[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.]
A P P E N D I X
Prepared Statements
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Submission for the Record
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Questions for the Record
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Statements for the Record
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
[all]