
    experience reflects the systemic barriers many veterans face
    with in accessing timely care. That's what inspired me to co-
    found Forge Health in 2016. We addressed urgent mental health
    and substance use needs for veterans and first responders,
    working closely with the VA to help those who couldn't find
    adequate care.
        The collaboration showcased the potential of how these
    relationships could work with the community, but it also
    highlighted the potential challenges. Some VAMCs and VISNs
    fostered strong partnerships. However, inconsistent
    implementation across the system resulted in delays
    highlighting need for clear standardized practices to ensure
    veterans receive timely and consistent care.
        While the MISSION Act has expanded options for veterans,
    many don't know about these options. Unclear eligibility
    requirements often lead to delays or denial even for those who
    meet the access standards. One veteran, after being told he
    couldn't continue care, that he developed a therapeutic
    relationship with a clinician for over a year, told me, ``I'm
    done. I give up. Before this year, I had been through four
    clinicians in less than six months.''
        When transitioning from VA to community care, many veterans
    face disruptions caused by poor communication and unclear
    processes. For example, a marine veteran I worked with
    struggling with severe post-traumatic stress was referred to
    community care, but waited months due to administrative delays.
    During that time, his condition worsened and he attempted
    suicide with a firearm.
        Some VA employees hesitate to refer veterans to community
    care, fearing it could negatively impact their budgets. This
    can create barriers forcing veterans to choose between systemic
    concerns and urgent care needs. The MISSION Act was designed to
    ensure timely high-quality care, whether through the VA or
    through community providers. Veterans and not funding
    structures should remain the top priority in the care of
    veterans.
        To address these challenges, the VA should enhance its
    efforts to educate veterans about their options under the
    MISSION Act. Clear communications during VA appointments,
    proactive outreach campaigns, and partnerships with VSOs can
    ensure veterans are fully informed about their rights and
    choices.
        The referral and approval process should be streamlined.
    Simplifying and automating these procedures can reduce delays,
    alleviating administrative burdens, and help veterans access
    care more efficiently. This includes ensuring that community
    providers, TPAs, and VISNs are all in transparent and constant
    communication.
        For rural and underserved areas, community care should act
    as a force multiplier and not a replacement for VA services,
    helping the VA fill and address critical service gaps.
    Telehealth is also a powerful tool for bridging these service
    gaps in these rural and underserved areas by providing
    immediate access to care. However, challenges such as limited
    broadband access could make this option unworkable. It's also
    crucial for some veterans, especially when you're talking about
    mental health, to have the option to see an in-person provider,
    especially if you're processing trauma.
        Chairman Moran, Ranking Member Blumenthal, and Members of
    the Committee, the VA has made progress in improving care for
    veterans, but significant challenges remain. By addressing
    these barriers and building on the foundation of the MISSION
    Act, we can ensure that all veterans receive timely high-
    quality care they deserve.
        It's our responsibility to ensure no veteran is left
    behind. By fostering collaboration and prioritizing veterans'
    needs, we can fulfill our promise to those who served. Every
    delay risks veterans' well-being, and their life. As one
    veteran told me, ``I shouldn't have to fight this hard to get
    help.''
        Thank you again for the opportunity to testify. I look
    forward to your questions, and working together to improve the
    care for our Nation's veterans.

        [The prepared statement of Mr. Golnick appears on page 39
    of the Appendix.]

        Chairman Moran. Thank you for your testimony and for your
    service. Ms. Marg.

                STATEMENT OF PAIGE MARG, VETERAN SPOUSE

        Ms. Marg. Good morning, Chairman Moran, Ranking Member
    Blumenthal and the Members of the Committee. Thank you for the
    invitation to speak at today's hearing. My name is Paige Marg,
    and I am the wife of Charles Marg. I'm not here to talk about
    the life of my husband in the past tense, but I'm here to tell
    you how Charlie was saved.
        Countless times, the VA and Community Care Program could
    have provided impactful mental health counseling, resources,
    and residential treatment, but failed again and again. I met my
    husband 27 years ago. We've been married for 23 years. In this
    time, I have seen my husband change dramatically from a pivotal
    deployment that he went on.
        In October 2012, Charlie deployed from Germany to
    Guantanamo Bay, Cuba for eight months. To this day, I'm not
    sure what happened on that deployment, but whatever did happen
    permanently and profoundly changed my husband.
        In August 2013, while still on active duty, Charlie
    attempted suicide and was hospitalized at Landstuhl Regional
    Medical Center. It was then that he disclosed that he attempted
    suicide twice on deployment. His doctors told us that he could
    not have PTSD because he was not deployed to a combat zone. He
    was diagnosed with major depressive disorder and anxiety, and
    was medically retired in July 2015.
        We moved back to San Antonio, and Charlie enrolled in the
    VA Heart of Texas Health Care Network. He was connected to a VA
    psychiatrist who only supported his mental health journey
    through medication. Counseling is not part of these quarterly
    appointments. Charlie has repeatedly requested counseling
    referrals from the VA psychiatrist, and the cycle that includes
    the Community Care Program failed Charlie again and again.
        He would wait six to eight weeks for the referral to be
    processed to see a community care provider. In each of the nine
    times that he went through this process, he's never been
    granted more than 12 visits with a counselor, even when he
    needed them more. And in each cycle, he saw a different
    provider and he spent time retelling his story and building
    rapport.
        In February 2023, Charlie went to see his VA psychiatrist
    to request immediate mental health support as he was in crisis.
    We were told to go outside of the VA to seek care, and we were
    given a list of local providers who accepted TRICARE. The
    earliest appointment that we could find was 30 days .
        On March 1, 2023, My husband sat in his truck in the VA
    clinic parking lot and attempted to overdose on his medication.
    I found him in his truck, drenched in sweat, crying, and
    incoherent. He was transported to a local hospital. When he was
    released, he was referred again to the VA community care system
    for counseling, and was seen for 12 visits before he was
    released from care again. His medication was adjusted multiple
    times over the next six months.
        Toward the end of this period, Charlie went missing and was
    found by the police in the ER waiting room at Audie Murphy VA
    Hospital. He was held on an emergency detention order and
    admitted to the psychiatric ward for 36 hours. For several
    reasons, I asked if he could be sent to a residential program
    and was told that no option like that existed through the VA.
        At his follow-up appointment, I explained the last few
    years of navigating fragmented community care counseling, and
    that these 12 session appointments were not adequate support,
    and that a longer-term solution was needed for him. I again
    requested that he needed to be put in a residential treatment
    program. A referral was submitted for residential treatment to
    the Community Care Program.
        Charlie's psychiatrist called and told him that the
    referral was denied and suggested that he reach out to TRICARE
    Wounded Warrior Project or another veterans service
    organization to get the care covered. Wounded Warrior Project's
    Complex Case Coordination Program assigned a case manager, and
    within three days, paid for his flight to Tucson, Arizona,
    secured a bed for him at Sierra Tucson and paid for six weeks
    of residential inpatient treatment.
        Sierra Tucson is in the VA's Community Care network, and
    the VA should have covered this expense, but failed to support
    Charlie again. While he was there, all of his medications were
    changed and reset, he received intensive counseling treatment
    for his nightmares, and was diagnosed with PTSD.
        Since he returned home, Charlie has avoided the VA for
    mental health support because he did not want to go through the
    familiar cycle of fragmented care again. Instead, he has sought
    outside support through local nonprofits. Charlie is currently
    attending counseling appointments through the local vet center
    in San Antonio. Wounded Warrior Project saved his life by
    getting him connected to care that he desperately needed for
    years that over and over again the VA fell short on.
        It's heartbreaking to see your spouse become a shell of a
    person, to repeatedly ask for help, to maintain prescription
    compliancy for more than a decade, and to not miss
    appointments, only to be discarded from the entity that should
    be providing treatment and care that he earned through his
    military service and sacrifice.
        The obtuse, heartless interactions with the VA over and
    over, are why veterans do not seek care. It's why veterans
    suffer in silence. How many veterans need to commit suicide for
    the VA to prioritize long-term mental health care? How long do
    veterans have to wait for mental health care? How many veterans
    are getting lost in giving up in the community care system that
    do not have someone to advocate and fight for them? We need the
    VA to be better.
        Thank you for the opportunity to share Charlie's story.

        [The prepared statement of Ms. Marg appears on page 41 of
    the Appendix.]

        Chairman Moran. Ms. Marg, thank you for your--must be
    difficult testimony, but very compelling and valuable to me and
    the Members of this Committee. Mr. Lorraine.

       STATEMENT OF JIM LORRAINE, PRESIDENT AND CHIEF EXECUTIVE
                 OFFICER, AMERICA'S WARRIOR PARTNERSHIP

        Mr. Lorraine. Chairman Moran, Ranking Member Blumenthal,
    and Members of the Committee, I'm honored to testify today
    regarding veteran access to healthcare, specifically care in
    the community.
        The ability to make our own decisions is a foundational
    American freedom. I've always told my Army-serving son, that a
    successful career should give him the choices throughout life.
    I remained in the military through retirement because I love
    service, but I also did it to ensure I had choices, especially,
    managing my healthcare through TRICARE or the VA, something my
    father, a World War II veteran never had the option.
        AWP believes veterans have a choice in managing healthcare
    they've earned. Providing veterans with healthcare choices of
    where, when, and most importantly, the continuity of care they
    seek is not only the right thing to do, but it's also
    affordable and effective.
        AWP operates at a community level by building proactive
    relationships with veterans. Our mission is to partner with
    communities to holistically improve the quality of life of
    their veterans and their families, thereby reducing veteran
    suicide. Community care is a vital tool for veterans,
    particularly those who don't trust the VA and who don't utilize
    the VA facilities due the factors like distance, time, and
    continuity.
        While we recognize the VA's crucial role in veteran care,
    AWP always sides with the veteran. We have supported empowering
    veterans to make their own healthcare decisions, and community
    care is one of the most popular and in-demand options. The
    MISSION Act and community care enabled veterans the opportunity
    to access outside VA facilities has been overwhelming.
        Community care helps veterans regain the trust in the
    system, especially given that almost half of the 17.6 million
    veterans in the United States are unknown to the VA. At AWP,
    nearly 9,000 veterans contacted us in 2024, over 4,000 needing
    assistance most often related to healthcare. These 4,000-plus
    represented 6,000 cases--issues--392 related to mental health.
    Of those 392, 329 had suicidal ideations within 30 days of
    contacting us.
        The most common theme we see is a struggle to access care.
    Even for veterans familiar with the system, navigating the VA
    can be frustrating. Confusion, long wait times, and canceled
    appointments, erode trust in the system. Though it's popular,
    full implementation of the MISSION Act has yet be to be
    realized.
        In the past years, the VA has continued to deny community
    care referrals, continue to expand VA hospitals, continue to
    hire more employees, often competing with the private providers
    for talented medical professionals in the community. We must
    get this right.
        Mr. Chairman, as you said during Mr. Collins' confirmation,
    America's national security is dependent on an all-volunteer
    military force and the VA that is successful in helping service
    members thrive as veterans is key to bolstering recruitment and
    keeping the Nation safe. We agree 100 percent and feel that the
    VA is not a social service department, it's a national security
    entity.
        Despite some opposition and clear data, and data is clear,
    veterans are voting with their feet to seek care outside the
    VA. The department should trust and empower veterans by
    allowing them to choose their care providers. After all, who
    knows what's best for the veteran; the government or the
    veteran?
        In my experience, both my wife, who's a veteran--service-
    connected disabled veteran, and I, have faced challenges
    accessing care in the VA. After years of frustration, we seek
    our care through TRICARE and Medicare because it provides us
    with so many other choices.
        Community care is essential. Veterans should be able to
    choose their providers who meets their needs the best. AWP has
    put forward several recommendations for improving care.
    Codifying the access standards. Congress should codify the
    existing access standards for the community to ensure the
    veterans have guaranteed access to timely healthcare.
        Eliminate the referrals for veteran health, substance
    abuse, and TBI care. I add TBI care because it's essential.
    Need for these services is often urgent, as Ms. Marg said, and
    referrals delay needed help. Further, TBI assessment and care
    have been neglected because of their similarities to post-
    traumatic stress disorder symptoms. We must include TBI
    services when discussing mental health and substance abuse. We
    also feel that we need to educate veterans on community care
    options, and allow veterans the preference for community care,
    and allow veterans to utilize TRICARE Select.
        Community care is essential to improving veterans access to
    healthcare. We must continue to improve the system by
    empowering veterans, not restricting them. Together, we can do
    better. Thank you, sir.

        [The prepared statement of Mr. Lorraine appears on page 47
    of the Appendix.]

        Chairman Moran. Thank you, sir. Ms. Mathis, welcome.

       STATEMENT OF NAOMI MATHIS, ASSISTANT NATIONAL LEGISLATIVE
                  DIRECTOR, DISABLED AMERICAN VETERANS

        Ms. Mathis. Chairman Moran, Ranking Member Blumenthal, and
    Members of the Committee, over the past decade, due to
    increased demand for services, VA's reliance on purchase
    medical care services has risen significantly. While the use of
    community care has grown, many veterans have encountered
    barriers to accessing that care.
        DAV supported the VA MISSION Act, which aimed to improve
    veterans access to timely, high quality and veteran focused
    care. Importantly, this support was based on maintaining a
    fundamental set of principles. Unfortunately, there are reports
    from some veterans indicating that they have been denied
    eligibility and access to the veteran Community Care Program.
        The access standards enacted in the MISSION Act are clear,
    and VA is responsible for educating its employees on the law
    and veterans' rights to access community care when VA cannot
    provide needed care in a timely manner or due to distance from
    a VA facility. In cases where it is determined to be in the
    best medical interest of the veteran.
        We also continue to hear about delays in scheduling
    community care appointments once a referral has been made. Due
    to the lack of an interoperable health record system, VA
    struggles with transmitting patient records to community
    providers and integrating those records into the patient's VHA
    electronic health record.
        Additionally, community providers report complications with
    transmitting healthcare information and test results back to
    VA. There are also complaints from veterans regarding billing
    issues associated with referrals to community care.
        VA must find an effective solution to ensure that patient
    records are transferred in a timely manner and provide
    community care providers the tools and procedures for
    transferring records back to VHA. VA should also require the
    return of patient records to VHA before payments for services
    rendered are made. Finally, VHA must ensure veterans are not
    erroneously billed and burdened with resolving billing issues
    related to community referrals.
        A bipartisan issue and VA's top clinical priority is
    suicide prevention. Yet it does not mandate community care
    providers to meet the same training and quality standards as VA
    direct care providers.
        DAV recommends VA amend its contracts with these providers
    and require clinicians who treat veterans to be trained in
    military culture, suicide prevention, lethal means safety
    counseling, and trauma-informed care. Accessing mental health
    and substance use disorder care is essential in preventing
    veteran suicide. And we made recommendations in our testimony
    to ensure quality services are provided to veterans referred to
    the community.
        Women veterans are also significant users of community
    care. They're referred to the community for all maternity care,
    and oftentimes, for other basic gender-specific or specialty
    reproductive health services.
        Although we want to see fixes to improve access to services
    in the community, we strongly believe that investing in VA's
    comprehensive, veteran-focused, evidence-based care model is
    likely to produce better health outcomes for veteran patients
    and ensure quality of care. It is essential to maintain VA as
    the primary provider and coordinator of veterans' healthcare. A
    bipartisan position supported by current and past VA
    secretaries and undersecretaries of health.
        A robust VA healthcare system also provides vital research,
    essential clinical provider training, and emergency
    preparedness for veterans and the Nation. The failure to
    adequately fund, maintain, and expand VA's direct care
    infrastructure, and increased staffing levels to meet rising
    specialty care demand has led to unsustainable growth in
    community care, threatening the long-term viability of the
    entire VA healthcare system. Likewise, an improperly managed
    veteran Community Care Program has resulted in some veterans
    receiving substandard care.
        In closing, Congress and VA must work together to resolve
    existing issues impacting veterans' healthcare. Improvements
    need to be made expeditiously to ensure veteran patients
    receive quality, timely care. Most important is to maintain a
    veteran-focused healthcare system for service-disabled veterans
    who rely exclusively on VHA for their healthcare needs.
    Ensuring VA specialized care and services remain available is
    part of honoring the commitment to those who served.
        Mr. Chairman, we look forward to working with you and the
    Committee. This concludes my formal statement.

        [The prepared statement of Ms. Mathis appears on page 57 of
    the Appendix.]

        Chairman Moran. Ms. Mathis, thank you for your testimony,
    and thank you for DAV's continued presence before Members of
    this Committee and the Committee when we're meeting. Thank you
    for your testimony. And, Mr. Eaton.

       STATEMENT OF JOHN EATON, VICE PRESIDENT FOR COMPLEX CARE,
                        WOUNDED WARRIOR PROJECT

        Mr. Eaton. Thank you, Chairman Moran, Ranking Member
    Blumenthal, and distinguished Committee Members for this
    opportunity to speak with you.
        Since 2003, Wounded Warrior Project has been working to
    transform the way America's injured Post-9/11 veterans are
    empowered, employed, and engaged in their communities. Over the
    past 20 years, our programs and services have matured to a
    point where we can now engage with each individual based on
    their unique needs.
        Part of our process for helping warriors is learning more
    about their journey to Wounded Warrior Project, and some of
    these veterans have used VA for mental health care, others have
    not. Using VA is not a prerequisite to accessing our free
    programs and services, nor is it a requirement to keep engaging
    with us. But as a majority of warriors we serve use VA and
    nearly half report using VA for mental health care, we often
    learn about what that care has looked like for those who come
    seeking mental health care and support from us.
        For some, wait times are still an issue. Despite efforts to
    expedite access through the VA MISSION Act, many warriors have
    reported wait times of several weeks to months before being
    provided with a mental health appointment. This is typically
    when a veteran or their family reaches out to organizations
    like ours for help. We have relationship with direct care
    providers and can help triage veterans into care sooner in many
    cases. And while the VA has its community care network for a
    similar purpose, we've learned that some warriors still wait
    for care well beyond 20 days after being referred to a
    community provider.
        For some of these same warriors and others, we hear a
    frustration with provider turnover at the VA. It can take time
    to develop the kind of trust and rapport with a counselor that
    is critical to effective care. But when VA mental health
    providers leave the VA system, their patients are left to start
    over.
        This can be an agonizing process for some, particularly
    those who struggle to tell their story. And even as some
    veterans are referred into the community, an enduring
    relationship with a community-based provider isn't always
    possible as VA workloads adjust and authorizations for external
    care lapse after a course of treatment.
        While these stories are not common, the challenge that
    we've seen firsthand is accessing care through VA's Mental
    Health Residential Rehabilitation and Treatment Programs, or
    RRTPs. VA's Mental Health RRTPs provide residential
    rehabilitative and clinical care to eligible veterans who have
    a wide range of symptoms, illness, or rehabilitative care
    needs.
        To be clear, the VA provides inpatient acute stabilization
    for veterans in crisis or suffering from severe mental illness.
    Our RRTPs serve as a step down to that acute stabilization and
    a more intense treatment option for those veterans in needs of
    substance abuse, PTSD care, and dual diagnosis treatment, for
    example, in a residential setting.
        RRTPs serve as small but high-need, high-risk population of
    veterans. Approximately, 32,000 veterans received RRTP
    treatment at the VA or in the community in 2023. By contrast,
    nearly 2 million veterans received individual or group mental
    health treatment in a VA over that same period. And despite the
    logical association between RRTP and mental health care, the
    access standards contemplated by the VA MISSION Act and
    memorialized in the Code of Federal Regulations do not in
    practice extend to mental health or substance use disorder care
    provided in a residential setting.
        This becomes a problem even more pronounced when we're
    working directly with high-risk warriors for placement at the
    VA or in the community. Stated most simply, we've encountered
    VA providers who have stopped making referrals to RRTP care in
    the community, even when there's no firm idea of when that care
    will be available in the VA direct care system.
        And when this happens, we will pay for that faster
    connection to community-based, military-competent care paid by
    donor dollars and with almost no opportunity to secure any
    reimbursement from the VA. We're proud to step in at this
    point, but we know we only see a small percentage of the
    veterans who are seeking this critical level of care.
        In totality, many veterans are not accessing care they need
    when they're ready to receive it. Delays in finding appropriate
    care in a timely manner not only fail to capitalize on the
    veteran's desire to change their life circumstances, but in
    some cases, cause further damage to their mental and physical
    health, declines in their family and social relationships, and
    even involvement with the justice system.
        To mitigate the risk associated with unpredictable RRTP
    access and ensure consistent VA help throughout the enterprise,
    we believe the MISSION Act access standards must apply to the
    delivery of residential programs. We want and need the VA to be
    successful in this. Simply put, the VA is our most critical
    partner in connecting veterans to the residential
    rehabilitative care that they need.
        In closing, we thank the Committee and its distinguished
    Members for this opportunity to share our perspective on VA
    community care. We're eager to support your efforts and to keep
    our promise to our Nation's veterans. And I look forward to
    your questions.

        [The prepared statement of Mr. Eaton appears on page 65 of
    the Appendix.]

        Chairman Moran. Mr. Eaton, thank you. Ms. Marg, I want to
    highlight really the testimony, maybe between you and Mr.
    Eaton. You indicated that on numerous occasions, the care that
    your husband needed was denied by the VA, and the suggestion
    was that you seek care through TRICARE, or through a private
    organization----
        Ms. Marg. That's correct.
        Chairman Moran [continuing]. Not-for-profit?
        Ms. Marg. That's correct.
        Chairman Moran. And that's despite the fact that Charlie
    had a 70 percent service-connected disability from the VA?
        Ms. Marg. Correct. And his rating has actually increased.
    So, he's 70 percent, but he is rated as IU, for individual
    unemployability. So, he is actually at 100 percent right now.
        Chairman Moran. And what was the reason that the VA made
    that recommendation that you seek care elsewhere? How did they
    explain that?
        Ms. Marg. At his follow-up visit, after the second suicide
    attempt, the nurse practitioner told us that the VA did not do
    long-term mental health well. And she turned around her
    computer screen and pulled up psychologytoday.com and told us
    to search and filter for which providers take TRICARE and to
    connect to a provider like that. The only explanation was they
    just don't do long-term mental health well.
        Chairman Moran. Is it true, Mr. Eaton, that the VA could
    refer Charlie to the same place that TRICARE would be paying
    for?
        Mr. Eaton. Yes, sir.
        Chairman Moran. Under Community Care, under the MISSION
    Act?
        Mr. Eaton. Yes, sir. The location that Ms. Marg highlighted
    is a member of the Community Care Network and would be eligible
    for a referral.
        Chairman Moran. And that caught my attention, that where
    you have helped find a place for Ms. Marg's husband, Charlie,
    is also--would be eligible for the VA to refer to in Community
    Care.
        Mr. Eaton. Yes, sir.
        Chairman Moran. How do you explain that?
        Mr. Eaton. Well, I think without clear defined access
    standards, the VA's left to other alternatives to find that
    level of care. It goes back to education, but also really
    clear, whenever a veteran is met with ambiguity in this
    critical time you can imagine the different barriers they have
    to face in accessing care. And so, we need clear standards that
    are dispersed across the entire VA that outline what veterans'
    options are and what their rights are in this case.
        Ms. Marg. Can I add something to his statement?
        Chairman Moran. Oh, please.
        Ms. Marg. So, when my husband went to Sierra Tucson, they
    actually have a program just for veterans. It's a Red, White,
    and Blue Program. My husband was there with other veterans, and
    was housed with veterans. Other veterans there had the VA pay
    for their care there. And so, it really seems very hit or miss
    as to what the provider understands and knows what the process
    is as to what kind of care they actually get connected with.
        Chairman Moran. That is a really a partial answer to my
    follow-up question with you again, is, do you know of other
    veterans, other veteran families that have experienced similar
    circumstances, or are you just a one-case circumstance?
        Ms. Marg. No, sir. There are other veteran families.
        Chairman Moran. Mr. Golnick, you were nodding your head.
        Mr. Golnick. Yes, Senator. We saw this a lot in Forge
    where--what's the old saying? ``If you've seen one VA, you've
    seen one VA.'' Unfortunately, like I had mentioned my
    testimony, some VISNs and VAMCs had a great education on
    community care, others didn't. And when that ambiguity came in
    with others, that's where people started--unfortunately, what
    happened with your husband, you're getting into those things
    and it's not necessarily something that is standardized across
    the system. So, that really is the bigger issue.
        Chairman Moran. My impression, and you can correct me if
    I'm wrong, that often the treatment at the VA, if you remain
    there for the kind of treatment you need for the circumstances
    that Charlie and Mr. Golnick both needed is often opioid
    prescription. Is that true?
        Mr. Golnick. Senator, it's in some cases, right? In some
    cases it is. A lot of it can be severely and persistent mental
    illness that the VA works a lot, SPMI. But, yes, that is a lot
    of the times the case.
        Chairman Moran. I don't know whether I made my question
    clear, at least for the point I wanted to make is--there are
    programs that don't involve opioid treatment, but the VA's
    tendency is to utilize opioids as a treatment. Is that true?
        Mr. Golnick. In a lot of cases, sir, yes. They're looking
    for a----
        Chairman Moran. You've already answered my question, but I
    wasn't sure.
        Mr. Golnick. Yes, sir.
        Chairman Moran. Anybody want to add anything to what I ask?
    And if not, we'll go on to send it to the Ranking Member. Mr.
    Lorraine?
        Mr. Lorraine. Thank you, sir. I think the other point that
    that's being missed is that the ability to do case coordination
    at a national level to understand where the resources are. WWP
    has figured it out and they've got a great group of people that
    do complex case coordination. We work closely with them, but I
    think that's the absence. If there is care out there, it's just
    a matter of--if you know about it, you know about it, but you
    have to know somebody to know about it, and you need somebody
    who can navigate the system that way----
        Chairman Moran. Thank you.
        Mr. Lorraine [continuing]. And sometimes it's outside.
        Chairman Moran. Senator Blumenthal.
        Senator Blumenthal. Thanks, Mr. Chairman. What I hear is a
    common theme; veterans should have choices, care should be
    timely, and it should be high quality. The most skilled
    professionals in the world ought to be available right away,
    especially in cases of mental health crisis such as you
    experienced in your husband, Ms. Marg.
        And the best laws in the world demand accountability. The
    VA must be held accountable, and one of the best means of
    holding it accountable is an effective inspector general. Would
    you agree, Mr. Eaton?
        Mr. Eaton. Yes, sir.
        Senator Blumenthal. Firing an inspector general sends a
    message on accountability, and it should be accountability not
    only for the VA, but also for dollars spent on community care.
    Would you agree with that, Mr. Eaton?
        Mr. Eaton. I believe so, yes, sir.
        Senator Blumenthal. And right now, the inspector general is
    barred from that kind of accountability when dollars are spent
    in community care, and they're scarce dollars. We can't afford
    to waste them. Whatever we think about the VA, at least there
    are means of tracking and record keeping there that often is
    unavailable when dollars are spent on community care. We spend
    a lot of time talking about VA facilities; wait times, for
    example. That data is transparent. It can be recorded, tracked,
    and acted upon, but that's not true in the private sector.
        Mr. Eaton, would you agree that there needs to be
    accountability in both the private sector and the VA?
        Mr. Eaton. I think when you consider access standards, what
    we've heard from veterans is even if they receive a Community
    Care Network referral, they could be waiting perhaps longer
    than they would within the VA system, that 20-day mark. And so,
    I think there's certainly opportunity to identify how we can
    ensure streamlined care throughout VA's entire integrated
    system, which includes the Community Care Network.
        Senator Blumenthal. That point is absolutely critical. That
    the wait times for community care actually may be longer in
    some instances, and we need to guarantee, again, the two
    systems have to be complementary, not competitive, that
    veterans are not delayed in the care they receive because care
    delayed can be cared denied, as Charlie's example shows so
    dramatically and graphically. And I want to thank you, by the
    way, Paige, for being here today. I know it's not an easy task
    to be here, and thank you for telling us, being the voice of
    Charlie's story.
        I want to talk about the hiring freeze. The hiring freeze
    was going to apparently deny positions being filled in VA
    facilities across the country; doctors, nurses, attendants,
    technicians, the people who provide direct care. The
    administration may have walked back on that hiring freeze. In
    so far as VA facilities are concerned, we are still unsure and
    clearly the hiring freeze still applies to essential core
    functions the VA provides.
        And I'm going to ask you again, Mr. Eaton, because your
    organization was so instrumental in providing care for Charlie,
    and your organization, Ms. Mathis, provides services for
    veterans, thousands of them across the country. Isn't this
    hiring freeze having a detrimental effect on the VA?
        Mr. Eaton. Thank you, Senator, for the question. As we are
    teams analyzing the details of the freeze, looking at the
    exemptions, we note that critical roles like psychologists,
    social worker, marriage, family therapist, and licensed mental
    health counselors, as of now are listed as exemptions. And so,
    we're going to continue to work closely with warriors to hear
    their experience throughout the system so that we can step in
    if and when there's an area for us to offer support.
        Senator Blumenthal. But if there are insufficient
    exemptions, it will have a deleterious effect. I assume you
    would agree?
        Mr. Eaton. Yes. The capacity and timeliness for care is
    definitely tied to provider capacity.
        Senator Blumenthal. And the freeze on funding, that affects
    vital programs including suicide prevention program. Just to
    give you one example, Staff Sergeant Parker Gordon Fox Suicide
    Prevention Grant Program provides grants to community-based
    suicide prevention resource meet the needs of veterans. You're
    familiar with it, Mr. Lorraine?
        Mr. Lorraine. Yes, sir.
        Senator Blumenthal. Including Easter Seals, for example, in
    New London, Windham Counties in my State of Connecticut. That
    program now is frozen----
        Mr. Lorraine. Yes, sir.
        Senator Blumenthal [continuing]. In terms of funding.
    That's a bad decision. Would you agree?
        Mr. Lorraine. I think it freezes our ability. We connect to
    235 veterans a week through the Fox Grant. That's 235 veterans
    I can't connect to.
        Senator Blumenthal. Thank you. My time has expired. I have
    quite a few more questions, and I hope the Chairman will give
    us a second round.
        Chairman Moran. Senator Cassidy.

                           HON. BILL CASSIDY,
                      U.S. SENATOR FROM LOUISIANA

        Senator Cassidy. Thank you. Mr. Golnick, maybe three years
    ago, we had testimony that VA was giving people iPads, and
    allowing telemental health, and also setting up satellite
    offices, for example, in a rural area in the back of a Walmart.
    So, it would be as if you're going to the pharmacy, but instead
    you slip back there and it would preserve--you know, you
    weren't going to the psychiatrist with a stigma that might be
    there, but rather very discreet.
        As I read each of your testimony, I didn't see any
    reference to that, so I'll throw that open, but I'll start with
    you. What about this telemental health program? Are you
    familiar with it?
        Mr. Golnick. I am, Senator. Yes, again, I think there are
    lots of good options getting out there. And again, I'm not
    anti-telehealth. I think that veterans should have the
    opportunity to be able to have the choice between seeing an in-
    person provider versus a telemedicine care, if that's the only
    option available.
        Senator Cassidy. Well, I only mention that because the rule
    aspect of it. I mean, this is obviously a way to--so someone
    doesn't have to drive an hour to get in and fighting traffic
    and maybe miss the appointment. I'm a physician. And by the
    way, Ms. Mathis, do anybody else have any experience with the
    telehealth and is it effective?
        Because, obviously, one issue here is the lack of
    providers, and this was portrayed to us, us as a way that maybe
    extra providers across the country would be able to provide
    services someplace else and therefore give some continuity of
    care and address that need. Yes, ma'am.
        Ms. Mathis. Yes, sir. We agree telehealth is an excellent
    option. I think, though, when it comes to license portability,
    there becomes an issue.
        Senator Cassidy. No, for the VA I'm told----
        Ms. Mathis. For VA that's not an issue.
        Senator Cassidy. Not an issue, correct.
        Ms. Mathis. But if you're talking about----
        Senator Cassidy. But be specific about the VA right now.
        Ms. Mathis. Yes, sir. Telemental health is a very good
    option, complementary with in person.
        Senator Cassidy. And so, is that being fully used and or is
    it fully effective? I guess that's because a lot of what we
    have here is a shortage of providers and therefore requiring
    long wait times and/or referral. Yes, ma'am.
        Ms. Marg. So, my husband has utilized telehealth before in
    some of his referrals to community care. Personally, for him,
    he would rather choose to see somebody in person, given the
    opportunity, especially when he's talking about his mental
    health struggles.
        Senator Cassidy. Again, I'm a physician, so when there's so
    much churn and that churn has been a feature of the discussions
    about mental health in the VA for some time, it's telling me
    something's wrong. Now, it could be that the salaries are less,
    but then why would you take the job in the first place? Or it
    could be that the administration is so frustrating that people
    just don't want to spend the rest of their life in this sort of
    a situation.
        Now, you're on the outside looking in, perhaps, but you may
    have special insights. Any ideas as regards why there is so
    much churn among providers?
        Mr. Golnick. In terms of them getting into the VA, or?
        Senator Cassidy. No, the providers. One of the things I
    read said, ``They provide us with this constant turnover. When
    you're trying to get that rapport, and then six months later
    you have somebody else, and then six months later you have
    somebody else.'' And we've seen previous statistics in which
    there's a lot of hiring, but there's a lot of departures. And
    so, I'm trying to--and there's a pattern there, and it's
    disruptive of the patient-physician relationship or the
    provider-patient relationship. Do we have any insight as to
    what might be causing that churn? Jim?
        Mr. Lorraine. Yes, sir. One of the things that we see, it's
    not just a churn about leaving the VA, it's a churn about
    leaving, moving within the VA, also. I think, continuity, and I
    mentioned it in my testimony, continuity is really critical.
    And I think whether when we talk about telehealth, seeing a
    patient face-to-face as a provider, myself, seeing a patient
    face-to-face can't be replaced by telehealth. It can be
    augmented and enhanced by telemedicine----
        Senator Cassidy. I accept that.
        Mr. Lorraine [continuing]. But in terms of the churn,
    you're moving within an enormous VA system. They just don't--
    it's not just leaving the system. It's leaving the facility
    that you're in.
        Senator Cassidy. So, they may go from Des Moines, Iowa to
    New Orleans, Louisiana?
        Mr. Lorraine. Or move within the facility to another area,
    yes, sir.
        Senator Cassidy. Okay. But then, obviously, theoretically
    you've systems that would limit that?
        Mr. Lorraine. But you'd lose your continuity. It's a churn.
    It's a churn from the individual's level out. It's a churn.
        Senator Cassidy. Okay. Well, I thank you-all for your
    testimony.
        Chairman Moran. Senator Gallego.

                          HON. RUBEN GALLEGO,
                       U.S. SENATOR FROM ARIZONA

        Senator Gallego. Thank you, Mr. Chairman. Thank you,
    everyone, for being here today, and for your service to your
    country whether by direct service or as a family of a service
    member. The testimony today illustrates the ways in which
    bureaucracy's failing our veterans, especially when it comes to
    veterans seeking mental health care.
        Personally, I have my personal experience with this. When I
    first got back from the war, I actually tried to go right to my
    VA, and my ask for services for PTSD was rejected because my
    paperwork hadn't caught up. And then continued to try to get
    help as well as many of my other guys that I serve with, and
    avoided therapy for almost 12 years after that. And luckily,
    and now in and have been, but a lot of us missed some
    opportunities, I think, to really put ourselves in the right
    path because of VA bureaucracy back in the day.
        And this is 2005, 2007 timeframe. So, this is, as I say,
    this is very personal to me. And even now, I still talk to my
    brothers in arms who are now also going through different
    levels of therapy and/or rehabilitation. So, thank you for the
    testimony you guys are providing because this is, obviously,
    important.
        As well as also, I am disappointed that we didn't get
    someone from the VA to come and talk because they could have
    brought us a very good firsthand experience about really what
    effective contracting looks like, as well as asking the
    Government Accountability Office about their assessment of the
    program last year. And I think that would've been a very good
    perspective, because we really need to look at this
    holistically. And for us, veterans that use services get PTSD
    services or other services, we know the best way to deal with
    anything of this nature is holistically.
        So, Mr. Golnick, thank you for sharing your experience
    seeking mental health care through the VA, and for the work
    you're doing with Forge Health--did I say that correctly?
        Mr. Golnick. Yes, sir.
        Senator Gallego. Okay. Just want to make sure. English is
    my second language, so sometimes I mess up things. I've also
    had the experience of seeking care, as I said, and dealing with
    the trauma of being told that you can't get help. And it's too
    common of a story among us veterans. It's our responsibility to
    ensure that veterans have access to timely high-quality
    healthcare.
        And in your testimony, you said that like the men that I
    was able to help catch in the first months really of trauma
    were the ones we were able to recuperate and put on a good
    path. And those that weren't has been a very long trial out.
    You mentioned the collaboration between Forge Health and VA
    showcase potential VA community partnerships, but also
    highlight some of these ongoing challenges.
        Can you speak more specifically about what you saw in terms
    of inconsistent implementation, and what solutions you would
    recommend be implemented to address these issues in particular?
        Mr. Golnick. Yes, Senator, thank you for your question. I
    think, again, going back to what I had mentioned previously,
    there are some VISNs and some VAMCs that are very collaborative
    and work well within the system if there's delays, and there
    are some where they were basically told not to refer out no
    matter what the case was, right? So, I think the standard, how
    we fix this, in my personal opinion, is to figure out a way to
    standardize those standards across the system to where every
    VISN, every VAMC has the same exact standards on how they're
    going to refer out the number of people they're going to refer
    out.
        I understand that community care costs money, but there's--
    you know, again, Senator, when you have a veteran and you don't
    catch them in time, and then they end up going to the emergency
    room.
        Senator Gallego. Becomes more expensive,
        Mr. Golnick. It becomes way more expensive, right? So, how
    do we go upstream to prevent that? And so, I think that
    standardized practice across the VISN and across the VAMC
    really is an important piece.
        Senator Gallego. Some of that is like tech, but some of
    it's just like SOPs as if we used to do the military. No matter
    what unit you were, you did the SOP. So, actually, you didn't
    have to have massive retraining, and there was at least
    uniformity across.
        Mr. Golnick. And, unfortunately, you saw it from the VAMC
    where the providers or the people that were referring out would
    say, ``Hey, I'm trying to refer. I understand this veteran
    needs that care.'' But the VISN is telling us no.
        Senator Gallego. Got it. And Naomi--did I say that
    correctly? Great organization that I really appreciate Disabled
    American Veterans. They actually helped me get my VA disability
    rating. So, thank you so much.
        But I wanted to follow-up on that. Are there currently any
    standards in place to ensure that community care providers are
    adequately trained to treat these types of conditions, in your
    opinion? And also, have you seen any specific instances where
    the lack of veteran-specific training standards have negatively
    impacted the quality of veteran care, at least from people that
    have been sharing with members, constituents of the DAV or
    other organizations?
        Ms. Mathis. Thank you for that question, Senator. Correct.
    There is a lack of training in community care. Currently,
    community care providers are only required to have opioid abuse
    treatment training, and this is as far as compared to direct
    care. So, there's a difference between what the direct care
    providers are required to have and the community care
    providers. And so, this is why we believe that if you
    strengthen the VA direct care, that then you would have better
    health outcomes.
        Senator Gallego. And so, community care--and I apologize,
    Chair--but so community care, sometimes there may be a veteran
    that goes, but only ends up getting some treatment specifically
    for opioids, but not, for example, trauma, deep trauma, or
    anything else of that nature. So, there's probably a mismatch
    at that point. And what you're saying is there's probably a
    better investment in direct care, or potentially maybe also
    doing community care, hyping up community care, making them
    more accessible to traditional PTSD?
        Ms. Mathis. Where they would understand military culture.
        Senator Gallego. Yes.
        Ms. Mathis. Right. And so, that's really where that
    opportunity is missed. Is you might have a veteran that
    presents before a community care provider and they don't
    understand military culture, and they're missing the cues where
    this patient might actually be suicidal.
        Senator Gallego. Thank you. Thank you, Mr. Chairman.
        Chairman Moran. Excellent. Senator Tuberville.

                         HON. TOMMY TUBERVILLE,
                       U.S. SENATOR FROM ALABAMA

        Senator Tuberville. Thank you, Mr. Chairman. Ms. Marg, I
    apologize for what's happened to your husband. I had a couple
    friends who went through the same situation. Terrible outcome.
    Even some were arrested at the VA for not having appointment
    and run off the property. It's a terrible mess. How do you
    communicate with other service members or family that come to
    you and asks you about your husband's problem? I mean, what's
    that conversation like?
        Ms. Marg. I'll tell them that any story that they've heard
    about the VA is true. When I've heard other people's stories,
    when I first heard them, I was surprised and shocked that,
    like, this must be a one-off situation. But my husband has been
    medically retired since 2015, and it seems like every step
    along the way, it is just such a struggle.
        There's been many times where my husband has just felt that
    he is done, and I tell him he is not. And we just keep
    fighting. And sometimes it takes going to an outside entity to
    get help, which I'm incredibly thankful that it exists, but
    that's ridiculous.
        Senator Tuberville. Ms. Mathis, I heard you say something
    in your opening statement. Are we still having problems getting
    information from the DoD to the VA?
        Ms. Mathis. Yes, sir. There is no interoperable.
        Senator Tuberville. And we've spent billions of dollars
    doing that. Billions, not millions, but billions. I wonder why
    we need a new IG. I wonder why we need to freeze the funds. We
    find out what the hell's going on. It's embarrassing.
    Absolutely embarrassing. I mean, the biggest healthcare system
    in the world and second largest budget in our country, and we
    can't figure out how to get information from one entity to
    another. But you know what? I've talked to people who said they
    could do it, but we won't go to those people. For some reason,
    we keep going to the same people. Any follow-up?
        Ms. Mathis. Senator, I think that's something that VA needs
    to really get a handle on, which is the records issue and the
    Electronic Health Records System. I believe, and I, I probably
    misspoke, I believe that VA, DoD, are probably easier to speak
    to each other. But when you talk about community care and VA,
    is where you have the rub, is where you have the issue. Records
    are not coming back into VA from community care, and they're
    not going out.
        Say for a mammogram. If I go for a mammogram for three
    years in a row, I go to the same provider, right? And then VA
    sends me, I don't know, maybe to another provider. That
    provider that is going to look at that radiograph needs to see
    the previous other images, not just the report. And so, then
    the onus is on the veteran to transfer those records and those
    images from one provider to the next, or from the provider to
    VA. And so, that's where they really need to need to have an
    interoperable system. A system that talks to each other.
        Senator Tuberville. So, we have the same problem in the
    DAV, just as bad as we do in the VA of information coming back
    and forth, that was the disabled veteran.
        Ms. Mathis. In DAV?
        Senator Tuberville. Yes, the same problem, informationwise,
    exchanging of the information from one entity to another.
        Ms. Mathis. You mean from VA?
        Senator Tuberville. Yes.
        Ms. Mathis. Oh, from VA to DoD. They've actually worked on
    that with Cerner and with Oracle. But it's really the issue is
    from community to entity.
        Senator Tuberville. Okay. Thank you, Mr. Chairman.
        Chairman Moran. Thank you, Senator Tuberville. Senator
    Duckworth.

                         HON. TAMMY DUCKWORTH,
                       U.S. SENATOR FROM ILLINOIS

        Senator Duckworth. Thank you, Mr. Chairman. And I want to
    welcome our witnesses for being here. Family members are
    caregivers. And thank you, Ms. Marg for your standing by your
    husband. As far as DAV, you hold my power of attorney as well.
    Says something. And Mr. Eaton, there might be a conflict of
    interest. I think I was the first female patient to receive a
    care pack, one of the backpacks that Wounded Warrior Project
    handed out at Walter Reed. I think I was one of the first 10
    you ever handed out. Unfortunately, it had jockey shorts,
    socks, and a shaving kit.
        [Laughter.]
        Senator Duckworth. None of which I could use, but my
    husband thanks you for them. The kits are much better now
    because now with the presence of women, they took my advice and
    readjusted, so. But certainly, Wounded Warrior Project was
    there for me very early on.
        I do want to take a moment to bring attention to that
    outrageous EO that President Donald Trump signed last night.
    And my colleague, Senator Blumenthal, touched on briefly that
    this EO will pause all federal grants effective 5 p.m. Eastern
    Standard Time today.
        We are in a hearing room full of policymakers and citizens
    dedicated to the welfare of our Nation's veterans, but let me
    tell you what this means for you or your loved ones who receive
    care from VA. This EO will pause critical and life-changing VA
    grants, including those that aid in VA's mission, ranging from
    community-based suicide prevention efforts, to rural veterans'
    telehealth, access and transportation services, to hiring and
    retention of nurses at State Veterans Homes, to especially
    adapted housing, assistive technology, and so much more.
        It is sadly ironic that we are here today to discuss
    expanding access to care for veterans. Meanwhile, the Trump
    administration is actively preparing to restrict their access
    to care in just a few hours' time. What happens then, in the
    meantime, to veterans who rely on these grants for suicide
    prevention resources? What happens to rural veterans who rely
    on VA transportation services to travel to their VA medical
    center? What happens to veterans who rely on these grants to
    live independently?
        This EO, which is illegal, by the way, creates chaos and
    threatens the stability of these programs that, in many cases
    offer, lifelines to people who sacrifice for their country.
    Congress alone has the power of the purse, and Trump
    unilaterally freezing billions of dollars of federal grants and
    loans that Congress already approved is unconstitutional and
    will hurt millions of people across this country. I hope that
    my Republican colleagues and the courts have the spine to stand
    up to Trump in the face of this cruel, chaotic, and
    unconstitutional order that hurts everyday Americans, including
    veterans.
        I could not agree more with the frustrations that have been
    described with trying to access care through VA, within VA
    itself, as well as through community care. I have both. I get
    care in the community because the VA cannot provide me care,
    for example, with the extremely advanced prosthetic devices
    that I use. I should have the right, and I do have the right to
    choose the prosthetist who provides me with that care.
        It's very ironic because the VA provides care for my left
    leg, but my prosthetist in the community provides care for my
    right leg. So, it's really important to me that they talk to
    each other, because otherwise, it makes it very difficult to
    walk.
        And, Ms. Mathis, I think you're touching on this
    communication piece is critically important. When I went from
    DoD to VA, I was given a CD-ROM. I had to wait 90 days to go
    talk to VA, at which point, I went and saw a physician
    assistant whose job it was to determine whether or not I was
    still an amputee.
        It was a waste of his time. It was a waste of my time. He
    wanted to be taking care of veterans, and yet he had to go
    through this rigmarole. To this day, there is still lack of
    good transferring of information from the DoD to the VA. It is
    also compounded when you go to community care. I do think that
    we need to do much more to allow veterans to make their own
    decisions.
        And Mr. Golnick, I appreciate that you brought attention to
    this very issue in you witness testimony about veterans being
    able to make the decisions. In your opinion, how should VA be
    ensuring that veterans are getting the information they need to
    make appropriate decisions about their care, including the
    choice to receive direct care at VA?
        Because VA needs to be your medical center home. I think
    you should go to VA, that's your medical center home. And they
    look at you and they go, okay, you're an Iraq veteran. We're
    going to take care of your mental health. But also, you may
    have respiratory illnesses. You need to be informed. And then,
    if you want to go to community to get the care, that should be
    made seamless. Can you speak to that?
        Mr. Golnick. Yes, Senator. I do think it's an education
    thing. And I think on the ground level, and I'm sure you've
    seen both of you, have seen this before, where the clinicians
    at the ground level, at VA, they want to do the right thing.
    They want to get veterans into care immediately. They want to
    get the care that they need. I think where it gets gunked up is
    when it gets up to a different level, right? So, it starts
    going up to the VISN level. They're putting the referral in.
        But in terms of educating, I think there needs to be an
    education across the VA system of, hey, these are your options.
    These are the things that are out there. Here's what we can
    provide. Here's what we can't provide, or it's going to take
    too long, and here's how you get there. And this is the process
    to do it. So, I think there really needs to be an education on
    the ground level, and I think it needs to go all the way up to
    the VISN level.
        Senator Duckworth. Thank you. Thank you, Mr. Chairman.
        Chairman Moran. Thank you, Senator Duckworth. Let me
    indicate there's a vote at noon and we have less flexibility
    than we used to have in enrolling the timeframe. So, I'm going
    to try to keep everybody to their five minutes. Senator
    Blackburn.

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

        Senator Blackburn. Thank you, Mr. Chairman. I appreciate
    what Senator Tuberville said, and Senator Duckworth just
    alluded to this; that it is very difficult for the veteran to
    get their records.
        And I think one of the things we should look at is who owns
    those records. It would be so much more helpful if the veteran
    himself controlled those records. If individually, we owned our
    healthcare records, every one of us. And then that way, you
    wouldn't have the problem that you're talking about, Ms.
    Mathis. The veteran would be in charge of their records, and
    would be able to take it whether they're in community care,
    whether they're in TRICARE.
        Because we have seen just an inordinate amount of waste in
    trying to build the Electronic Health Records. Whether it is
    Cerner, Epic, Oracle, it is like they can't figure this out. In
    Nashville, Tennessee, we've got a lot of health IT innovators.
    They can figure this out. And one way to do it is to let
    individuals, not the doctor, not the insurance company, not an
    agency, own their healthcare records.
        I also want to say, I find it very sad that for many of our
    vets, Tunnel to Towers and Wounded Warrior are the people that
    can help them get help, because the VA can't figure out how to
    do their job. They're still working remote. They do not show
    up. It takes forever. That's why there are 956,000 claims in
    the queue, and nearly 300,000 over 120 days. And veterans
    cannot get a response from these people.
        I know a lot of it is because of the union that is there at
    the VA that is stifling access to this care and benefits. And I
    find it just something that should not be tolerated. And it's
    frustrating to the veterans that we're trying to serve. And
    it's why community care is so vitally important. And Ms. Marg,
    thank you for speaking to that.
        Mr. Golnick, I want to come to you and thank you for your
    service, and thank you for what you're doing with Forge in
    trying to solve a problem, because the VA has thrown up
    barriers to healthcare. And you're trying to get around that
    and improve access. So, I want you to give like a 1, 2, 3
    point. What could this Committee require the VA to do to
    improve that access?
        Mr. Golnick. Thank you, Senator. And just to be clear I am
    a co-founder of Forge. I've stepped down from full-time with
    them, so that's why I'm representing myself. But I will say
    there are things, and to your point, Senator, I think there's a
    lot of friction points that are preventing veterans from
    getting access to care, especially when you're talking about
    mental health, right?
        I think what this Committee could do is work with the VA to
    ensure that they're educating veterans. That the VA is
    educating veterans on what their options are. Number two would
    be the administrative side of this. Ensure that the access
    standards are codified so people that within VA system know,
    okay, if X, then Y, right? I think that's as simple as that.
        And then I think ensuring that there's some oversight on
    certain VAs and certain VISNs in terms of that care being--
    making sure that that care of the veteran is the true North
    Star. It's not what their local budget is. It's not anything
    else. Care of veterans should be the true North star of all
    care decisions.
        Senator Blackburn. I agree with that. And putting the
    veteran at the center. That's why I've got this VA Health Care
    Freedom Act that would remove those obstacles, and really put
    the criteria in the MISSION Act for eligibility for community
    care, and give full choice to veterans in select regions. Let's
    roll this out as a pilot project and then put it on a four-year
    path to fully implement it so a veteran can go get what they
    need when they need it, where they need it. Show their VA card,
    and the VA gets the bill, not the veteran. And that would solve
    this and this enormous backlog that we have. Give the veteran
    the choice, put them at the center of this. Thank you, Mr.
    Chairman.
        Chairman Moran. Senator Blackburn, thank you. Senator King.

                        HON. ANGUS S. KING, JR.,
                        U.S. SENATOR FROM MAINE

        Senator King. Thank you, Mr. Chairman. In answer to Senator
    Tuberville's questions, I think the beginning of this
    electronic medical records problem started with a no bid
    contract about five years ago, six years ago, that was extended
    by the last administration. And I still don't understand why we
    don't go out to the market, whether--I'm sorry you mentioned
    Epic, Senator. Because Epic is a successful medical records
    system that I've observed in my system----
        Senator Blackburn. All running slow.
        Senator King. Well, okay. In any case, it seems to me, in
    order to analyze the issue of the relationship between VA
    direct care and community care, we need more data. We know
    exactly the VA wait times and all those kinds of things. We
    don't have that kind of data in terms of the private sector. I
    know in the private sector in Maine, it's pretty hard to get an
    appointment particularly with a specialist.
        So, I think in order to make policy here, Mr. Chairman, we
    need some, we need some information. We need to have cost
    comparisons. We need to have time comparisons, wait times. So,
    I--everybody's nodding, but that won't show up in the record.
    Could somebody say yes?
        [Laughter.]
        Senator King. ``Yes, Senator, you're right.''
        Ms. Mathis. Yes, Senator, I wholeheartedly agree. There is
    no data coming back out of the community back into VA. And
    there is no sort of accountability either when the records
    don't show up back to VA. So, you have a provider, a primary
    care provider, say at VA, that may have sent a patient out to
    the community for specialized care, and the information when
    the patient comes back to VA, the information is not coming
    back. Therefore, that provider is not able to provide an
    accurate treatment plan for that patient.
        Senator King. So, we know we don't have a handle on cost,
    quality, or time. Is that correct?
        Ms. Mathis. Correct, Senator.
        Senator King. And, by the way, when we're talking about the
    time of VA's responsibility on backlogs, a staff freeze isn't
    going to help that problem. If there are fewer people to answer
    the phone, fewer people to process claims, that's only going to
    exacerbate the problem, not, not make it any better.
        And I note that the administration the other day appeared
    to walk back part of the hiring freeze with regard to direct
    care providers, but to leave a hiring freeze in effect that has
    fewer people responding, processing claims, and those kinds of
    things, that's in effect, a denial of benefits itself. Is it
    not, Mr. Eaton?
        Mr. Eaton. Yes. I think the big focus area, and that's
    where we come in, and Senator Duckworth mentioned in terms of
    the backpack. You know, in 2003, we started providing backpacks
    to the first injured, ill, and wounded Warriors coming back
    from Iraq and Afghanistan. And we made a promise. And so, we'll
    continue that promise that we'll be there for their needs for a
    lifetime.
        And so, we're doing that today in times where there's
    changes throughout the system that we can be a constant, to
    support them and remove barriers to increasing access to care.
        Senator King. And I think one other factor we need to talk
    about when we're talking about private sector is that there are
    huge shortages in the private sector. My major hospital, one of
    my major hospitals in Maine is down something like 800 nurses.
    And so, it's not enough to say, oh, the community can take care
    of it when, indeed, there are shortages in the community in
    terms of CNAs, nurses, psychiatrists, psychologists.
        And I think we need to recognize that there's no simple
    answer to this. To me, the answer is better coordination,
    better data, and understanding the results that we want for our
    veterans. That's really the goal. Is that correct?
        Mr. Golnick. Yes, Senator, absolutely. And to your point,
    even the private sector, a lot of the commercial payers aren't
    even collecting this data because it makes them look bad if the
    wait times are too long or any of this other stuff. So, it
    really needs to be complementary.
        Senator King. I just want to be sure we're comparing apples
    to apples when we're deciding policy here, and that we don't
    move toward a policy that in the real world, doesn't
    necessarily improve things for the veterans. And I'm just
    concerned that we not hollow out the VA capacity and then say,
    ``oh, look, the VA's not doing very well,'' when we've made it
    impossible for them to do it, to do the work that they've been
    charged to do.
        So, I appreciate you-all joining us here today, and look
    forward to continuing to work with you because I think this is
    an issue that needs attention. Thank you. Thank you, Mr.
    Chairman.
        Chairman Moran. Senator, thank you. The Elizabeth Dole Act
    that we passed and became law requires significant data
    collection regarding community care. So, maybe we'll have some
    information that we can make that analysis. I also would point
    out that I've argued with the VA about when the wait time
    starts, and they want to start the wait time when the
    appointment is made, not when the veterans ask for the
    appointment. But I don't need to get----
        Senator King. You ought start with the call.
        Chairman Moran. Yes.
        Senator King. Thank you.
        Chairman Moran. Senator Cramer.

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

        Senator Cramer. Thank you, Chairman. Thank you to all of
    you for being here, and for your testimony, and for your
    service. So, a couple of things come to mind. Well, one of the
    things with regard to Senator King's comments about shortage of
    workforce, that's a real problem. That's a problem in
    healthcare. It's a problem in manufacturing. It's a problem in
    everything. But it is particularly challenging in healthcare.
        Which is why the CMS rule, the staffing rule, is so awful
    because it literally, literally provides less opportunity
    because it runs the risk of shutting down healthcare providers
    simply because they don't have a 24-hour day, 7 day a week RN.
    And I would submit to you that access is not just about the
    quality of the care, it's about access, period, if the
    alternative is none.
        And so, while standards are important, I would also submit
    that I don't share some of my friends' view that it shouldn't
    be competitive. I think the best way to improve care is
    competition. Whether it's competition between the private
    sector and the public sector, or two private sectors or two
    public sector agencies. A little bit of competition is fine.
        I agree, I don't want to gut the VA's direct care system.
    There are unique things about the VA that I know several of my
    veterans--I have a veteran who would drive 300 miles to Fargo
    every day before he would see a local provider, particularly
    for counseling. All of that said, whether there are all kinds
    of barriers to community care, a lot of it is the bureaucracy
    itself. I mean, even in North Dakota where we have a quite a
    cooperative VA hospital in Fargo, we hear many, many stories of
    roadblocks being put up to community care. They check all the
    boxes except one, or you know, they only check 99 out of the
    100 boxes, therefore null.
        I just think we need to make it--I agree with what Senator
    Blackburn said. If we put the choice in the hands of the
    veteran, the market will determine where they go. The type of
    care they get will determine where they go, how long the wait
    is will determine where they go.
        So, a little bit about North Dakota. We have one VA center.
    It's in Fargo. That's right on the Red River. I mean, literally
    on the--it's on the shores of the Red River, which is the
    barrier, the border to Minnesota. That means if you're in
    Williston, or Dickinson, or Beach, you might be 400 miles away
    from the VA hospital.
        We have eight CBOCs, I think it is. And we have 37 critical
    access hospitals. Critical access care hospitals are there on
    purpose, and it has to do with access, right? And they're
    reimbursement by CMS particular formula. And we have veterans,
    and by the way, I think it's just a handful of those CBOCs are
    in the same community as a critical access hospital.
        What I'd like to see us do, and I've got a proposal to do
    this, and you'll be hearing more about it eventually, and if
    training's required, I'm all for it. But for many of these
    critical access hospitals, their margins are this thin. They're
    barely hanging in there. And two, or three, more patients, or
    five more patients in the community might be what keeps that
    hospital open. And if it's 50 miles to the next hospital or 350
    miles to the VA hospital, that critical access hospital might
    be the only provider that could save a veteran.
        I'd like to make this automatic. No doubt, smart people can
    figure out the records thing. I don't know why it's taking as
    long as they can. And maybe I'll start with you, Mr. Lorraine.
    Is that plausible? Am I somewhere in the ballpark of a possible
    solution in a very, very rural place?
        Mr. Lorraine. Yes, sir. I know I've been to Minot, I know
    how rural and out there it is.
        Senator Cramer. That's one of our biggest cities.
        [Laughter.]
        Mr. Lorraine. But, you know, one of the things that I spoke
    about was continuity of care. And not only continuity care is a
    healthcare provider, I want the family there, I want the
    physical therapist nearby, I want the staff that does this. And
    we talk a lot about mental health and substance abuse, but it's
    really more than that. We're talking about access to
    healthcare, right? So, it's surgery. How many total knees are
    done in this location versus this location.
        So, the answer is we need to look at what's the best long-
    term outcome for a veteran in terms of getting their care. It
    may be the VA that's in their community. But it may be your
    local hospital that the family can be present, the physical
    therapist is there, the staff is invested. And it's all one.
    Thank you.
        Senator Cramer. I'd just rather have it easy rather than
    confusing, and then likely, a denial for community care. Thank
    you.
        Chairman Moran. Senator Hassan.

                       HON. MARGARET WOOD HASSAN,
                    U.S. SENATOR FROM NEW HAMPSHIRE

        Senator Hassan. Well, thank you, Chairman and Ranking
    Member Blumenthal, and thanks to all of our witnesses for being
    here today. Whether you've served, been an advocate for
    veterans, or both, we really appreciate your support for and
    commitment to our veterans and to our Nation.
        I appreciate that this hearing is focused on community
    care. It's a really important component of providing care to
    our veterans, especially in a state like New Hampshire, which
    doesn't have a full-service VA hospital of its own. It matters
    that we get this right and that we ensure that veterans who
    qualify for community care really get prompt access to it,
    understanding as Senator King has pointed out that access in
    the private community care system is challenging for private
    citizens as well right now.
        But before I get to any questions, I want to take a moment
    to discuss what are illegal and unconstitutional acts by this
    administration because of the way they affect the very issues
    we are talking about today. As Senator Duckworth referenced,
    the administration last night ordered a full halt on a whole
    lot of federal funds, including some states are now locked out
    of Medicaid funds. Community care in rural areas that Senator
    Cramer was just talking about won't exist if hospitals don't
    exist. And they are very dependent on Medicaid.
        But the administration appears to be halting that funding
    as it is halting critical funding today for veterans in rural
    areas that depend on it. The administration also took an
    illegal act when it decided to unilaterally try to fire
    inspectors general contrary to law, and this is really
    troubling for a lot of reasons.
        But just for example, the VA inspector general's office
    just released a report last fall on community care scheduling
    delays in the VA health service. But the administration is
    unilaterally, contrary to law, decided to fire all of these
    inspectors general. The report that that inspector general did
    concluded that leaders had failed to focus on the patient,
    respond to staff concerns, and get to the root cause of
    concerns regarding delayed scheduling of urgent consults.
        This type of work holding government accountable and making
    sure that our system operates as efficiently as it can is at
    the heart of what independent, Senate-confirmed inspectors
    general do. So, that's why I am really concerned by President
    Trump's illegal firing of at least 17 inspectors general over
    the weekend, including VA Inspector General, Michael Missal,
    who was confirmed to that position with unanimous consent by
    the United States Senate.
        The letter to these inspectors general said that priorities
    were changing. That's what the Donald Trump administration
    said. What greater priority is there to ensure that taxpayer
    dollars are used? Well, it is in the interest of every American
    that these public servants be able to investigate waste, fraud,
    and abuse without political interference, and be able to stand
    up to powerful interests without fear of losing their jobs. We
    owe that to our country and especially to our veterans.
        Now, I have time for a couple of questions. I want to
    start, Mr. Eaton, with you. In your written testimony, you
    discussed some of the obstacles veterans encounter when seeking
    mental health care, and in particular, identified that more
    providers are needed regardless of whether they are in the
    community or in the VA system.
        Mr. Eaton, can you please speak to the need for veterans to
    have access to steady, high quality mental health treatment,
    and how increasing the number of mental health providers could
    support that?
        Mr. Eaton. Thank you for the question, Senator. When you
    think about an effective care team, and we understand that,
    first of all, the personal journey that it takes to get to that
    first appointment, building a relationship, rapport and telling
    your story is incredibly meaningful to building that
    relationship.
        And so, as VA employees or even community care network
    employees are transitioning, really it leaves the veteran to
    navigate that system, again, on their own. And so, as we've
    highlighted here today, not only a veteran issue, but also just
    as civilians, in general, mental health is a shortage area. And
    so, looking at ways to incentivize providers create
    environments where practicing medicine and mental health is a
    thriving environment, is really important, as we're helping to
    buildup a system to support veterans.
        Senator Hassan. Well, I appreciate that. Thank you very
    much. Ms. Mathis, community care provides a chance to receive
    timely quality care close to home for many veterans who don't
    live near VA facilities. This is especially true for rural
    veterans and veterans who live in states like New Hampshire
    that don't have a full-service VA hospital.
        Ms. Mathis, could you please discuss the importance of
    ensuring timely access to local care for rural veterans, and
    the role that community care plays in ensuring that veterans
    get the care that they need and deserve?
        Ms. Mathis. Absolutely. Thank you for that question,
    Senator. As outlined in the MISSION Act, it should be
    complementary, the two. We believe that access to community
    care is essential, especially in a rural community where you're
    fighting with the community to get specialized care. And so,
    yes, absolutely, access is critically important and really
    could be lifesaving.
        Senator Hassan. Thank you very much. Thank you, Mr. Chair.
        Chairman Moran. Senator Banks.

                            HON. JIM BANKS,
                       U.S. SENATOR FROM INDIANA

        Senator Banks. Thank you, Mr. Chairman. Mr. Golnick,
    healthcare organizations get more frustrating and impersonal
    the bigger they get. I think we all agree about that. And the
    Veterans Health Administration is the largest hospital system
    in the country. Why do you think the VA is so bureaucratic, and
    what can Congress do to change that culture?
        Mr. Golnick. Senator, that's a tough question. Every large
    healthcare system is frustrating, right? There's a lot of--
    there are a lot of things that are structurally in place that I
    think are important things, that are safety. You know,
    especially when you're talking about mental health, right?
    Like, accreditations, certain things. Clinicians should have a
    certain criterion.
        Again, I don't think it's on the clinical side that we're
    seeing the issues where I see the issues are when you get up
    into the administrative, right? I think the processes that are
    in place right now between VA into community care and back and
    forth, what my colleague from DAV has been talking about,
    that's really where I think there could be some good work done
    in codifying those access standards so that everybody in this
    bureaucracy--you know, I look at things as a naval officer,
    right? They always said the instructions are written in blood,
    right? Because there needs to be a very clear line that shows
    okay, if X then Y. And we don't see that a lot in a lot of
    these places because there's no standardization.
        Senator Banks. Yes. As a Navy officer, you understand
    culture, though. So, how do we change the culture, and what can
    I do, Members of the Congress do to force that culture to
    change?
        Mr. Golnick. I think the ability to ensure that the
    leadership at VA--I've talked to some VAMC directors in my time
    where they said, you know, I give directives not orders, right?
    So, sometimes things are just not followed, right? So, I think
    there needs to be, you know, in order to change that culture, I
    think really streamlining and codifying things in a more clear
    manner, and having an SOP. And having those things in place is
    going to ensure that people are following the letter of those
    instructions.
        Senator Banks. Mr. Lorraine, we hear a lot about community
    care being too expensive. It accounts for about 40 percent of
    veterans healthcare, and it makes up about 25 percent of the
    VHA budget. That sounds like a pretty good deal to me. Isn't
    it?
        Mr. Lorraine. Yes, it is. But I don't think we've given
    enough chance to the community care to measure the long-term
    impact of local, meaningful, well-rounded healthcare. The other
    thing, if I can just add to the question that you asked Eric,
    in my opinion, the veteran needs to be the center of the
    universe for the VA, not the VA, the center of the universe for
    the veteran.
        Senator Banks. Amen. Well put. The VA added 120,000
    employees over the last decade, and I support giving the VA the
    resources it needs to take care of our veterans. But there are
    only so many doctors and nurses to hire. How do you think the
    department can deliver more healthcare with the personnel that
    it already has?
        Mr. Lorraine. You know, I think there needs to be, not
    managed healthcare, but coordinated care. Coordinated care.
    Somebody needs to take responsibility for the veteran and
    connect them to private organizations like WWP, public
    healthcare providers that are in the Community Care Network and
    the VA. To look for the best opportunity, but to unify, to
    coordinate the care for the best outcome. It doesn't just need
    to be in the VA.
        Senator Banks. Mr. Eaton, we want VHA care and community
    care to complement each other, not compete as they have over
    the last decade. What VA policies need to change to make that
    happen?
        Mr. Eaton. Thank you for the question, sir. I would say,
    again, we've hit on throughout today; standard access across
    the board. We think about VHA as the largest integrated health
    network. That's their direct care, but also the Community Care
    Network. And these are cultivated networks created in
    partnership with third-party administrators that have been
    found to offer high-quality, veteran-centric care. And so,
    having the same standards and then care coordinated throughout
    the entire system, not thought about as two separate would be
    really a great first step.
        Senator Banks. The VA has 120 residential mental health
    rehab facilities, and veterans in crisis are waiting about
    three weeks to get placed. It takes the VA three to five years
    to lease a new facility. Do you think the VA could ever open
    enough residential rehab facilities to fully meet the veterans'
    needs?
        Mr. Eaton. I think if we take a step back, that's why the
    Community Care Network exists, right? To really complement the
    VA in areas where there's gaps, higher demand, and where
    veterans' needs are most sought. And so, I think if we take a
    step back and look at all inputs from both footprint from the
    VA, as well as the Community Care Network, we'll have all the
    data points to make an informed decision.
        Senator Banks. Thank you. I yield back
        Chairman Moran. Senator Banks, thanks. We're not doing
    another round because if somebody else walks in the door, I'm
    in trouble on the time. But Senator Blumenthal has a couple of
    questions, and I have a couple of questions, then we're going
    to wrap this up.
        A vote was expected at noon. We no longer have the
    flexibility because we're attempting to enforce the votes only
    lasting 15 minutes. And we used to be able to do this much
    differently, but we cannot. So, Senator Blumenthal,
        Senator Blumenthal. Thanks, Mr. Chairman. I have a few
    questions which I think are answerable by yes or no because
    what I'm hearing is, as Mr. Lorraine said so well, veteran
    ought to be the center of the universe. Veterans' choices
    should be respected, veterans' decisions should be informed so
    that the veterans' medical interest is put first.
        And an informed decision can't be made by a veteran based
    on an ad that he/she sees on television saying, go get this
    drug. You know, anybody watching TV these days, you are deluged
    by ads that depict certain drugs as cure-alls. A veteran
    shouldn't be permitted to go into the community and just say,
    ``Give me this opioid.'' I assume all of you would agree?
        Ms. Mathis. I would agree with that, Senator.
        Senator Blumenthal. And I'm taking the absence of a
    disagreement as a yes. Let me pose another question to you real
    quickly. My fear, as I said at the very beginning, is that
    there will be an erosion, a starving of the VA because the
    attempt to shift care to the community without veterans having
    choices will mean less investment in the VA system and
    Connecticut.
        We're rebuilding our VA facility in West Haven. It will
    provide for a new surgical suite, new parking, new care
    facilities, particularly for women. That kind of investment
    will make VA care better than it is now. I assume all of you
    would agree that we need to make those capital investments in
    VA facilities across the country, and maybe build facilities in
    parts of Kansas that right now don't have any. Would you-all
    agree?
        Mr. Lorraine. I disagree, sir.
        Senator Blumenthal. I'm sorry?
        Mr. Lorraine. I disagree.
        Senator Blumenthal. Tell me why?
        Mr. Lorraine. I don't think that we can build enough VA
    facilities to meet the needs of every veteran in the United
    States. I think that there needs to be a merge between good VA
    facilities and none. I don't mean to use up your time.
        Senator Blumenthal. And you are absolutely right. And if I
    was unclear, I'm not saying that VA facilities should be built
    for every veteran. We need some community care, no question
    about it. But the VA facilities that exist right now serving
    veterans in Connecticut or Kansas, should be the gold standard.
    They ought to be top flight. They ought to give veterans the
    best care possible. Would you agree with that point?
        Mr. Lorraine. 100 percent.
        Senator Blumenthal. Thank you. Let me just conclude by
    saying this conversation seems a little bit surreal this
    morning. Because I'm hearing from--I'm getting emails from
    healthcare groups in Connecticut whose funds have been frozen.
    These are suicide prevention, they're addiction treatment,
    their payrolls are halted, their budgets are in danger. We're
    talking here about community care potentially decimated.
    There's chaos and confusion as a result of this freezing of
    funds.
        You know, in my prior life as Attorney General in the State
    of Connecticut, I would be in court saying that this action is
    illegal, it's unconstitutional. Congress has the power of the
    purse. It's a seizure of that power, monarchical and
    autocratic, and it's a violation of the Impoundment Control
    Act.
        But put aside the legalities, it is potentially devastating
    to healthcare for veterans. The Fox Suicide Prevention Program
    that was mentioned is just one of literally tens, maybe
    hundreds, of programs that are in peril right now. And so, I
    call on my colleagues to join in protesting and opposing. Once
    again, I ask veterans to rise up and say, please, Mr.
    President, clarify that you are not going to make veterans the
    victims of this illegal policy.
        And the same point I would make as to the firing of
    inspectors general, accountability for community care as well
    as veterans care. Let's put veterans care, first and foremost,
    including holding accountable the VA. The VA ought to have its
    feet to the fire. As Michael Missal has done as inspector
    general, he saved $40 billion. That's a rough estimate. And
    there was a mention of the electronics record program.
        There was a provision that would've provided more
    accountability for the electronic records program. Apparently,
    it was deleted at the last moment. I think we can include it in
    whatever legislation we pass. I'm fully in favor of making sure
    that standards and criteria are applied, and that they
    eliminate wait times, whether at the VA or in community care.
        Mr. Chairman, I really appreciate your leadership. I know
    you made reference to the importance of inspectors general when
    we had a hearing recently. I think this cause can be bipartisan
    and that the hiring freeze, as Mr. Eaton said so well, can be
    clarified so that it doesn't affect the VA and our veterans'
    care. Thank you, Mr. Chairman.
        Chairman Moran. Thank you, Ranking Member. There are five
    minutes left in the vote, but I still have questions. So, we're
    about done. Mr. Eaton and Mr. Mr. Lorraine, both the Wounded
    Warrior Project and American Warrior Partnership, indicate
    they've seen trends over the last year indicating pressures
    from VA administrators on VA providers to not place referrals.
    Would one or both of you explain what you've seen?
        Mr. Eaton. Yes, sir. Thank you for the question. What we're
    hearing, again, from clinicians is really that pressure from an
    administrator perspective to minimize referrals out and even a
    referral decision being made at the administrative level versus
    a clinical level.
        And so, this could mean that instead of going out into the
    community a longer wait time for care within the VA, it could
    also result in a different level of care than initially
    indicated. So, whether individual counseling could be shifted
    into a group setting which is really not aligned with what the
    veteran was looking for or what his clinician recommended his
    or her.
        Chairman Moran. And that, I mean, just for me to point out
    what I think is obvious, that can very well be contrary to
    what's in the best interest of the veteran patient. And who,
    but the VA, including their administrators, ought to be the
    most interested in the quality, and not only the timeliness,
    but the quality of the care a veteran receives.
        I spoke about this, and it bothers me because for my
    involvement in veterans' issues, for as long as I've been in
    Congress, I sometimes can get individual cases altered, fix a
    problem for a veteran. But it doesn't seem like when I do that
    it fixes the problem for the system for every other veteran
    who's experiencing the same thing.
        I highlighted it on the Senate floor. The veteran in my
    hometown who was receiving cancer treatment. 60 treatments, he
    was receiving them in the community at the authorization of the
    VA. He had 59 treatments of the 60 he needed, and the VA called
    him back to the VA hospital for the 60th care treatment.
        The other example is the constant--I mean, I've indicated
    so many times that what I think I know is based upon what I
    hear from veterans. What we call casework, is part of that. The
    number of times, for example, that chiropractic care has been
    recalled back out of the community. So, you have a veteran
    who's been receiving chiropractic care with the same
    chiropractor for months and years, but the VA says, no, that's
    no longer permissible. Community care will not cover your visit
    to a chiropractor, come back to the VA.
        Those decisions can't be being made based upon what's in
    the best interest of the healthcare and well-being of the
    veteran. I mean, I was involved in the creation of the MISSION
    Act. One of the components by which a person can be referred to
    the, to community care is what's in the best interest of the
    veteran. And we intentionally defined ``best interest of the
    veteran'' to be determined by the veteran and his or her
    provider, not an administrator at the VA, so that the decision
    is made on the best healthcare interest of the veteran, not on
    the financial well-being or the caseload of the VA.
        I mean, I'm all interested in seeing that the law is
    complied with. And that's what I have spent so much time in
    trying to convince, in recent months, the VA to utilize the
    MISSION Act in the way that it was not only intended, but in
    many instances, actually written. So, we're trying to get the
    law to be the law at the VA.
        And I appreciate the testimony that we heard today. And I
    think there's a takeaway for me, and I hope others, that this
    is particularly important, Mr. Golnick and Ms. Marg, when it
    comes to mental health, suicide ideation. All the care for
    veteran matters, but there are certain things in which the
    timeliness, and the consistency, and the personal nature of the
    care determines the outcome and whether there's success.
        And so, I take your testimony very seriously with a renewed
    interest in trying to be a better advocate for not just
    community care or the MISSION Act, but community care and the
    MISSION Act as it may save a life and improve the quality of
    life of veterans who can't get what they need within the VA. I
    wanted to talk about residential treatment in the length of
    time, but I don't have the time. But that has captured my
    attention as well. What can the Department of Veterans do to
    provide more longer-term care for veterans?
        I'm going to conclude the hearing. It's concluded with this
    expression of gratitude for all of your presentations and your
    willingness to visit with us, and we'll try to be a Committee
    that listens to those who tell us what the challenges are and
    respond appropriately.
        Each Member of our Committee has five legislative days in
    which to revise and extend their remarks, what we all said. And
    I ask any Senator who'd like to submit a question to you, to do
    so in a timely manner. And we'd like for you to respond for the
    record following today's hearing in a timely manner as well.
        With that, this hearing is adjourned.
        [Whereupon, at 12:19 p.m., the hearing was adjourned.]

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