```

[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]

 FY2019 DEPARTMENT OF VETERANS AFFAIRS BUDGET REQUEST FOR THE VETERANS 
                         HEALTH ADMINISTRATION

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        THURSDAY, MARCH 15, 2018

                               __________

                           Serial No. 115-51

                               __________

       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
                    
35-388                      WASHINGTON : 2019                        
                     
                     
                     
                     
                     COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BRAD R. WENSTRUP, Ohio               JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   KILILI SABLAN, Northern Mariana 
JODEY ARRINGTON, Texas                   Islands
JOHN RUTHERFORD, Florida             ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                     BRAD WENSTRUP, Ohio, Chairman

GUS BILIRAKIS, Florida               JULIA BROWNLEY, California, 
AMATA RADEWAGEN, American Samoa          Ranking Member
NEAL DUNN, Florida                   MARK TAKANO, California
JOHN RUTHERFORD, Florida             ANN MCLANE KUSTER, New Hampshire
CLAY HIGGINS, Louisiana              BETO O'ROURKE, Texas
JENNIFER GONZALEZ-COLON, Puerto      LUIS CORREA, California
    Rico

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                            
                            
                            
                            C O N T E N T S

                              ----------                              

                        Thursday, March 15, 2018

                                                                   Page

FY2019 Department Of Veterans Affairs Budget Request For The 
  Veterans Health Administration.................................     1

                           OPENING STATEMENTS

Honorable Brad Wenstrup, Chairman................................     1
Honorable Julia Brownley, Ranking Member.........................     2

                               WITNESSES

Adrian M. Atizado, Deputy National Legislative Director, Disabled 
  American Veterans..............................................     3
Sarah S. Dean, Associate Legislative Director, Government 
  Relations Department, Paralyzed Veterans of America............     5
Patrick Murray, Associate Director, National Legislative Service, 
  Veterans of Foreign Wars of the United States..................     6
Matthew J. Shuman, Director, National Legislative Division, The 
  American Legion................................................     7
    Prepared Statement...........................................    24
Carolyn M. Clancy M.D., Executive in Charge, Veterans Health 
  Administration, U.S. Department of Veterans Affairs............     9
    Prepared Statement...........................................    28

                        STATEMENT FOR THE RECORD

The Co-Authors of THE INDEPENDENT BUDGET.........................    33
American Federation of Government Employees, AFL-CIO.............    39

 
 FY2019 DEPARTMENT OF VETERANS AFFAIRS BUDGET REQUEST FOR THE VETERANS 
                         HEALTH ADMINISTRATION

                              ----------                              

                        Thursday, March 15, 2018

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                  Subcommittee on Oversight
                                        and Investigations,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:01 a.m., in 
Room 334, Cannon House Office Building, Hon. Brad Wenstrup 
[Chairman of the subco mmittee] presiding.
    Present: Representatives Wenstrup, Bilirakis, Dunn, 
Brownley, Takano, Kuster, and Correa.

          OPENING STATEMENT OF BRAD WENSTRUP, CHAIRMAN

    Mr. Wenstrup. The Subcommittee will come to order. Good 
morning and thank you all for joining us today to discuss the 
Department of Veterans Affairs fiscal year 2019 budget 
submission for medical programs. The President's budget request 
includes $198.6 billion in total funding for VA, an increase of 
nearly $12 billion over last fiscal year. It also includes $90 
billion in discretionary funding, an increase of more than 8 
percent above last fiscal year.
    It is a budget request that is robust, and it is one that 
continues this Nation's long tradition of investing in our 
veterans and in the care, benefits, and services that they 
earned through their service to us. Most importantly, it is a 
budget request that is reflective of Veterans Voice, as the 
American Legion will testify momentarily.
    During today's hearing, I am interested in learning more 
about how this budget would set VA up for long-term success 
and, in doing so, increase productivity, efficiency, access to 
care, and quality of care across the VA health care system. I 
also want to know more about how this budget would fund and 
encourage a top to bottom review of VA's resources; physical, 
financial, and human.
    This Committee, led by Chairman Roe, has been working hard 
hand-in-hand with our veterans' service organization partners 
over the last year to craft legislation that would institute a 
VA asset and infrastructure review. I want to reiterate this 
morning how necessary that effort is and my intention for it to 
encompass a review of more than just buildings and property.
    During the Full Committee budget hearing one month ago, 
Chairman Roe and Secretary Shulkin noted that VA's budget has 
increased by 175 percent since 2006. In that timeframe overall 
Federal spending increased by just 54 percent, and gross 
domestic product increased by only 40 percent.
    In order for VA to move forward into a fruitful future, we 
must ensure a clear and accurate understanding of VA has, what 
VA needs, and where VA is going. We need to know that our 
medical facilities are well staffed and well equipped to 
provide modern, high quality care where our veterans live.
    We need to know that VA's relationship with community 
partners are strong and able to respond quickly to meet needs 
when and where VA cannot, and we need to know what VA's 
significant and growing financial resources are--that VA's 
significant and growing financial resources are being used to 
their highest purpose and never squandered, wasted, or abused.
    Absent that, we cannot assure veterans that their needs 
will be meet today, next week, or next year, not to mention 10 
or 20 years from now, and we also cannot assure American tax 
payers that their hard-earned dollars are being used by VA 
appropriately, wisely, and well.
    I am grateful to our witnesses from VA and from our veteran 
service organization partners for being here this morning to 
discuss the President's budget request, and will now yield to 
Ranking Member Brownley for any opening statement that she may 
have.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you. Thank you, Mr. Chairman. I 
certainly would like to take this opportunity to--excuse me--
welcome our distinguished VSO stakeholders here today. Your 
insight is always and continues to be invaluable. And, Dr. 
Clancy, I appreciate you and your team being here with us today 
as well. I look forward to hearing from you on how VHA intends 
to continue to meet veterans' health care needs with this 
budget request.
    However, it would be unreasonable for me to ignore the 
current state of affairs at the District of Columbia's VA 
Medical Center, a facility that for all intents and purposes 
should be considered a crown jewel of VA facilities. A little 
over a week ago, VA's Office of Inspector General issued 40 
recommendations that would not only improve the operations at 
the D.C. hospital, but provided lessons learned for medical 
facilities nationwide.
    While the IG did not explicitly state the issues at the 
D.C. VA were systemic in nature, history shows that issues 
surrounding leadership failure point in that direction. My 
fears were further confirmed when VA placed VA medical centers 
in VISN 1, 5, and 22 under VA Central Office Receivership.
    Dr. Clancy, your experience implementing significant 
changes throughout VHA following the Phoenix wait list crisis 
makes you uniquely positioned to ensure VA quickly corrects 
course in these three VISNs. I would urge you to ensure that 
the lessons learned from the Phoenix crisis, and any relevant 
subsequent events, are applied in VISNs 1, 5, and 22.
    I hope VA is committed to implementing lasting change that 
can be effectively applied to VA medical systems nationwide. I 
also ask VA to remain transparent during this process so that I 
and my colleagues here on the Committee can continue to both 
oversee and support your progress.
    Dr. Clancy, I am also concerned that the political in-
fighting within VA Central Office has diverted resources and 
attention from what really matters; the delivery of benefits 
and health care services to veterans. Every employee at VA 
should be focused on what is best for veterans. Not what is 
best for their careers or for the White House, but for the 9 
million veterans currently enrolled in the VA's health care 
system. Perhaps this in-fighting is limited to one particular 
office or a handful of employees, but it is unnecessarily 
distracting, and in my opinion is unprofessional.
    We can see that within your fiscal year 2019 budget 
request, VHA intends to vastly improve the delivery of health 
care by accomplishing many significant goals. Members of this 
Committee on both sides of the aisle want VA to succeed in 
achieving each of these goals.
    I am hopeful that today's conversation will result in a 
better understanding of how VHA's budget request will support 
the accomplishment of these incredibly important goals. Goals 
that I strongly support, like the expansion of mental health 
services, continued support of woman veterans, and the 
development of IT infrastructure capable of supporting the 21st 
century high performing VHA our veterans deserve.
    To each of our witnesses, I am thankful for your 
participation and look forward to hearing your comments. Thank 
you, Mr. Chairman, and I yield back the balance of my time.
    Mr. Wenstrup. Well, thank you, Ms. Brownley.
    So joining us this morning on our first and only panel are 
first Adrian Atizado, the Deputy National Legislative Director 
for the Disabled American Veterans. Sarah Dean, the Associate 
Legislative Director for the Government Relations Department 
for the Paralyzed Veterans of America; Patrick Murray, the 
Associate Director of the National Legislative Service for the 
Veterans of Foreign Wars of the United States; Matthew Shuman, 
the Director of the National Legislative Division for the 
American Legion; and Dr. Carolyn Clancy, Executive in charge of 
the Veterans Health Administration for the U.S. Department of 
Veterans Affairs, who is accompanied by Rachel Mitchell, Deputy 
Chief Financial Officer for the Veterans Health Administration.
    I want to thank you all for being here this morning. Mr. 
Atizado, we will begin with you, and you are now recognized for 
five minutes.

                  STATEMENT OF ADRIAN ATIZADO

    Mr. Atizado. Chairman Wenstrup, Ranking Member Brownley, 
Members of the Subcommittee, first I would like to thank you 
for allowing us to testify along with our partner-at-arms with 
American Legion, and, of course, Executive in Charge, Dr. 
Clancy on this panel to talk about VA's budget request for 
fiscal year 2019 and 2020.
    I first do need to start out by having to recognize, I 
think, the elephant in the room which is VA's current shortfall 
funding that it is operating in now for nearly close to half 
this fiscal year. When we are looking at the budget that has 
been provided and the budget that has been requested, we are 
looking at a $3 billion shortfall, which is a significant 
amount of money considering VA's under tremendous pressure even 
this fiscal year to meet increased demands.
    I think that we have to urge Congress very strongly to 
address not only that shortfall for today's needs, but also 
because it will affect future estimates and projections, and 
starting out at a low baseline will clearly affect future 
performance.
    So as part of the independent budget, DAV with our 
partners, Paralyzed Veterans of America and Veterans of Foreign 
Wars, we are certainly please to present our budget 
recommendations for 2019. I think at the offset the Committee 
should be aware that our recommendation uses baseline that is 
currently what the Congress is contemplating, and hopefully 
will be passing next week to fund the Department of Veterans 
Affairs.
    We have to do this because using any other baseline will 
set VA's 2019 recommendations well below what we estimate the 
need will be. So for 2019 for medical programs, the IB 
recommends $82.6 billion. This amount includes $53.7 billion 
for medical services, $14.8 billion for medical community care, 
$6.8 billion for medical support and compliance, and $7.3 
billion for medical facilities.
    Now we do recommend an additional $829 million for medical 
and prosthetics research. This amount includes $65 million for 
the Million Veteran Program. As this Committee knows, there is 
a little over 600 million veterans who have volunteered to 
participate in the Million Veteran Program, it is the most 
future-looking research project that VA has going, and we 
believe that $65 million, or if the Congress so inclined to 
provide more, will help VA finally reap the benefits of this 
program.
    They need to do much deeper sequencing than is currently 
being done to be able to leverage and tailor its programs to 
the specific needs that veterans have. We also believe that 
Congress should provide VA $1.6 billion for its electronic 
health record modernization. I believe this was the amount that 
Secretary Shulkin had initially requested, and we are thankful 
that this budget from the President and the Department of 
Veterans Affairs includes recognition of that need as 
modernizing a critical aspect of VA in its delivery of services 
to veterans.
    I would be remiss, Mr. Chairman, if we did not talk about a 
couple of things, a couple of legislative proposals in the 
President's budget which we have specific comments on. The 
first thing I would like to bring to your attention is their 
request to finally pay for medical foster home, which is a far 
less costly alternative to nursing home care, and one that many 
veterans are flocking to because it is still set in a community 
setting.
    This authority allows VA to pay for that care instead of 
veterans having to pay out of pocket, and it would allow VA to 
pay for those veterans who otherwise VA would have to pay for 
nursing home anyway, and we think this would save tax payer 
money. In fact, VA estimates the first year of saving about $12 
million going all the way up to $90 million a few years after 
that.
    We do oppose, however, a legislative proposal that would 
offset the current practice of offsetting veterans co-payments 
when VA receives reimbursements from veterans health plan. We 
think this is a disingenuous way of supplementing 
appropriations to provide veterans medical care that they have 
earned.
    The second one that we would have to oppose,
    Mr. Chairman, is the punitive enforcement of making 
veterans have to pay over $8 million worth of medical care if 
somehow VA is not able to recover reimbursements from their 
health plans. We think, again, that is a misguided attempt to 
supplement its needed medical care resources on the backs of 
veterans.
    I see my time has run out, Mr. Chairman, I will end my 
testimony at this point. Be happy to speak more about our 
recommendations and any of the contents in our testimony. Thank 
you.

    [The prepared statement of Adrian Atizado appears in the 
Appendix]
    Mr. Wenstrup. Thank you. Ms. Dean, you are now recognized 
for five minutes.

                    STATEMENT OF SARAH DEAN

    Ms. Dean. Chairman Wenstrup, Ranking Member Brownley, and 
Members of the Subcommittee, as one of the co-authors of the 
independent budget, Paralyzed Veterans of America is pleased to 
be here today. I will focus my comments to a few areas of 
concern.
    In September of 2016, Congress authorized appropriations 
through fiscal year 2018 to provide the reproductive service in 
vitro fertilization for veterans with catastrophic disabilities 
or injuries that precluded their ability to have children.
    VA projected through the two years that this service would 
affect no less than 500 veterans and their spouses, and cost no 
more than $20 million. As of January of this year, some 500 
consults for IVF have been made. And we thank those of the 
Subcommittee for insuring that these veterans now have the 
chance at a family that otherwise would have been denied them 
because of their service. However, these procedures are not 
directly funded and, therefore, the independent budget 
recommends $20 million to cover the costs through fiscal year 
2020.
    Regarding women veterans, the medical services 
appropriation should be supplemented with $500 million for 
women's health care programs in addition to those already 
included in the 2018 baseline. These funds would allow VHA to 
hire and train the necessary 1,000 women health providers that 
are needed to meet the increasing demand for gender specific 
care.
    These funds would also enable the facilities to address 
privacy and safety issues for women patients, and further the 
work of cultural transformation throughout the agency to ensure 
women are welcomed at VA, are free from harassment, and are 
recognized for their service. This is also needed for VA to 
continue the work it's been doing to improve mental health 
services, particularly in order to combat suicide and substance 
abuse disorders.
    As women veterans are the fastest growing cohort of 
patients, VA must have the resources to properly provide the 
appropriate care. To that aim, this Subcommittee must also 
conduct the necessary oversight to ensure that that care is the 
quality they deserve.
    In addition to an increasing women veteran population, VA 
must also be resourced and ready to accommodate a majority 
aging population. The demand for and utilization of long-term 
care services and home and community-based services has 
increased consistently, and will continue to in the decades to 
come.
    As such, the IB recommends a modest increase of $82 million 
for fiscal year 2019. This reflects the demand for long term 
care services in 2017, particularly home and community-based 
care, as well as the increase in use and long and short term 
stay nursing home care. This increase would help balance home 
care services with the institutional settings, a strategy 
currently pursued at the state level. VA must be properly 
provisioned and ready to meet this impending wave of aging 
veterans.
    And so in that vein, a new addition to this year's 
independent budget recommendation is the necessary funding to 
implement the eligibility expansion of VA's caregiver program 
to severely injured veterans of all areas. The funding level is 
based on the CVO's estimate for the expansion preparation costs 
that includes increasing staff and IT fixes. And for that 
initial phase, we recommend $11 million for fiscal year 2019.
    We appreciate the attention this Subcommittee and the Full 
Committee has given to caregivers. This issue is a high, if not 
the highest, priority for most of our members. And we hope to 
see change happen soon. As you heard from many of us last 
month, this issue is time sensitive. Pre-911 caregivers are in 
need of support as quickly as possible, and we hope that 
Congress will enable VA to provide those services, their well-
being quite literally depends on it.
    So, Mr. Chairman, I thank you for the opportunity to speak 
here today, and I am happy to answer any questions.

    [The prepared statement of Sarah Dean appears in the 
Appendix]

    Mr. Wenstrup. Thank you. Mr. Murray, you are now recognized 
for five minutes.

                  STATEMENT OF PATRICK MURRAY

    Mr. Murray. Chairman Wenstrup, Ranking Member Brownley, and 
Members of the Subcommittee, on behalf of the men and women of 
Veterans of Foreign Wars, the United States (indiscernible) 
Auxiliary, and our partners in the independent budget, I thank 
you for the opportunity to provide remarks on the 
infrastructure portion of the budget.
    While this year's numbers are significantly higher than the 
previous years, we still feel it does not quite hit the mark. 
For more than 100 years the Government's solution to provide 
health care for our military veterans has been to build, 
manage, and maintain a network of hospitals across this Nation.
    This model allows VA to deliver care at thousands of 
facilities, but it is left with ownership of more than 6,000 
buildings and 38,000 acres, many of which are past their 
building life cycle. Many of these facilities need to be 
replaced, some need to be disposed of, others need to be 
expanded, and all of them need to be maintained.
    The process to manage this network of facilities is a 
Strategic Capital Infrastructure Plan, or SCIP. The SCIP 
identifies VA's current and projected gaps in access, 
utilization, condition, and safety. Then it lists them in order 
based on GAPs priority. In VA's fiscal year 2019 budget 
submission, the ten-year full implementation plan to close 
these gaps is estimated to cost $53 to $65 billion, including 
$9 to $11 billion in activation costs alone.
    Congress and VA need to realign the SCIP process to allow 
VA to enter into public/private partnerships and sharing 
agreements both Federal and private to right-size VA's 
footprint. It must continue to fund the projects currently as 
partially funded and begin the advanced planning and design of 
those projects it knows we will need to fund through the 
traditional appropriations process.
    VA's SCIP program clearly identifies the current and 
projected ten-year gaps in delivery of health care. What is 
missing is a long-term strategy to effectively close these gaps 
in the most veteran-centric and cost-effective way. This must 
include a strategic plan for removing vacant or underutilized 
space so VA can invest those funds used to maintain these 
buildings into facilities that can provide direct care for 
veterans.
    Facilities will need to be replaced, improved, and reduced 
over the years, and the methods used to decide when and how to 
move forward with these projects must be comprehensive. VA can 
no longer afford to build a new facility and with only a few 
years have a need to expand the facility because they did not 
properly forecast the need. Nor should VA feel compelled to 
maintain a facility that is so underutilized that it is 
becoming cost-prohibitive.
    As VA works to close these gaps in utilization, VA and 
Congress must make it a priority to maintain what we have, 
finish what has been started, and chart a long-term plan to 
effectively close future gaps. Repeating the sins of the past 
such as the Denver replacement medical facility must never 
happen again. And VA needs to move ahead in the 21st century 
always looking to find ways to build more effectively and 
efficiently.
    Finally, outside the budget analysis, the VFW has specific 
best practice suggestions that could cut time and money from 
future construction projects by implementing some new 
innovative ways to course correct some of the mistakes of the 
past and align their practices with private sector builders.
    Thank you for the opportunity to testify today before the 
Subcommittee, and I look forward to answering any questions you 
might have.

    [The prepared statement of Patrick Murray appears in the 
Appendix]

    Mr. Wenstrup. Thank you very much. Mr. Shuman, you are now 
recognized for five minutes.

                  STATEMENT OF MATTHEW SHUMAN

    Mr. Shuman. Making a promise is easy, honoring the promises 
you made, particularly in the heated climate--political climate 
we find ourselves in, is more difficult. Chairman Wenstrup, 
Ranking Member Brownley, distinguished Members of the 
Subcommittee, on behalf of Denise H. Rohan, National Commander 
of the American Legion, and our 2 million members, we thank you 
for the opportunity to present our position on President 
Trump's proposed budget for the Department of Veterans Affairs.
    The American Legion appreciates the President following 
through with the promises he made on the campaign trail to take 
care of those who have served the United States in uniform. At 
a time when most Federal agencies are experiencing a decrease 
in their respective budgets, the VA will hopefully, with 
assistance from this critical Committee, receive a much-needed 
increase.
    Our members tell us they prefer to receive their medical 
care at VA. When an overwhelming force of veterans are all 
saying the same thing, it is vital that we listen. The 
President's proposed budget is reflective of veterans' voices 
and should encourage this Congress to invest in the largest 
integrated medical system, not only in the United States, but 
the world.
    Acknowledging my time before you is short, I will focus on 
a few critical topics. The conversations surrounding community 
care is at an all-time high, the need to finally streamline 
multiple programs into one effective system is vital, 
especially as current funding may run dry in May. Streamlining 
the many programs into one is cost effective, efficient, and 
most importantly, it is common sense.
    Following through with the promises he made, President 
Trump's budget requests funding to ensure veterans receive the 
best care possible, be it at the VA or in their community. That 
said, in order for that to happen, Congress must take action to 
join and modify their programs for the benefit of all veterans 
utilizing the VA Community Care Program.
    Additionally, the President's budget echos Secretary 
Shulkin's desire to expand mental health access for those with 
other than honorable discharges, which falls in line with the 
executive order President Trump signed compelling the DoD, VA, 
and the Department of Homeland Security to ensure all new 
veterans receive at least one year of mental health care post-
military service.
    Continuing on with the focus of health care, the 
President's proposed budget not only calls for funding to be 
allocated but also requests the funding be placed in a separate 
account for VA to obtain the same electronic health record 
system that the DoD is deploying. Like streamlining community 
care, restructuring VA's EHR to be the same as the DoD is also 
common sense and will aid veterans by having one seamless 
record that will follow them from service to veteran status.
    Since his time in Congress and on this Committee, Chairman 
Roe, like many of you, have called for VA to have a simple, 
effective, and integrated system with the DoD, and will help 
support--with help from this Committee, it can finally happen.
    Moving on to a topic that is near and dear to my heart is 
the eradication of homeless veterans in this Nation. The 
American Legion was beyond pleased in 2009 when then VA 
Secretary Shinseki laid out a comprehensive plan to eradicate 
veteran homelessness by 2015. Through General Shinseki's 
efforts, veteran's homelessness saw over a 40 percent decrease, 
which was an amazing feat by anyone's standards.
    That said, at any given point now, there are roughly 40,000 
homeless veterans on the streets of America, and that is not 
acceptable by the American Legion, and I imagine it is also not 
acceptable by this Committee. The President's proposed budget 
calls to sustain funding levels for the SSVF program, a program 
that essentially is the center's spoked wheel and aids multiple 
non-profits at ending homelessness within the veteran 
community.
    The American Legion appreciates the President's desire to 
maintain the level of funding, but highly encourages this 
Committee to make SSVF program permanent along with increasing 
the funding for this critical program which could send a clear 
message that this Committee and Congress wants to end the 
horrific plague within the veteran community.
    Lastly, Mr. Chairman, while reviewing the President's 
proposed budget we noticed an attempt to reduce the promised 
benefits of some veterans to provide funding for others. The 
American Legion has long opposed the rounding down of the cost 
of living adjustment, and urges this Committee to fight the 
attempt to rob Peter to pay Paul.
    We understand that $12 is not a lot of money to some, but 
to others it is. We understand that some veterans have proudly 
declared that they would happily give it up to help other 
veterans. And that only speaks to the character of those this 
Committee and the American Legion aims to help. However, the 
American Legion, which celebrates its 99th birthday today, has 
spent the last 99 years advocating and fighting so veterans do 
not have to shed their own benefits for the sake of helping out 
their brothers and sisters in arms.
    In closing, Mr. Chairman, the American Legion appreciates 
the work this Committee and your staff does in the name of 
truly helping those who have served this Nation. Further, we 
are thankful for the leadership from you and Ranking Member 
Brownley to review the President's proposed budget and for 
engaging the American Legion on these important and critical 
issues.
    With that, Mr. Chairman, and Ranking Member Brownley, and 
Members of the Committee, I am happy to answer any questions 
you may have, and thank you very much.

    [The prepared statement of Matthew Shuman appears in the 
Appendix]

    Mr. Wenstrup. Thank you. Dr. Clancy, you are now recognized 
for five minutes.

                  STATEMENT OF CAROLYN CLANCY

    Dr. Clancy. Thank you. Good morning, Chairman Wenstrup, 
Ranking Member Brownley, Members of the Subcommittee, and thank 
you for the opportunity to be here today. Your commitment to 
and leadership on behalf of our Nation's veterans is unwavering 
and inspiring. And I want to thank the VSOs for their continued 
commitment and advocacy. And as you noted, today I am 
accompanied by the Deputy Chief Finance Officer Rachel 
Mitchell.
    This budget request for 2019 is strong and allows VHA to 
continue on the path towards improving timeliness and quality 
of care, ensuring greater access to care, as well as increasing 
investments in our foundational services. It is our duty to 
ensure the necessary resources, clarity, and tools are 
available in order to provide care to veterans, and this budget 
request fulfills that obligation.
    The budget includes $8.6 billion for mental health 
services, an increase of $468 million, or 5.8 percent increase 
above the 2018 current estimate. This increase enables about 
162,000 more outpatient mental health visits in 2019, and 
directs $190 million for suicide prevention outreach.
    As you know, we have a nationwide epidemic for the entire 
country which disproportionately impacts veterans, and that is 
suicide, which is why suicide prevention is one of Secretary 
Shulkin's top priorities. VHA recognizes that veterans are an 
increased risk, and we have implemented a national suicide 
prevention strategy to address this crisis.
    It is based on a public health approach that is ongoing, 
utilizing universal strategies while recognizing that suicide 
prevention requires ready access to high quality mental health 
services. So that means we have programs that address the risk 
for suicide directly. And very importantly, starting far 
earlier in the trajectory.
    We also know VHA cannot do this alone. Of the 20 veterans 
who suicide each day, 14 are not enrolled in our system. So 
when I was speaking at a conference yesterday, I think the 
Surgeon General was Tweeting, ``Find the 14,'' because that is 
what we rely on our partners to help us with. We know that the 
six who are enrolled in and get mental health care from VHA 
actually do better than those who are not.
    And this nationwide community approach that we need will 
help us solve some of the upstream risks veterans face, such as 
loss or belonging, meaningful employment, and engagement with 
family, friends, and communities. The budget also enables us to 
effectively implement the President's executive order that 
supports transitioning military members with mental health 
services during that first critical year. And at this moment I 
just have to salute our VSO partners on this. They have been 
all over this with us, and so I wanted to say thank you.
    This joint action plan was developed by the Departments of 
Defense, Homeland Security, and VA, submitted to the White 
House on March 9th. Another big problem that we have in VA and, 
frankly, in the Nation, is management of chronic pain. And at 
the same time, we know the risks to patients of excessive use 
of opioids.
    We have made impressive strides working with our veterans 
to rely less on opioids and use non-pharmacologic treatments 
such as acupuncture and other alternatives, but we are not done 
yet. As we continue to reduce excessive reliance on opiate 
medication and respond to the requirements of the CARA 
legislation, we are expanding pain management research in 2019 
in two areas.
    One is testing and implementing complimentary and 
integrative approaches to treating chronic pain. And in a 
second longer term initiative we are working on other drug 
models and current drugs in the market to test their efficacy 
for treating pain.
    You may have seen a VA research study published just last 
week comparing one-year use of opioids with nonsteroidal anti-
inflammatory drugs, which you might know as Advil or Aleve. And 
actually at one year the people who were not on opioids had 
better outcomes. So I might ask to submit that for the record.
    Another study being developed under the learning health 
care initiative is being launched that will evaluate the impact 
of implementing a new tool to identify veterans at high risk of 
adverse effects from their opiate medication.
    As a couple of my partners here have acknowledged, we have 
too many veterans sleeping on the streets at night instead of 
in their own bed in their own home. In 2019 we will be 
investing $1.75 billion in programs to assist homeless veterans 
and prevent at risk veterans from becoming homeless.
    Our initiative develops strategies for identifying and 
engaging homeless veterans, and researchers also work to assure 
that homeless veterans receive proper housing, a full range of 
physical and mental health care, and other relevant services, 
and they are using existing data to identify, engage veterans 
who are currently homeless, and to develop strategies to 
identify and intervene as early as possible.
    As the Nation's only health research program focused 
exclusively on veterans' needs, VA research continues to play a 
vital role on the care and rehabilitation of our men and women 
who have served in uniform. Building on more than 90 years of 
discovery and innovation, our research has a proud track record 
of transforming VA health care by bringing new evidence-based 
treatments and technologies into everyday clinical care.
    The 2019 budget includes $727 million for development of 
innovative and cutting-edge medical research for veterans, 
their families, and the Nation. Advances in treatment and 
medical technologies have significantly reduced the impact of 
certain disabilities in the lives of many veterans. And we have 
a full spectrum of research from very, very basic science to 
the cutting edge; Million Veteran Program, rehabilitation 
medicine, and so forth.
    Finally--whoops--yes, we are also focusing on women's 
health, one of our fastest cohorts of veterans, by adding 
almost $29 million in fiscal year 2019, an increase of nearly 6 
percent over 2018. The number of women using VHA services has 
more than doubled since 2006 to 2016. And in order to address 
the growing number of women veterans, we are strategically 
enhancing services and access for women veterans.
    Together, we are working to address all of these critical 
health issues that affects so many of our veterans. We have 
made a great deal of progress with your support, and there is 
still a lot more to do. This budget request is a step toward 
that continued progress, and throughout all of health care, we 
know that the best systems know that providing care that is 
timely and consistently high quality is a team sport.
    Mr. Chairman, I look forward to working with you and the 
Committee on doing what is right for veterans, and to your 
questions.

    [The prepared statement of Carolun Clancy appears in the 
Appendix]

    Mr. Wenstrup. Well, I have to say I am pretty impressed 
with everyone today because everyone was easily under five 
minutes. And we do not often see that, so I appreciate it, so 
that we can spend the time with our questions, and getting some 
answers.
    Before I start asking some questions, I do want to make a 
couple comments. I do appreciate what you are doing for pain 
management in the VA. You know, I operated on extremities, and 
you would think that breaking bones and putting hardware in 
would be extremely painful, but if you manage it correctly it 
does not have to be.
    My patients hardly ever used opioids for the very reasons 
you are talking about. The use of steroids and anti-
inflammatories after surgery, local anesthetic blocks. We need 
to continue to produce best practices in pain management that 
avoid opioids. And that is not just in the VA, obviously, but 
across the country. So I appreciate the work that is being done 
there.
    Mr. Murray, you talked about closing the gaps. We need to 
fill the gaps. That is really what we have to do is fill gaps, 
and I know that is what you intended to mean there, and I 
appreciate that. And we need to eliminate dead space and fill 
the gaps that we need to fill.
    I just was in Puerto Rica when we did a VA hearing there 
over the weekend, and you talk about an interesting situation 
that they have there. The VA in Puerto Rico, their penetration, 
of those eligible to use VA, is 72 percent when it is about 36 
across the United States. So those eligible to use VA that do 
use VA is about 72 percent. It is a very high number.
    During the disaster that occurred down there, they kept 
their lights on, they were open 24/7 taking care of people. 
They were the main caregiver on that island compared to anyone 
else. It was very moving to see. And I do want to compliment 
what I was able to find out from the VSOs that we met with 
while we were down there.
    When this disaster took place, you had very high-risk 
veterans in their homes, if they were even in their homes by 
the way, if they even had a roof, some on CPAP machines and 
things like that that require electricity. And they went out, 
they gave of their time and treasure to voluntarily go and find 
high risk veterans to make sure that they were okay, to make 
sure that they were getting what they needed, to make sure they 
could get them a generator so they could keep their CPAP 
machine running. My hat is off to those veterans that were out 
there looking out for other veterans during that time.
    So I thank you all for being here today. Now the questions. 
If I may, I will go with that. And, Dr. Clancy, we know that 
there is a shortage of providers, there is a shortage of 
providers across the country, but in the VA particularly mental 
health, primary care, and certain specialties. The VA health 
profession scholarship program has not provided any 
scholarships for physicians or dentists in the past five years. 
Will your budget commit some funds to achieve this purpose?
    Mr. Clancy. This budget for 2019 gives a much bigger 
increase to the education and debt reduction program. There has 
been quite a bit of study, Mr. Chairman, on is it more 
effective to give people scholarships at day zero or to pay 
back their loans in a very meaningful way later. And in terms 
of retention rates, I believe that most programs have found 
that it is actually more effective to do the later, which is 
the program that we have. So we are very, very grateful for the 
support, and we will be using those funds to target and 
particular providers in their mission critical occupations.
    Mr. Wenstrup. So you are finding that is a better route to 
take--
    Dr. Clancy. Yes.
    Mr. Wenstrup [continued]. --is what is--it would be curious 
to see some of the numbers that you have on that and how--
    Dr. Clancy. Sure.
    Mr. Wenstrup. --you are filling some of the positions that 
we need. And in that same vein, the budget request proposes 
hiring almost 6,000 additional full-time employees. Can you 
provide the Subcommittee with a break-down of the positions 
that these new employees would fill?
    Dr. Clancy. Yes. I would need to take that for the record, 
but would be happy to do that.
    Mr. Wenstrup. I appreciate that. I would like to--we will 
probably have a few rounds here today, but I would like to 
proceed, and, Ms. Brownley, I yield to you.
    Ms. Brownley. Thank you, Mr. Chairman.
    I thank you all for your testimony and I just wanted to 
bring up two issues that I think are pretty simple and straight 
forward, and easily achievable in this budget. One is the--that 
Ms. Dean brought up in terms of IVF.
    You know, this is a new program that was established that 
has been ongoing, but yet the funding is not there in the 
budget, and I just think that we need to be clear that this is 
going to be an ongoing program for our veterans who cannot have 
children because of their service to our country, and it is 
just critically important that we do that. I do not think 
anybody disagrees with it, that is why I think it is like a 
simple, straight forward thing that we can be done. The other 
think is as it relates particularly to women is understanding 
that there is a $29 million increase around support for our 
women veterans, I think, Dr. Clancy, that you said. And that is 
great. I think you said it was a 5 percent increase, but you 
also said that the increase of women veterans has doubled. So--
    Dr. Clancy. Over ten years.
    Ms. Brownley [continued]. --Over ten years.
    Dr. Clancy. Yeah.
    Ms. Brownley. But, you know, I think we need to, you know, 
look at that number and try to really determine what the 
impacts and improvements will be with that kind of investment 
and where we still need to go I think in terms of investment 
around women's health.
    The main issue for me sort of on the macro level, overall 
looking at this issue, and, Dr. Clancy, we discussed this in my 
office yesterday, is the fact of this particular budget 
proposal takes all of the health care delivery accounts, if you 
will, and merges them, you know, sort of all into one.
    So, you know, the whole issue--the issue that we continue 
to talk about in this Committee is our investment in the VA, 
and its infrastructure, and our investment into a community 
care program. So I want to, you know, I want to understand why 
this is, and as I expressed to you in my office yesterday, it 
is a big concern for me because I think we need to account for 
how these resources are being spent, and from my perspective I 
am looking for a more equitable distribution of those funds to 
increase health care delivery for our veterans across the 
country.
    So I worry that if we combine all of this into like, you 
know, one fund, you know, how, you know, how are we going to 
make sure where the resources are going? I know you mentioned, 
well, we are worried about running out of money too early for 
community care, and this gives us a little bit more flexibility 
and (indiscernible) with funds, but on the other hand I am 
concerned about, you know, shifting funds, you know, fully one 
way and not the other. So if you would comment on that.
    Dr. Clancy. So, thank you, and thank you very much for your 
support for women's health and the other issues that you 
mentioned. I think it is easy and direct to say because it is 
absolutely true, that the Secretary and I share a very, very 
strong commitment to making our system as strong as possible.
    At the same time, we recognize that on the ground, 
particularly in areas where there is competition for particular 
types of providers, that may not necessarily be a national 
case, or it may be, or it just may be a very idiosyncratic 
issue for that market.
    If a provider leaves, for example, and we have appointments 
stacked up for that provider, but that person has moved on to 
another job, or maybe we asked them to leave for some very good 
reason, then we have--we want to hire as quickly as possible. 
We are not at a place yet where we can hire that quickly, and 
more to the point I think running this health care system like 
a business you would want our directors to be making a 
strategic decision, are we go to make or buy.
    So, for example, in one of our facilities a few years ago a 
couple of gastroenterologists left and their biggest need for 
gastroenterology happened to be colon cancer screening. So they 
actually did a pretty good assessment of what was the capacity 
in the community, and decided that it was actually to the 
Government and the veterans' advantage to buy those services in 
the community.
    I take your point loud and clear with concerns about the 
appropriate balance between VHA and our use of community care 
as we transition to becoming a high performing network. The 
point I would emphasize is that what we are hoping for is 
flexibility at the local level so that our directors are making 
the right decisions rather than saying which way is easiest in 
terms of needing to go through layers of approval, but that 
that flexibility needs to come with oversight so that we could 
report to you. And I know that you expressed some frustration--
    Ms. Brownley. Yeah.
    Dr. Clancy [continued]. --that we have not--
    Ms. Brownley. I am concerned about the--
    Dr. Clancy [continued]. --been exposed.
    Ms. Brownley [continued]. --oversight piece of it.
    Dr. Clancy. Yeah.
    Ms. Brownley. I understand, you know, at some level the 
ability that be flexible to meet the needs in a community that 
is going to be different from another community across the 
country, I get that. But I am very much worried about the 
accountability piece of it. My time has run out, but if we have 
another round of questions, I want to ask the VSOs to comment 
on this particular issue.
    Dr. Clancy. Okay. Great.
    Ms. Brownley. With that, I yield back.
    Mr. Wenstrup. Mr. Bilirakis, you are now recognized for 
five minutes.
    Mr. Bilirakis. Thank you. Thank you, Doctor, I appreciate 
it very much.
    Dr. Clancy, you mentioned that the--on the mental health 
services, I really appreciate the President's budget increasing 
the mental health services by $468 million. Specifically, how 
much will be spent with regard to the executive order on mental 
health services for the post-one-year transition period? And 
then if you could elaborate a little bit on the transition 
period, the executive order, I would really appreciate that.
    Dr. Clancy. Sure. And let me just say, starting with the 
executive order first. That whole plan is just we are just 
getting some feedback and working through that from the White 
House, but we will very much look forward to sharing that with 
you. And really, as it happened, I had my monthly breakfast 
with VSOs the morning that this was going to be announced, the 
actual date was a bit of a work in progress until about a day 
or two earlier.
    And when I shared that information, everyone was out of 
their seats saying, we are in, we have got to be in because we 
have got people on bases or we have got people providing 
services to veterans who can part of this solution. I mean, it 
was really amazing, and since then, they have very much been 
very active partners.
    Our plan, Congressman, is to invest $500 million over the 
next two years in implementing this executive order. Now that 
includes more mental health care services. In some cases, it 
includes hiring more suicide prevention coordinators. It will 
include some investments in partnerships and as well as our 
whole health initiative.
    I mean, what we--we want to have a safety net for 
transitioning servicemembers for that year because we know it 
is a year of higher risk, at the same time we do not 
necessarily want to convey the message that by definition you 
are broken because you are transitioning out of military 
service.
    So the whole health model is a model that focuses on the 
importance of the mind/body connection alternatives to dealing 
with stress and coping with life issues. And, actually, at the 
initial step for that in implementing the executive order will 
be a series of orientation sessions, it also includes a very 
strong focus on peer supports, which many veterans find to be 
very, very helpful.
    So happy to give you more details as we build that up, but 
we do have a very robust plan. And as soon as we are finished 
dealing with the feedback, we will look forward to sharing that 
with you.
    Mr. Bilirakis. So veterans will be involved, the 
stakeholders will be involved in that--
    Dr. Clancy. Absolutely.
    Mr. Bilirakis [continued]. --as well?
    Dr. Clancy. And they have been phenomenal. And we will be 
testing it at all times. I had a lovely conversation with the 
Chairman about this who thinks that actually this needs to 
start way before the time of transition and--
    Mr. Bilirakis. I agree with that.
    Dr. Clancy. I am totally good with that. And I think this 
collaboration gives us the space to raise all those issues, but 
we will look forward to sharing with you the whole plan.
    Mr. Bilirakis. Please do.
    Dr. Clancy. I think of that year as both no wrong door, but 
also no wrong time.
    Mr. Bilirakis. Very good. I have one more question, Mr. 
Chairman.
    The written statement from the independent budget alleges--
for Dr. Clancy again--that VA research for post-deployment 
mental health conditions, gender specific care, prosthetic 
care, Gulf War illness, toxic exposure, TeleHealth, and 
caregiver support, quote, ``remain critically underfunded,'' 
according to the independent budget, underfunded by the VA. Do 
you agree with this statement, Doctor?
    Dr. Clancy. So having run a research agency, not at VA but 
part of HHS, for a lot of years, first of all, anyone who says 
we need more money for research, I am about to say that is 
wonderful. That said, I recognize, particularly with the 
investment that we have made in the Million Veteran Program, 
that we are constantly looking at what is the best strategy for 
making those investments and how do we set priorities.
    I think we get a huge return on investment, both by virtue 
of how much we get per grant in terms of productivity but also 
because of our direct proximity to the delivery system where we 
can translate those findings into practice in improved care for 
veterans.
    Mr. Bilirakis. Thank you very much. And I yield back the 
rest of my time. Thanks.
    Mr. Wenstrup. Mr. Takano, you are now recognized for five 
minutes.
    Mr. Takano. Thank you, Mr. Chairman.
    I would like to ask some of the VSOs if they have any 
thoughts or concerns regarding VA's recruiting and retention 
efforts or initiatives. What more can be done to address the 
ongoing challenges related to recruiting and retaining top 
talent at the VHA?
    Mr. Murray. Sir, one of the things that we view as critical 
is keeping the Public Service Forgiveness Loan Program. 
Currently right now in the Prosper Act, the Higher Education 
Authorization Act, there is a plan to remove that. We think 
that that is a critical tool for VA to use to recruit and 
retain the best and the brightest.
    Mr. Atizado. Congressman Takano, I appreciate that 
question, thank you so much for that. I think one of the thing 
that VA needs, at least something that Congress can do to help 
VA, is actually help pay these folks better. When we are 
talking about pay increase, I think they have been hurting for 
a few years now. So if we could start with who is there and 
help them, you know, feel like they are being recognized for 
the hard work that they do day in and day out, I think that 
will go a long way.
    Move along to the investment that VA's requesting, it is a 
pretty small percentage considering the amount of vacancies 
that they have. Granted that there will always be a certain 
amount of vacancies, but I think that Delta there is a little 
bit too high for us to have confidence that the number of folks 
that they are going to hire is actually going to meet the needs 
of the over 6 million veterans that come to VA every year.
    Mr. Takano. Great. Thank you.
    Mr. Shuman. Congressman, I will echo--I am sorry, ma'am--I 
will echo the same sentiments that have shared here. I will 
also add, this comes to no surprise that, you know, there are 
over 40,000 vacancies at VA, and the problem is is that weight 
of the job that is not being done by those 40,000 people is 
added to the other people. We need to ensure that those 40,000 
vacancies are filled with quality people in a much faster 
process, in a much faster way to ensure that the work load is 
not divided between everyone else.
    Ms. Dean. I agree with the sentiments of my colleagues. I 
would only add that for regarding pay, is considering also that 
the majority of these providers are providing care for people 
with a high level of need that involves everything--involves 
more physical risk, but also the burnout is that much faster. 
So taking into account the toil that they are in and the level 
of work that they are doing when considering pay.
    Mr. Takano. All right. Thank you.
    Dr. Clancy, in the fiscal year 2019 budget request, I 
notice that the VA has advanced the number of new GME positions 
created under the VA CAA to 774 positions. When do you 
anticipate filling the other 726 spots?
    Dr. Clancy. First of all, that was just a phenomenal 
opportunity for those of who remember from the initial Choice 
legislation we were given the opportunity to create 1,500 new 
residency slots. I believe that we are looking at a couple of 
hundred additional ones over the next few years.
    The reason we have been a bit slower than I think many had 
hoped was that the legislation also specified that we should be 
recruiting providers in primary care in underserved areas, and 
rural communities, and so forth. So we invested a couple of 
years, which I think was exactly the right thing to do, and we 
did in broad consultation with the academic teaching community 
in building the necessary infrastructure at some of the rural 
facilities that we have that did not necessarily have it.
    This is necessary to make sure that students and residents 
get a good experience but also, quite frankly, to comply with 
accreditation requirements from external regulators.
    Mr. Wenstrup. So I realize you had these challenges, and I 
am pleased that we have allocated additional resources. Are you 
confident you are going to be able to use--be able to fill--
utilize the rest of these spots that we have authorized? We 
worked so hard to do--
    Dr. Clancy. Absolutely. Absolutely. And one reason that 
gives me huge confidence and optimism is there are more and 
more osteopathic schools and their leadership was just meeting 
with us, with me and the Secretary, last week. And, frankly, 
they are producing a much higher proportion of primary care 
providers, which I think is terrific. But huge growth in that 
community as well as in the Nation's allopathic medical 
schools.
    Mr. Takano. Of course, I would--I am hopeful that we can 
try to continue to address the supply of doctors as well as 
nurses and other practitioners, but especially our physicians, 
and in these underserved areas.
    Dr. Clancy. Yes.
    Mr. Takano. And I hope we can continue to work together to 
help districts like mine, and Ms. Kuster's, and all of the 
rural states that we have represented on this Committee.
    Dr. Clancy. No, we would love that. And, you know, to be 
honest, it creates a new level of excitement and enthusiasm at 
some of these facilities as well who have been missing out 
because they do not have the standard academic affiliates.
    Mr. Takano. Well, thank you. I appreciate that.
    Mr. Chairman, I yield.
    Mr. Wenstrup. Ms. Kuster, you are now recognized for five 
minutes.
    Ms. Kuster. Thank you very much. And thank you to my 
colleague for the shout out about academic affiliates. We are 
working on that right now with Manchester, New Hampshire, VA. 
So thank you for all your help on that.
    Couple quick questions about the situation in Manchester. 
For my colleagues, we have a task force now that is trying to 
look into the future for better access to health care services 
for our New Hampshire veterans. But I am troubled by two 
developments that I want to bring to your attention.
    One is that unfortunately the President's budget is not 
encouraging. Manchester, New Hampshire, has only one project 
ranked in the top 50 of the Department's strategic capital 
improvement plan despite the serious issues that have been laid 
out in the Boston Globe, and that the Secretary and
    Dr. Clancy are well aware of. The desperate need for 
primary care translated to an expansion project ranking number 
181 on the priority list. So I do want to bring that to your 
attention and work with you going forward for a commitment on 
prioritizing projects and the urgency of getting care to our 
veterans.
    The second issue has to do with the maintenance budget. And 
I am very troubled to read that an additional $4 billion of 
nonrecurring maintenance funding provided by Congress as part 
of the budget balance agreement is going to be taken back and 
used for other purposes, and yet we have dozens of Manchester 
projects as nonrecurring maintenance that were listed as future 
potential projects.
    And I just want some clarification, if not now, then we 
will take it off-line. But I am concerned, we, you know, it is 
an old facility as there are old facilities all across the 
country, and maintenance is critical.
    The third issue I do want to get direction on because I am 
very troubled by this. There has been--part of the VA 
initiative in developing the Vision 2020 Task Force was to 
investigate the needs, which is a good place to start. There is 
an assessment that has been done, though, that has a glaring 
error that I want to bring to your attention.
    It references several times a CBOC in Saint Johnsbury, 
Vermont, that does not exist. And so this whole methodology is 
called into concern because--called into question because the 
market assessment used a facility that does not exist and talks 
about expanding that facility, et cetera.
    So I am concerned because, obviously, that calls into 
question the whole study. So those are the issues related to 
Manchester. If you can respond, feel free. If not, I will keep 
going, and we will take it off-line.
    Dr. Clancy. Yes. So just on the last. We will fix that 
error. And, also, have our people take another look at that 
entire assessment. It was our belief in establishing this task 
force and, frankly, with your help and many others, we got 
phenomenal health care leaders outside of VA as well as VSOs 
and others; the State Director for Veterans Affairs serves as 
the co-chair.
    We wanted this to be--to have the conclusions be the 
conclusion of the task force not what we were directing. At the 
same time, if the inputs were wrong then we need to fix those 
right away.
    Ms. Kuster. And I do want to say, I appreciate the 
collaboration with the community leaders. What my number one 
concern is that the outcomes from the task force have 
credibility with our veteran community, with our VSOs, and with 
our general public. At this point, we have heightened awareness 
for everyone about the future of the Manchester VA and 
providing health care to our veterans. So I appreciate your 
follow up on that.
    And I will just close by saying I was very pleased to hear 
your testimony about the VA research on the opioid epidemic, 
and I think it is very promising. Veterans were first in, I am 
hoping that they will be first out of the opioid epidemic, and 
New Hampshire is very hard hit. But what you laid out for 
research on expanding alternatives for pain management, 
expanding alternative drug options, I definitely want to look 
at the research you talked about about anti-inflammatories, I 
think that is critical, and identifying veterans at high risk 
of opioid addiction.
    These are all holes in our understanding. And I think, once 
again, the VA could lead the country in helping us to solve a 
critical public health emergency. So thank you for that. And I 
yield back.
    Dr. Clancy. Well, thank you. That is clearly our goal. Just 
very quickly, we will follow-up with you off-line about the 
maintenance and infrastructure issues.
    I am very, very proud to say that in terms of veterans who 
are on opioids chronically, new starts, veterans who are 
started on that path have been reduced by 90 percent, which is 
really beginning to change the equation. That said, we are not 
achieving the results that we have seen by simply telling 
people time is up. We are working very closely in partnership 
with veterans, so I wanted people to be very clear about that.
    Mr. Wenstrup. Dr. Clancy, we hear different numbers on the 
vacancy rate. And I do not know if you have a particular point 
in time, a date, where you can say when we last checked, you 
know, on January 1st of 2018, this was our vacancy rate, and 
maybe that is something you have come back with me on. But I 
would like to know if you have some kind of data and maybe 
provide us with accounting of every vacancy by position, job 
title, et cetera.
    Dr. Clancy. I think a productive conversation would be a 
follow-up off-line, and happy to do that, or on the record. I 
will make a couple of points. One is that what the Department 
has just recently established about four months ago a new 
office of--it was supposed to be called Manpower, I asked for a 
different name, so I do not know the official name.
    But the point is that there would be position management 
across the entire department, of which VHA would be the largest 
part. We have not had that before. The walk around number I 
would use for vacancies is 36,000, which if you look at 
turnover in health care and turnover within our system, sounds 
about right. That does not mean that there are 36,000 empty 
chairs today, but some are in transition to being filled, and 
so forth.
    All that said, I think you are all aware that until this 
year, our HR system required us to more or less send an email 
to all the facilities to say how many openings do you have, 
because HR had a separate database at each facility. We are now 
constructing a centralized database, which I know requires a 
lot of cleanup which is why it is taking time. So I am 
confident that in the next few months we will have numbers that 
I would feel very comfortable with. Right now, they are all 
ballpark
    Mr. Wenstrup. And periodically getting those numbers would 
certainly be something to look at, and I realize the exact 
numbers will change daily--
    Dr. Clancy. Yes.
    Mr. Wenstrup [continued]. --and the exact number of 
positions will change daily, but if we can start to look at 
some patterns here that would be helpful. I also, you know, as 
we see medicine changing and we have talked about that, VA 
assets over the years, we are just like everyone else, it was 
more hospital-based, inpatient beds, and this, and that, and we 
have obviously seen medicine change dramatically. That there 
are fewer overnight stays, and shorter stays within the 
hospital, more outpatient type surgery.
    So where are we in reviewing and maybe realigning some of 
our assets like the other hospital systems have to where you 
have a low census inpatient facility converting that to 
outpatient clinics, and surgery centers, and maybe less than 24 
hours stay, that type of thing?
    Dr. Clancy. So we are looking that very close-- looking at 
that issue very closely from a couple different lenses. One is 
the Department and Administration's overall focus on 
modernization so that each VISN will be doing a market 
assessment of their markets. That has been slowed down a bit by 
a contract dispute or protest. But we are not going to be 
stopping there, it just may take us a little longer to get to 
the same end goal.
    I think the-- we are taking a special look as well at our 
rural facilities, some of which are quite vital in their 
communities, but, you know, the average daily census is pretty 
low. So we are trying to take a very good look at that to 
figure out what is the right thing to do. For some patients, 
that is lifesaving to have that stop even if they end up 
getting transferred elsewhere. On the other hand, if you have 
got an average daily census of five or six, you have to be very 
concerned about quality, and safety issues, and so forth. But 
happy to follow up with you on that.
    Mr. Wenstrup. I appreciate that. And Ms. Brownley, you are 
now recognized.
    Ms. Brownley. Thank you, Mr. Chairman.
    I just, again, wanted to follow up now with the VSOs on my 
question to Dr. Clancy in terms of in this budget proposal sort 
of the merging of all the different health care delivery 
accounts into one and zeroing others out. Do you have any 
concerns--anybody can speak to it, but do people have concerns 
about that?
    Mr. Atizado. Thank you for that question, Congresswoman 
Brownley. You know, I can appreciate facilities wanting to have 
the flexibility to do with as they see is required at the local 
level with the monies that they receive, and I am pretty sure 
that community care outside of Choice funds is actually all 
within the flexibility that facilities need to use it in.
    I think the request to merge the two accounts, the 
community care account and the future of Choice, I think, as 
well as the regular medical discretionary medical services, the 
concern that we have is the ability to conduct oversight and 
aggregate. I am all for letting local facilities use the funds 
that they are provided the way they need it to meet the needs 
locally, but--and for oversight purposes I do not see why it 
would be so much trouble to allow us an aggregate in the higher 
level to look at the performance of them providing care in VA, 
as well as in the community.
    Ms. Brownley. Anybody else? Or does that represent 
everybody else's perspective?
    Mr. Shuman. I think exactly what he said we share those 
sentiments. I will sort of hit the ball out of the park in 
terms of oversight. That is exactly what this Committee is 
designed to do, and I think it will continue to need to do 
that. I think streamlining will be, as I said already, 
effective, and sort of streamlining and try to prevent waste I 
think during this will probably be go good idea. But ensuring 
this Committee exercises its constitutional right of oversight 
is vital.
    Ms. Brownley. Well, thank you for that. And I did, Dr. 
Clancy knows this, in our meeting yesterday I talked about, you 
know, exactly this piece in terms of, you know, transparency, 
accountability oversight piece of it. And, honestly, my sort of 
lack of confidence at this particular point in time that VA 
would provide those deliverables, you know, to the Committee in 
a timely way so that we really know kind of on a quarterly or 
monthly basis kind of the direction and where things are sort 
of going so that we, if we need to we can, and sort of 
reassess. But we are going to just have to wrestle with that I 
think as time goes on.
    Dr. Clancy. If I could make one point briefly?
    Ms. Brownley. Sure.
    Dr. Clancy. We do have one model that works this way, and 
this is how we allocate medication funding. So there is a 
central medication pharmacy benefit management program in a 
central warehouse, which gets, you know, higher and higher 
scores every year in terms of customer satisfaction and so 
forth.
    But in terms of purchasing medications and pharmaceuticals 
at the facility level, they all have an account they can draw 
on and that has worked very, very well. What I do not know, but 
we could certainly find out, is how long it took them to get to 
that level of reliability, but we would be happy to follow up 
with you on that, just as a model.
    Ms. Brownley. Very good. So, Dr. Clancy, also I know that 
in February the Secretary received three names from the 
commission that is tasked with finding viable candidates for 
the position of Under Secretary of VHA. Do you know if the 
Secretary submitted any of these candidates for review and 
potential nomination from the White House?
    Dr. Clancy. He mentioned them in a meeting, but that is as 
much as I know. I believe the commission met and interviewed a 
variety of candidates in late January or right at the very 
beginning of February. We would be happy to follow up with you 
on that.
    Ms. Brownley. Thank you. And just one last question. I 
concur with my colleague Mr. Takano on, you know, the issues 
that he was raising about so many unfilled positions across the 
VA. I see that as a critical problem, and I do see these sort 
of vacancies and IT systems across the VA as sort of 
foundational pieces that we are not going to move forward on a 
lot of the objectives that we want to achieve and we spend a 
lot of time talking about new programs and, you know, new goals 
and so forth, but we have to get back down to some of the 
foundational issues which is filling these positions and 
having, you know, sort of state-of-the-art IT systems across 
the VA.
    Just in terms of one very important IT system, if you 
could, Dr. Clancy, kind of provide us with a status update on 
where we are in terms of Cerner and where that stands. My 
understanding is that the Secretary was supposed to appear at a 
health care information and management systems society 
conference in Las Vegas, and he was going to publically 
announce the award of the electronic health record management 
project to Cerner, but that did not occur so if you could 
update us.
    Dr. Clancy. He did appear and made some other 
announcements, which I think will be also very important. But 
we are closing in on signing this contract. We have one more 
round of technical review, and we have actually brought in some 
(indiscernible) very credible and highly recognized experts 
from the private sector, and really focused on are we getting 
interoperability right, because not only with the Department of 
Defense but within our own system, and also with our partners 
in the community, that is vital to making sure that information 
flows seamlessly in terms of providing veterans great care.
    The announcement the Secretary did make was to say that we 
are opening up our system so that innovators can actually 
develop apps for the public for veterans and, you know, that 
there is no entry barrier. So if some startup company has got 
great ideas for how to do that they will be able to do that.
    And he also announced that 11 other large health systems 
have made the same commitment and Cerner will not charge us a 
transaction fee for doing that. So I think that is going to be 
a big game changer in electronic records, and looking forward 
to celebrating with you when it is all signed.
    Ms. Brownley. So thank you for that and I just to get back 
to Cerner for one moment, and I agree interoperability is 
critically important. When do you think this is going to get 
nailed down?
    Dr. Clancy. I am told in the very near future. I was just 
checking--
    Ms. Brownley. What is that? Two months, three months, three 
months, a year?
    Dr. Clancy. I would guess one month, but we will get you a 
definitive or the best estimate we can give. We are actually 
anxious to get moving because we have had people working on 
this for close to a year now, in terms of doing the 
preplanning, learning everything the Department of Defense did, 
and, frankly, learning about what maybe they wish they did 
differently, and so forth. So those folks are like very 
impatient.
    Ms. Brownley. Thank you. And I yield back.
    Mr. Wenstrup. I just have one more quick question. We have 
veterans that have non-service-connected conditions that they 
want to get treated at the VA and they use their private 
insurance to do that. My understanding is the collection rate 
based on billings is only about 36 percent. Where are we with 
improving garnishing that revenue from their insurance if they 
choose to use the VA, which is a compliment to the VA that they 
want to do that?
    Dr. Clancy. Yes. We have a new leader in community care who 
comes from the private health insurance industry and actually 
has vast experience in this. So I would like to take that off-
line but bring it back to you. One of the other issues that we 
run into, of course, is I do not think we are as good as we 
should be, it is just this is how we are supposed to do in 
terms of asking veterans.
    So I think the conversation that goes on a lot is, do you 
have your insurance card, and someone says no, and we say okay. 
I mean, that is kind of the end of the conversation. And, 
frankly, I think that we need to educate our veterans more, 
that this is not a special punishment that we are 
administering, that this is actually what the statute requires.
    Mr. Wenstrup. Got you. Well, listen, I want to thank 
everybody for being here today. And if there are no further 
questions. The panel is now excused.
    And I ask unanimous consent that all Members have 5 
legislative days to revise and extend their remarks, and 
include extraneous material. Without objection, so ordered. The 
hearing is now adjourned.

    [Whereupon, at 11:12 p.m., the Subcommittee was adjourned.]

 
                            A P P E N D I X

                              ----------                              

                Prepared Statement of Matthew J. Shuman
                                   ON
``DEPARTMET OF VETERANS AFFAIRS FISCaL YEAR 2019 BUDGET SUBMISSION FOR 
                  MEDICAL PROGRAMS AND CONSTRUCTION''

    Chairman Wenstrup, Ranking Member Brownley, and distinguished 
members of this Subcommittee, on behalf of Denise H. Rohan, National 
Commander of The American Legion; the country's largest patriotic 
wartime service organization for veterans and our 2 million members; we 
thank you for inviting The American Legion to present our position on 
President Trump's proposed FY19 budget for the Department of Veterans 
Affairs.
    The American Legion is a resolution-based organization. We are 
directed and driven by the millions of active Legionnaires who have 
dedicated their money, time, and resources to the continued service of 
veterans and their families. Our positions are guided by 99 years of 
consistent advocacy and resolutions that originate at the grassroots 
level of the organization - local American Legion posts and veterans in 
every congressional district of America.
    The American Legion appreciates the president's following through 
with the promises he made on the campaign trail. At a time when most 
federal agencies are experiencing a decrease in their respective 
budgets, the Department of Veterans Affairs (VA) will hopefully, with 
assistance from this critical committee, receive a much-needed 
increase.
    Our members tell us they prefer to receive their medical care at 
VA. When an overwhelming force of veterans are all saying the same 
thing, it is vital that we listen to them. The president's proposed 
budget is reflective of veterans' voices, and should encourage this 
Congress to invest in the largest integrated medical system not only in 
the United States, but the world.
    In 2003, The American Legion created and implemented our System 
Worth Saving program, designed to visit, examine, and audit Veterans 
Affairs Medical Centers (VAMCs). Through our program's town hall 
meetings, veterans have shared with us that they appreciate the VA, the 
VA understands them, and that the VA system is a system worth saving. 
The proposed budget, and the increase in funding in particular, is 
reflective of a desire to ensure there is a strong and robust 
Department of Veterans Affairs.
    In a VA Fact Sheet, they stated, ``The Budget demonstrates VA's 
ongoing commitment to providing Veterans more efficient, timely, and 
quality services by requesting an increase of $12.1 billion, more than 
six percent, above the FY2018 Budget. The Budget makes every dollar 
count by using management efficiencies and savings, modernizing 
systems, and focusing resources on foundational series and key 
priorities.'' The American Legion appreciates the requested increase 
and looks forward to engaging with this committee and the VA to ensure 
they use the funds appropriately, for the benefit of the veteran.
    In reviewing the proposed budget, we will highlight and focus on 
three main impacted topics.

COMMUNITY CARE

    ``I intend to build a system that puts veterans first and allows 
then to get the best possible health care and services wherever they 
may be -in VA or in the community.''

-VA Secretary David Shulkin, February 1, 2017

    The veteran community learned from the 2014 Phoenix wait time 
scandal that there is a need for care in the community. After the 
Choice Act was passed and signed into law, the number of veterans who 
had the desire to receive care in the community, opposed to the VA, 
skyrocketed. In 2018, a large percentage of veterans, many of which are 
proud members of The American Legion, have a preference to receive 
medical services closer to their homes.
    When the Choice program was implemented, there were multiple other 
non-VA care programs such as Fee-Basis, Project Access Received Closest 
to Home (ARCH), Patient Centered Community Care (PC3) and others. By 
resolution, The American Legion has long endorsed combining and 
streamlining these multiple programs, creating one unified system that 
has the veteran and the best clinical interest of the veteran at heart.
    Because of The American Legion's efforts, advocacy, and resolution, 
we stand by the president's budget request and appreciate the 
investment in the VA and the community care programs, with the 
intention to streamline and unify. President Trump's budget states, 
``The Budget provides $70.7 billion, a 9.6-percent increase above the 
2017 enacted level, to provide high-quality healthcare services to 
veterans and eligible beneficiaries. The Budget also proposes $75.6 
billion in advance appropriations for VA medical care programs in 2020, 
a 6.9-percent increase above the 2019 request. In addition, $11.9 
billion would be used to enhance and expand veterans' access to high-
quality community care, by consolidating multiple community care 
programs, including the Veterans Choice Program, into one unified 
program.''
    The American Legion calls on this committee, and the 115th Congress 
to ensure the Department of Veterans Affairs is properly equipped to 
provide state-of-the-art medical care to veterans through their 
facilities and community care providers. Further, The American Legion 
supports increasing funding levels, as this proposed budget calls for.
    The American Legion applauds Secretary Shulkin for his focus on 
mental health issues leading to veteran suicide. The proposed budget 
calls for slightly more than $8.6 billion to expand and transform VA's 
focus on mental health services and is listed as VA's number one 
clinical priority. This funding is absolutely critical, not only as an 
attempt to reduce the number of veteran suicides, but also supports 
President Trumps Executive Order to improve mental health resources for 
veterans transitioning from active duty to civilian life and the 
Secretary's decision for VA to provide emergent mental healthcare 
treatment for veterans with other-than-honorable discharges. Losing one 
life to suicide is one too many.

VA INFRASTRUCTURE REVITALIZATION

    The ability to provide the best care anywhere is not only about the 
medicine or methods in which medicine is delivered. The facility in 
which the care is administered is absolutely critical to the safety and 
successful treatment of those who have selflessly raised their right 
hand in defense of our Nation. Taking the necessary steps to ensure 
each and every VA facility, a VAMC, Community Based Outpatient Clinic 
(CBOC), Regional Office or others, is safe, modern, and efficient will 
only assist the agency in providing the best care for those who have 
served.
    Veterans deserve a VA that is clean, modern, and safe. Providing 
the VA with the appropriate funding to deliver modern healthcare is the 
first step, but the subsequent steps include bolstering funding to 
guarantee that VA facilities are the best they can be.
    The proposed budget would provide for $1.8 billion for 91 major and 
minor construction projects including new medical care facilities, 
national cemeteries, and projects at regional offices. The budget also 
provides $1.4 billion for non-recurring maintenance projects to 
maintain and modernize medical facilities. These investments enhance 
the safety and security of VA facilities and help VA programs and 
services keep pace with modern technologies.

      Approximately $1.1 billion will fund major construction 
projects, including construction of a community living center and 
domiciliary at Canandaigua, New York; construction of a facility that 
would specialize in spinal cord injuries at Dallas, Texas; and 
expansion of four national cemeteries that would provide slightly more 
than 80,000 new gravesites. This funding will also include $400 million 
to address critical seismic issues at VA facilities.
      In addition, $707 million will fund minor construction 
projects, including corrections and additions to Veterans Health 
Administration facilities, gravesite expansions at national cemeteries, 
and renovations at regional offices.
      VA would use the $1.4 billion in funding for non-
recurring maintenance to address infrastructure needs in its medical 
facilities.

    The American Legion understands the need to invest and modernize 
the infrastructure of VA, in order to provide quality services to 
veterans and their families. Considering and acknowledging that VA is 
the largest integrated medical system in the country, the need to 
update facilities and systems is never-ending. We support the increased 
funding and expansion of and for VA facilities. Further, we applaud and 
welcome the increased funding aimed at making sure the VA is not only 
modern and safe, but that this critical agency is physically here for 
future generations of veterans.
    We also applaud the creation of a new facility in Dallas, Texas, 
that would specialize in spinal cord injuries. The Global War On 
Terror, and any armed conflict, returns servicemembers with 
catastrophic injuries, often times impacting and damaging their spinal 
cord. The creation of a new spinal cord facility is a clear message 
that the VA will continue to be on the cutting edge of battle-borne 
injury, all in the name of the fine men and women who wore the fabric 
of our military in distant lands.

LIFETIME ELECTRONIC HEALTH RECORDS

    The American Legion, through resolution, has long endorsed and 
supported the Department of Veterans Affairs in creating a Lifetime 
Electronic Health Records (EHR) system. Additionally, The American 
Legion has encouraged both the Department of Defense (DoD) and the VA 
to use the same EHR system, or, at the very least, systems that were 
interoperable.
    In 2009, The American Legion was pleased when the Obama 
administration announced that the DoD and the VA would finally create a 
path to integrate the flow of patients' information between DoD's AHLTA 
(Armed Forces Health Longitudinal Technology Application) and VA's 
VistA (Veterans Information System and Technology Architecture) 
Electronic Health Record (EHR) platforms.
    In 2015, DoD announced that Cerner was awarded a $4.3 billion, 10-
year contract to overhaul the Pentagon's electronic health records for 
millions of active military members and retirees. However, around the 
same time, VA announced it would maintain and modernize VistA.
    The American Legion was disappointed in VA's and DoD decisions to 
go in different directions and voiced concerns about their decision. 
Then, on June 6, 2017, Secretary Shulkin announced that the VA would 
adopt the same Cerner EHR system as the DoD during a news briefing at 
VA's headquarters in Washington, D.C.
    The impending contract, that the VA is in the final stages of 
negotiating, will set the standard for record transferability and 
standardization in America. This new national standard will increase 
patient access, decrease wait times, and enhance good medicine for all 
Americans, not just veterans.
    Through the president's proposed budget, it calls on Congress to 
provide $4.2 billion for the Office of Information Technology (OIT). If 
allocated, the budget would provide $204 million to recapitalize VA's 
legacy IT systems with new enterprise and business-lines as the data 
within these systems are vital, pertinent, and crucial to the success 
of future IT systems. Furnishing funds for legacy systems is not only 
necessary for the current systems, but is quite mandatory in order to 
ensure the data is transferred to the new EHR system.
    In addition to maintaining the legacy systems that VA created and 
continues to utilize, $1.2 billion of the allocated funds for the OIT 
would be placed in a separate budget account for the acquisition of the 
current Cerner electronic health records system . Ensuring that VA has 
the necessary funding to maintain the Cerner system, and allowing the 
agency to obtain and utilize the same system as the DoD, is a massive 
step forward in interoperability with the benefit of the veteran.
    The American Legion supports allocating the increased funding for 
the OIT and for the Cerner Electronic Health Records system, as both 
the DoD and VA have had disjointed systems for far too long.

VETERAN HOMELESSNESS

    According to the VA, at any given point in January 2017, there were 
roughly 40,000 homeless veterans in the United Stated of America. Of 
those 40,000 homeless veterans, about 15,000 were physically living on 
the street and had no shelter. The American Legion has long assisted 
homeless veterans and has encouraged both the VA and the Congress to 
take necessary steps to drastically reduce that number.
    The American Legion was beyond pleased in 2009 when then-VA 
Secretary Eric Shinseki laid out a comprehensive plan to eradicate 
veteran homelessness by 2015. Secretary Shinseki stated, ``President 
Obama and I are personally committed to ending homelessness among 
Veterans within the next five years,'' said Shinseki.`Those who have 
served this nation as Veterans should never find themselves on the 
streets, living without care and without hope.'' Now in 2018, Secretary 
Shinseki's plan to eradicate homelessness among veterans was not 100% 
successful; it did, by many people's standards, put a massive dent in 
this disgraceful problem.
    Ending homelessness among veterans has been a substantial priority 
of The American Legion for many years. Supporting and making permanent 
the Supportive Services for Veteran Families (SSVF) program has been an 
American Legion legislative priority for nearly a decade.
    The SSVP program is a critical program and has been described as 
the center of the spoked-wheel in terms of corralling efforts to end 
veteran homelessness. The SSVF is a program within the Department of 
Veterans Affairs that provides grants and other resources to non-
profits and organizations that assist homeless veterans and their 
families. The American Legion understands that simply providing a 
veteran a home is not the final solution to ending this national 
embarrassment of allowing the men and women who have served their 
Nation to be homeless. We have long endorsed and called for supportive 
services to assist homeless veterans, such as medical and mental 
healthcare, assistance in employment opportunities, aid in deciphering 
how to access and utilize the G.I. Bill, and other life changing 
services that help veterans. The programs, non-profits, and 
organizations that the SSVF program funds are proving veterans with 
more than just a home, they are providing them with much-needed 
services and most importantly, hope.
    In context of eradicating homelessness within the veteran 
community, the president's proposed budget states, ``The Budget 
supports VA's commitment to ending veteran homelessness by sustaining 
funding levels and providing opportunities to improve the targeting of 
intervention for veterans impacted by homelessness. Specifically, the 
Budget requests $1.8 billion for veteran homelessness programs 
including Supportive Services for Veteran Families and VA's component 
of the Department of Housing and Urban Development-VA Supportive 
Housing Program. These programs provide critical wrap-around care to 
help address and prevent veteran homelessness''.
    The American Legion applauds and supports President Trump's 
continued support of the SSVF program and the veterans it assists. By 
resolution, The American Legion calls upon this committee and the 
entire Congress to make the SSVF program permanent, and not simply 
sustain funding, but increase the funding to accomplish both Secretary 
Shinseki's and The American Legion's goal to completely end the plague 
of veteran homelessness.
    The Supportive Service for Veteran Families program is the only 
national, veteran-specific program to help at-risk veterans avoid 
becoming homeless, and rapidly re-house those veteran families who lose 
their housing. It is critical, and this committee has the ability to 
truly put an end to an issue that is a dark stain on the veteran 
community.

CONCERNS

    Lack of Research Funding: In reviewing the president's proposed 
budget, The American Legion was thankful to see a section focusing on 
the national epidemic of opioids. In fact, the budget states that 
``fighting the opioid epidemic is a top priority for this 
administration, and VA is at the forefront of combatting this public 
health emergency.''
    The American Legion is excited that the Nation is awakening to a 
concern we have been speaking of for years on the prescription of 
opioids, particular to those who have the invisible wounds of war.
    During our review, we identified that addressing and combatting the 
opioid epidemic falls within the responsibility and scope of the 
Veterans Health Administration (VHA). Our concern is the lack of 
funding to research alternative therapies for this crisis. For example, 
the budget states the funding would be used for ``multidisciplinary 
approaches in opioid prevention and treatment, including investments 
in: provider training to assess risk and manage treatment; mental 
health outpatient and residential treatment programs; opioid overdose, 
recognition, rescue and response training programs; medication assisted 
therapy for opioid use disorders; patient advocacy; and distribution of 
naloxone kits.''
    At a time when over-prescription seems to be an important issue, 
not only within the walls of the Department of Veterans Affairs, but 
the nation at large, The American Legion encourages the Trump 
administration, and through them the VA, to allocate funding for 
research into complementary and alternative medicines. The members of 
The American Legion, and veterans across this nation share stories 
everyday of remedies that assist them. Medical cannabis, service 
animals, hyperbaric oxygen therapy, equine therapy, and other therapies 
should receive a heightened amount of research.
    If our goal, as a Nation, is to address the opioid epidemic, then 
we must properly fund the clinical research that may be an alternative 
solution to help those who have proudly served in the U.S. Armed 
Forces.
    Cost of Living Adjustment: As previously stated, The American 
Legion supports many sections of President Trump's proposed FY19 
Budget. By resolution, The American Legion staunchly opposes the Cost 
of Living Adjustment (COLA) round-down.
    Asking veterans to reduce their benefits to pay for the benefits of 
other veterans is a textbook definition of robbing Peter to pay Paul, 
and is unethical. Men and women served their country, often in harm's 
way, with the knowledge that if they were physically damaged from their 
military service, the United States would either aide them to recovery 
or would supplement them appropriately. If we, as a Nation, decide to 
deploy troops to conflict, then we have a moral obligation to care for 
them when they return.
    The motto of the Department of Veterans Affairs is ``To care for 
him who shall have borne the battle, and for his widow, and his 
orphan,'' and it is always incumbent to follow through with this 
obligation, not only when it suits the budget.
    The American Legion urges this critical committee, along with the 
entire 115th Congress to oppose any form of benefit reduction of 
veterans in the name of providing benefits to others.

CLOSING

    Chairman Wenstrup, Ranking Member Brownley, and other members of 
this critical committee, The American Legion thanks you for the 
opportunity to elucidate the position of the 2 million veteran members 
of this organization on President Trump's proposed FY19 budget as it 
relates to the Department of Veterans Affairs. deg.r additional 
information regarding this testimony, please contact Mr. Matthew 
Shuman, Director of The American Legion Legislative Division at 
[email protected], or (202) 861-2700.

                                 
             Prepared Statement of Carolyn M. Clancy, M.D.
    Good morning Chairman Wenstrup, Ranking Member Brownley, and 
members of the Subcommittee. Thank you for the opportunity to testify 
today in support of the President's Fiscal Year (FY) 2019 Budget and 
FY2020 Medical Care Advance Appropriation (AA) request. I am 
accompanied today by Rachel Mitchell, Deputy Chief Finance Officer, 
VHA.
    The President's FY2019 Budget requests $76.5 billion for VHA 
including collections. The $76.5 billion is comprised of $74.1 billion 
previously requested (including collections) and an annual 
appropriation adjustment of $500 million for Medical Services for 
community care and $1.9 billion for the Veterans Choice Fund. In total, 
the discretionary request is an increase of $4.2 billion, or 5.9 
percent, over the President's FY2018 Budget request. It will sustain 
the progress we have made and provide additional resources to improve 
patient access and timeliness of medical care services for the 
approximately 9 million enrolled Veterans eligible for VA health care.
    This is a strong budget request that fulfills the President's 
commitment to Veterans by ensuring the Nation's Veterans receive high-
quality health care and timely access to services while concurrently 
improving efficiency and fiscal responsibility. As previously noted by 
Secretary Shulkin, these resources are critical to enabling the 
Department to meet the increasing needs of our Veterans and 
successfully executing the Secretary's highest priorities. My written 
statement will address those priorities specific to VHA and how the 
FY2019 budget request will assist.

Priority 1: Focus Resources

    The FY2019 Budget includes $76.5 billion for Medical Care, 
including collections, $4.2 billion above the FY2018 Budget and $79.1 
billion for the FY2020 AA. In order to ensure that Veterans get high-
quality, timely, and convenient access to care that is affordable for 
future generations, we are implementing reforms that will prioritize 
foundational services while redirecting to the private sector those 
services that they can do more effectively and efficiently. These 
foundational services are those that are most related to service-
connected disabilities and unique to the skills and mission of VHA.
    Foundational Services include these mission-driven services, such 
as:

    Primary Care, including Women's Health;

    Urgent Care;

    Mental Health Care;

    Geriatrics and Extended Care;

    Rehabilitation (e.g., Spinal cord, brain injury/polytrauma, 
prosthesis/orthoses, blind rehab);

    Post-Deployment Health Care; and War-Related Illness and Injury 
Study Centers functions.

    VA facility and Veterans Integrated Service Network (VISN) leaders 
are being asked to assess additional, community options for other 
health services that are important to Veterans, yet may be as 
effectively or more conveniently delivered by community providers. 
Local VA leaders have been advised to consider accessibility of VA 
facilities and convenience factors (like weekend hours) as they develop 
recommendations for access to community providers for Veterans in their 
service areas.
    While the focus on foundational services will be a significant 
change to the way VA provides health care, VHA will continue to ensure 
that the fully array of statutory VA health care services are made 
available to all enrolled Veterans. VHA will also continue to offer 
services that are essential components of Veteran care and assistance, 
such as assistance for homeless Veterans, Veterans Resource Centers, 
the Veterans Crisis Line / Suicide Prevention, Mental Health Intensive 
Case Management, treatment for Miliary Sexual Trauma, and substance 
abuse programs.
    In order to provide Veterans and taxpayers the greatest value for 
each dollar, the Budget also proposes certain changes to the way in 
which we spend those resources. For example, our FY2019 request 
proposes to merge the Medical Community Care appropriation with the 
Medical Services appropriation, as was the practice prior to FY2017. 
The separate appropriation for Community Care has restricted our 
Medical Center Directors as they manage their budgets and make 
decisions about whether the care can be provided in their facility or 
must be purchased from community providers. This is a dynamic 
situation, as our staff must adjust to hiring and departures, 
emergencies such as the recent hurricanes, and other unanticipated 
changes in the health care environment throughout the year. This change 
will maximize our ability to focus even more resources on the services 
Veterans most need.

Ending Veterans Homelessness

    VA's homelessness research initiative develops strategies for 
identifying and engaging homeless Veterans. Researchers also work to 
ensure homeless Veterans receive proper housing, a full range of 
physical and mental health care, and other relevant services. They are 
using existing data to identify and engage Veterans who are currently 
homeless, and to develop strategies to identify and intervene on behalf 
of Veterans at-risk for homelessness.
    In FY2019, VA is investing $1.7 billion in programs to assist 
homeless Veterans and prevent at-risk Veterans from becoming homeless. 
Funding provided for specific programs that reduce and prevent Veteran 
homelessness include $549.7 million for U.S. Department of Housing and 
Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) for 
case management and supportive services to support about 93,000 
vouchers; $320 million for Supportive Services for Veteran Families 
(SSVF); and $257.5 million for Grant and Per Diem program, including 
program liaisons.

Priority 2: Modernizing VA Systems and Services

Electronic Health Record Modernization

    Having a Veteran's complete and accurate health record in a single 
common Electronic Health Record (EHR) system is critical to that care 
and to improving patient safety. We need to modernize VHA systems and 
services in order to continuously provide high-quality, efficient care 
and services, and keep up with the latest technology and standards of 
care.
    The Budget invests $1.2 billion in Electronic Health Record 
Modernization (EHRM). On June 5, 2017, the Secretary announced that VA 
will start the process of adopting the same EHR system as the 
Department of Defense (DoD). This transformation is about improving VA 
services and significantly enhancing the coordination of care for 
Veterans who receive medical care not only from VA, but also DoD and 
our community partners. This is a remarkable opportunity for the future 
with EHRM to build transparency with Veterans and their care providers, 
expand the use of data, and increase our ability to communicate and 
collaborate with DoD and community care providers. In addition to 
improving patient care, a single, seamless EHR system will result in a 
more efficient use of VA resources, particularly as it relates to 
health care providers.
    This new EHR system will enable seamless care between the 
departments without the current manual and electronic exchange and 
reconciliation of data between two separate systems. The Secretary also 
insists on high levels of interoperability and data accessibility with 
our commercial health partners in addition to the interoperability with 
DoD. Collectively, this will result in better service to our Veterans 
because transitioning Servicemembers will have their medical records at 
VA. VA is committed to providing the best possible care to Veterans, 
while also remaining committed to supporting Veterans' choices to seek 
care from private providers via our continued investment in the 
Community Care program.

Medical and Prosthetic Research

    As the Nation's only health research program focused exclusively on 
the needs of Veterans, VA research continues to play a vital role in 
the care and rehabilitation of our men and women who have served in 
uniform. Building on more than 90 years of discovery and innovation, VA 
research has a proud track record of transforming VA health care by 
bringing new evidence-based treatments and technologies into everyday 
clinical care. Innovative VA studies in areas such as basic and 
clinical science, rehabilitation, research methodology, epidemiology, 
informatics, and implementation science improve health care for both 
Veterans and the general public.
    The FY2019 Budget includes $727 million for development of 
innovative and cutting-edge medical research for Veterans, their 
families, and the Nation. One example includes continuing the Million 
Veteran Program (MVP), a groundbreaking genomic medicine program, in 
which VA seeks to collect genetic samples and general health 
information from one million Veterans. The goal of MVP is to discover 
how genomic variation influences the progression of disease and 
response to different treatments, thus identifying ways to improve 
treatments for individual patients. These insights will improve care 
for Veterans and all Americans.
    Chronic pain is prevalent among Veterans, and VA has experienced 
many of the problems of opiate misuse and addiction that have made this 
a major clinical and public-health problem in the United States. As VA 
continues to reduce excessive reliance on opiate medication and respond 
to the requirements of the Comprehensive Addiction and Recovery Act of 
2016 (CARA, Public Law 114-198), VA will expand pain management 
research in 2019 in two areas. VA is testing and implementing 
complementary and integrative approaches to treating chronic pain, 
building on a successful state-of-the-art conference in late 2016 on 
non-opioid therapies for chronic musculoskeletal pain. In a second, 
longer-term initiative, VA is working on other drug models and current 
drugs in the market to test their efficacy for treating pain. A study 
being developed under the Learning Healthcare Initiative is being 
launched that will evaluate the impact of implementing a new tool to 
identify Veterans at high-risk of adverse effects from their opiate 
medication.

Priority 3: Improve Timeliness

Access to Care and Wait Times

    VHA is committed to delivering timely and high-quality health care 
to our Nation's Veterans. We are also committed to ensuring that any 
Veteran who requires urgent care will receive timely care. As a part of 
this, Veterans now have access to same-day services for primary care 
and mental health care at the more than 1,000 VHA clinics across our 
system.
    In_017, 81.5 percent of nearly 6 million outpatient appointments 
for new patients were completed within 30 days of the day the Veteran 
first requested the appointment (``create date''), whereas 97.3 percent 
of nearly 50.2 million established appointments were completed within 
30 days of the date requested by the patient (``patient-indicated 
date'').HA has reduced the Electronic Wait List from 56,271 entries to 
20,829 entries, a 63.0 percent reduction between June 2014 and December 
2017. The Electronic Wait List reflects the total number of all 
patients for whom appointments cannot be scheduled in 90 days or less. 
During FY2018 and FY2019, VHA will continue to focus its efforts to 
reduce wait times for new patient appointments, with a particular 
emphasis on primary care, mental health, and medical and surgical 
specialties.
    In FY2019, VHA will expand Veteran access to medical care by 
increasing medical and clinical staff, improving its facilities, and 
expanding care provided in the community. The FY2019 Budget requests a 
total of $76.5 billion in funding for Veterans' medical care in 
discretionary budget authority, including collections. The FY 19 
request will support nearly 315,688 medical care full-time equivalent 
employees, an increase of over 5,792 above the 2018 level.
    VHA is implementing a VISN-level Gap Coverage plan in primary care 
that will enable facilities to request gap coverage providers in areas 
that are struggling with staffing shortages. It is a seamless 
electronic request that allows VISNs to focus resources where they are 
most needed according to supply and demand. Telehealth will be the 
principal form of coverage in this initiative, which is budget neutral.

Priority 4: Suicide Prevention

    Suicide prevention is VHA's highest clinical priority, and Veteran 
suicide is a national health crisis. On average, 20 Veterans die by 
suicide every day - this is unacceptable. The integration of Mental 
Health program offices and their alignment with the suicide prevention 
team and the Veterans Crisis Line is being implemented to further 
enhance VA's ability to effectively meet the needs of the most 
vulnerable Veterans. The FY2019 Budget Request increases resources to 
standardize suicide screening and risk assessments and expand options 
for safe and effective treatment for Veterans struggling with PTSD and 
suicide.
    The FY2019 Budget requests $8.6 billion for Veterans' mental health 
services, an increase of 5.8 percent above the 2018 current estimate. 
It also includes $190 million for suicide prevention outreach. VHA 
recognizes that Veterans are at an increased risk for suicide, and we 
have implemented a national suicide prevention strategy to address this 
crisis. VHA is bringing the best minds in the public and private 
sectors together to determine the next steps in implementing the Ending 
Veteran Suicide Initiative. VA's suicide prevention program is based on 
a public health approach that is ongoing, utilizing universal, 
selective, indicated strategies while recognizing that suicide 
prevention requires ready access to high quality mental health 
services, supplemented by programs that address the risk for suicide 
directly, starting far earlier in the trajectory that leads to a 
Veteran taking his or her own life. VHA cannot do this alone; 70 
percent of Veterans who die by suicide are not actively engaged in VA 
health care. Veteran suicide is a national issue and can only be ended 
through a nationwide community-level approach that begins to solve the 
upstream risks Veterans face, such as loss of belonging, meaningful 
employment, and engagement with family, friends, and community.

Executive Order to Improve Mental Health Resources

    On January 9, 2018, President Trump signed an Executive Order 
(13822) titled, ``Supporting Our Veterans During Their Transition from 
Uniformed Service to Civilian Life.'' This Executive Order directs DoD, 
VA, and the Department of Homeland Security to develop a Joint Action 
Plan that describes concrete actions to provide access to mental health 
treatment and suicide prevention resources for transitioning uniformed 
Servicemembers in the year following their discharge, separation, or 
retirement. We encourage all transitioning Servicemembers and Veterans 
to contact their local VA medical facility or Vet Center to learn about 
what VHA mental health care services may be available.

REACH VET Initiative

    As part of VA's commitment to put forth resources, services, and 
technology to reduce Veteran suicide, VA initiated the Recovery 
Engagement and Coordination for Health Veterans Enhanced Treatment 
(REACH VET) program. This program finished its first year of full 
implementation in February 2018 and has identified more than 30,000 at-
risk Veterans to date. REACH VET uses a new predictive model to analyze 
existing data from Veterans' health records to identify those who are 
at a statistically elevated risk for suicide, hospitalization, 
illnesses, and other adverse outcomes, so that VHA providers can review 
and enhance care and talk to these Veterans about their needs. REACH 
VET was expanded to provide risk information about suicide and opioids, 
as well as clinical decision support to Veterans Crisis Line 
responders, and is being further expanded to provide this important 
risk information to frontline VHA providers. REACH VET is limited to 
Veterans engaged in our health care system and is risk-focused, so 
while it is critically important to those Veterans it touches, it is 
not enough to bring down Veteran suicide rates. We will continue to 
take bold action aimed at ending all Veteran suicide, not just for 
those engaged with our system.

Other than Honorable Initiative

    We know that 14 of the 20 Veterans who, on average, died by suicide 
each day in 2014 did not, for various reasons, receive care within VA 
in 2013 or 2014. Our goal is to more effectively promote and provide 
care and assistance to such individuals to the maximum extent 
authorized by law. To that end, beginning on July 5, 2017, VA promoted 
access to care for emergent mental health care to the more than 500,000 
former Servicemembers who separated from active duty with other than 
honorable (OTH) administrative discharges. This initiative specifically 
focuses on providing access to former Servicemembers with OTH 
administrative discharges who are in mental health distress and may be 
at-risk for suicide or other adverse behaviors. As part of this 
initiative, former Servicemembers with OTH administrative discharges 
who present to VA seeking emergency mental health care for a condition 
related to military service would be eligible for evaluation and 
treatment for their mental health condition. Such individuals may 
access the VA system for emergency mental health services by visiting a 
VA emergency room, outpatient clinic, Vet Center, or by calling the Vet 
Center Call Center (1-877-WAR-VETS) or Veterans Crisis Line. Services 
may include assessment, medication management/pharmacotherapy, lab 
work, case management, psycho-education, and psychotherapy. As of 
December0, 2017, VHA had received 3,241 requests for health care 
services under this program. In addition, in FY2017, Readjustment 
Counseling Services through Vet Centers provided services to 1,130 
Veterans with OTH administrative discharges and provided 9,889 
readjustment counseling visits.

Priority 5: Greater Choice for Veterans

    Veterans deserve greater access, choice, and control over their 
health care. VHA is committed to ensuring Veterans can make decisions 
that work best for themselves and their families. Our current system of 
providing care for Veterans outside of VHA requires that Veterans and 
community providers navigate a complex and confusing bureaucracy. VHA 
is committed to building an improved, integrated network for Veterans, 
community providers, and VA employees; we call these reforms Veteran 
Coordinated Access & Rewarding Experiences, or Veteran CARE.
    Veteran CARE would clarify and simplify eligibility requirements, 
build a high performing network, streamline clinical and administrative 
processes, and implement new care coordination support for Veterans. 
Veteran CARE would improve Veterans' experience and access to health 
care, building on the best features of existing community care 
programs. This new program would complement and support VA's internal 
capacity for the direct delivery of care with an emphasis on 
foundational services. The CARE reforms would provide VA with new tools 
to compete with the private sector on quality and accessibility.
    Demand for community care remains high. The Veterans Choice Program 
comprised approximately 62 percent of all VA community care completed 
appointments in FY2017. We thank Congress for the combined $4.2 billion 
provided in Calendar Year 2017 to continue the Choice Program while 
discussions continue regarding the future of VA community care. Based 
on historical trends, current Choice funding may last until the end of 
May 2018 depending on program utilization. VA has partnered with 
Veterans, community providers, Veterans Service Organizations, and 
other stakeholders to understand their needs and incorporate crucial 
input into the concept for a consolidated VA community care program. 
Currently, VA is working with Congress to develop a community care 
program that addresses the challenges we face in achieving our common 
goal of providing the best health care and benefits we can for our 
Veterans. The time to act is now, and we need your help.
    In FY2019, the Budget reflects $14.2 billion in total obligations 
to support community care for Veterans. This includes an additional 
$2.4 billion in discretionary funding that is now available as a result 
of the recently enacted legislation to raise discretionary spending 
caps. Of this amount, $1.9 billion replaces the mandatory funding that 
was originally requested in FY2018 to be carried over into FY2019. This 
funding will be used to continue the Choice Program for a portion of 
FY2019 until VA is able to fully implement the Veteran CARE program. 
The remaining $500 million will support VHA's traditional community 
care program in FY2019. The Administration would also support using 
discretionary funding provided in FY2018 in the cap deal to ensure that 
the Choice Program can continue to operate for the remainder of FY2018.
    Finally, the Budget transitions VA to recording community care 
obligations on the date of payment, rather than the date of 
authorization. This change in the timing of obligations results in a 
one-time adjustment of $1.8 billion, which would support a total 2019 
program level of $14.2 billion for community care needs.

Closing

    VA is committed to providing the highest quality care that our 
Veterans have earned and deserve. I appreciate the hard work and 
dedication of VA employees, our partners from Veterans Service 
Organizations-who are important advocates for Veterans-our community 
stakeholders, and our dedicated VA volunteers. I respect the important 
role that Congress has in ensuring that Veterans receive the quality 
health care and benefits that they rightfully deserve. I look forward 
to continuing our strong collaboration and partnership with this 
Subcommittee, our other committees of jurisdiction, and the entire 
Congress, as we work together to continue to enhance the delivery of 
health care services to our Nation's Veterans.
    Mr. Chairman, Members of the Subcommittee, this concludes my 
remarks. Thank you again for the opportunity to testify. My colleague 
and I will be happy to respond to any questions from you or other 
Members of the Subcommittee.

                                 
                       Statements For The Record

                      Joint Prepared Statement of
                THE CO-AUTHORS OF THE INDEPENDENT BUDGET
                       DISABLED AMERICAN VETERANS
                     PARALYZED VETERANS OF AMERICA
                        VETERANS OF FOREIGN WARS

    Chairman Wenstrup, Ranking Member Brownley, and members of the 
Subcommittee:

    On behalf of the co-authors of The Independent Budget (IB)-DAV 
(Disabled American Veterans), Paralyzed Veterans of America (PVA), and 
Veterans of Foreign Wars (VFW)-we are pleased to present the views of 
the IB organizations regarding the funding requirements for the 
Department of Veterans Affairs (VA) for fiscal year (FY) 2019, 
including health care advance appropriations for FY2020.
    The IB's recommendations include funding for all discretionary 
programs for FY2019 as well as advance appropriations recommendations 
for medical care accounts for FY2020. The full budget report recently 
released by the IB addressing all aspects of discretionary funding for 
the VA can be downloaded at www.independentbudget.org. However, the 
current FY2018 funding for VA medical care programs is particularly 
concerning because previous VA Secretary Robert McDonald admitted last 
year that the VA's FY2018 advance appropriation request was not 
sufficient and would need significant additional resources provided 
this year.
    This insufficient level is reflected in the ``Continuing 
Appropriations Act, 2018 and Supplemental Appropriations for Disaster 
Relief Requirements Act, 2017'' as approved and amended by Congress. 
VA's medical care programs are currently funded at $71.7 billion and in 
light of the Administration's revised request of $74.7 billion for 
FY2018, submitted last year, VA has been forced to operate under a $3 
billion shortfall for nearly half this fiscal year despite increased 
demands on the system.
    The IB veterans service organizations (IBVSO) believe that the 
FY2019 VA revised budget request for VA medical programs and 
construction is similarly insufficient to meet the health care needs of 
ill and injured veterans, their families and survivors.
    The Administration's revised budget request for medical programs 
includes $74.1 billion in total discretionary spending and $1.9 billion 
in mandatory spending for FY2019. Considering the additional $1.9 
billion that the Administration requests to replenish the Choice Act 
funds in addition to the $14.2 billion Congress has already 
appropriated under emergency designation since 2014, the total 
projected expenditure from VA for medical programs in FY2019 is 
approximately $76 billion. The IBVSOs recommend $82.6 billion in total 
medical care funding for the VA. For FY2020, the Administration is 
requesting $79.1 billion for medical care programs and the IB 
recommends $84.5 billion.
    The IBVSOs share growing concerns about the massive growth in 
expenditures in community care spending in FY2019, which includes $8.4 
billion in community care, $1.9 billion and any remaining Choice Act 
funds. We understand the need for leveraging community care to expand 
access to health care for many veterans, as discussed in the IB 
framework, but we are troubled by the virtually uncontrolled growth in 
this area of VA health care spending.
    Congress and the Administration must be sure to devote critical 
resources to expand capacity and increase staffing of the VA health 
care system, particularly for specialized services such as spinal cord 
injury or disease, blind rehabilitation, polytrauma care, mental health 
care, and to address the added health care reliance of veterans on the 
VA attributed by the Department from the Choice Act. The integrated and 
holistic nature of VA health care cannot simply be punted into the 
private sector. Simply outsourcing more care to the community without 
the same accountability of health outcomes, quality of care, and 
treatment efficacy could yield higher costs to the tax payer and will 
ultimately undermine the larger health care system on which so many 
veterans with the most catastrophic disabilities must rely.
    The Bipartisan Budget Act of 2018 (BBA) significantly raised the 
defense and non-defense discretionary spending caps in FY2018 and 
FY2019, and the President has signed these new caps into law. In light 
of the BBA, the Administration modified its FY2019 budget request to 
account for these new cap levels.

Medical Services

    For FY2019, the IB recommends $53.7 billion for Medical Services. 
This recommendation includes:

 
 
 
                         Current Services Estimate                                          $50,794,232,000
                      Increase in Patient Workload                                           $1,636,092,000
             Additional Medical Care Program Costs                                           $1,230,951,000
 

    Total FY2019 Medical Community Care $53,661,275,000

    The IBVSOs believe that significant attention must be placed on 
ensuring adequate resources are provided through the Medical Services 
account to ensure timely delivery of high quality health care. The 
budget shortfall this fiscal year is emblematic of the insufficient 
funding that has plagued, and may continue to plague, the VA health 
care system going forward. In FY2018 (and subsequent fiscal years), the 
problem will be compounded as the VA will be shedding funds from its 
traditional Medical Services account to push more care into the 
community. With these thoughts in mind, for FY2019, the IB recommends 
$53.7 billion for Medical Services.
    Additionally, we believe the Administration's advance appropriation 
request for Medical Services in FY2020-$48.5 billion-is woefully 
inadequate to meet even today's demand for VA health care services. The 
Administration appears to ignore its responsibility to request a budget 
that meets its requirements particularly for VA medical care. In light 
of recent history of Congress advance appropriating based on VA's 
initial advance appropriation request, the request for FY2020 is an 
unacceptable proposition. For FY2020, the IBVSOs recommend Congress 
appropriate $54.7 billion as an advance appropriation for Medical 
Services.
    Our recommendations for Medical Services reflect the estimated 
impact of uncontrollable inflation on the cost to provide services to 
veterans currently using the system. We also assume a 1.1 percent 
increase for pay and benefits across the board for all VA employees in 
FY2019, as well as 1.2 percent in the advance appropriation 
recommendation for FY2020.
    Our medical programs funding recommendation for FY2019 is adjusted 
in the baseline for funding within the Medical Services account based 
on VA's revised request for FY2018. The Independent Budget believes 
this adjustment is necessary in light of the nearly $3 billion 
shortfall that the VA health care system is currently experiencing. If 
the baseline from FY2018 is not adjusted to better reflect the true 
demand for services, we believe VA will once again face a shortfall 
this fiscal year and the next, while forcing veterans who choose VA for 
care to unnecessarily wait to receive such care.

Additional Medical Care Program Costs:

    The Independent Budget report on funding for FY2017 and FY2018, 
delivered to Congress on February 9, 2016, also includes a number of 
key recommendations targeted at specific medical program funding needs 
for VA. We believe additional funding is needed to address the array of 
long-term-care issues facing VA, including the shortfall in 
institutional capacity; critical resources to address the continually 
increasing demand for life-saving Hepatitis C treatments; to provide 
additional centralized prosthetics funding (based on actual 
expenditures and projections from the VA's Prosthetics and Sensory Aids 
Service); funding to expand and improve services for women veterans; 
and new funding necessary to improve the growing Comprehensive Family 
Caregiver program.

Long-Term Services & Supports

    The Independent Budget recommends a modest increase of $82 million 
for FY2019. This recommendation reflects a significant demand for 
veterans in need of Long-Term Services and Supports (LTSS) in 2017 
particularly for home- and community-based care, we estimate an 
increase in the number of veterans using the more costly long-stay and 
short-stay nursing home care. This increase in funding also reflects a 
rebalancing of available resources towards home- and community-based 
care, which will likely yield a commensurate decrease in institutional 
spending as is being achieved by state with their balancing of spending 
initiatives.

Prosthetics and Sensory Aids

    In order to meet the increase in demand for prosthetics, the IB 
recommends an additional $320 million. This increase in prosthetics 
funding reflects a similar increase in expenditures from FY2017 to 
FY2018 and the expected continued growth in expenditures for FY2019.

Women Veterans

    The Medical Services appropriation should be supplemented with $500 
million designated for women's health care programs, in addition to 
those amounts already included in the FY2018 baseline. These funds 
would allow the Veterans Health Administration (VHA) to hire and train 
an additional 1,000 women's health providers to meet increasing demand 
for health services based on the significant growth in the number of 
women veterans coming to VA for care.
    Additional funds are needed to expand and repair VA facilities to 
meet environment of care standards and address identified privacy and 
safety issues for women patients. The new funds would also aid VHA in 
continuing its initiative for agency-wide cultural transformation to 
ensure women veterans are recognized for their military service and 
made to feel welcome at VA. Finally, additional resources are needed to 
evaluate and improve mental health and readjustment services for 
catastrophically injured or ill women veterans and wartime service-
disabled women veterans, as well as targeted efforts to address higher 
suicide rates and homelessness among this population.

Reproductive Services (to Include IVF)

    Congress authorized appropriations for the remainder of FY2018 and 
FY2019 to provide reproductive services, to include in vitro 
fertilization (IVF), to service-connected catastrophically disabled 
veterans whose injuries preclude their ability to conceive children. 
The VA projects that this service will impact less than 500 veterans 
and their spouses in FY2019. The VA also anticipates an expenditure of 
no more than $20 million during that period. However, these services 
are not directly funded; therefore, the IB recommends approximately $20 
million to cover the cost of reproductive services in FY2019.

Emergency Care

    VA has issued regulations to begin paying for veterans who sought 
emergency care outside of the VA health care system based on the 
Richard W. Staab v. Robert A. McDonald ruling by the U.S. Court of 
Appeals for Veterans Claims.
    The requested $298 million increase in funding reflects the amounts 
VA has estimated it will need to dispose of pending and future claims. 
VA has indicated it will not retroactively pay benefits for such claims 
that were finally denied before April 8, 2016, the date of the Staab 
decision, and will only apply the new interpretation to claims pending 
on or after April 8, 2016.

Extending Eligibility for Comprehensive Caregiver Supports

    Included in this year's IB budget recommendation is funding 
necessary to implement eligibility expansion of VA's comprehensive 
caregiver support program to severely injured veterans of all eras. 
Funding level is based on the Congressional Budget Office estimate for 
preparing the program, including increased staffing and IT needs, and 
the beginning of the first phase as reflected in our $11 million FY2019 
recommendation.

Medical Community Care

    For Medical Community Care, the IB recommends $14.8 billion for 
FY2019 and $15 billion for FY2020.

 
 
 
                         Current Services Estimate                                          $14,534,613,000
                      Increase in Patient Workload                                             $235,009,000
               Total FY2019 Medical Community Care                                          $14,752,153,000
 

    Our recommended increase includes the growth in current services to 
include current obligations under the Choice program. The Choice 
program is a temporary mandatory program funded under emergency 
designation and is outside the annual budget process that governs 
discretionary spending. VA received an infusion of $2.1 billion in 
August 2017 and another $2.1 billion in December 2017 after it notified 
Congress program resources could be depleted. While increasing access 
to community care, the Choice program has in turn increased veterans' 
reliance on medical care.
    We also believe funding VA programs for community care with a 
discretionary and mandatory account creates unnecessary waste and 
inefficiency. The Independent Budget has advocated for moving all 
funding authorities for the Choice program (and other community care 
programs) into the discretionary accounts of the VA managed under the 
Medical and Community Care account.

Medical Support and Compliance

    For Medical Support and Compliance, The Independent Budget 
recommends $6.8 billion in FY2019. Our projected increase reflects 
growth in current services based on the impact of inflation on the 
FY2018 appropriated level. Additionally, for FY2020 The Independent 
Budget recommends $7.4 billion for Medical Support and Compliance. This 
amount also reflects an increase in current services from the FY2019 
advance appropriation level.

Medical Facilities

    For Medical Facilities, The Independent Budget recommends $7.3 
billion for FY2019, which includes $1.2 billion for Non-Recurring 
Maintenance (NRM). The NRM program is VA's primary means of addressing 
its most pressing infrastructure needs as identified by Facility 
Condition Assessments (FCA). These assessments are performed at each 
facility every three years, and highlight a building's most pressing 
and mission critical repair and maintenance needs. VA's request for 
FY2019 includes $1.4 billion for NRM funding assumes an investment of 
$1.9 billion in FY2018. While the Department has actually spent on 
average approximately $1 billion yearly for NRM, we are concerned its 
FY2019 request includes diverting funds programmed for other purposes-
$210.7 million from Medical Support and Compliance and $39.3 million 
from the Medical Services/Medical Community Care accounts.
    For FY2020, the IB recommends approximately $7.5 billion for 
Medical Facilities. Last year the Administration's recommendation for 
NRM reflected a projection that would place the long-term viability of 
the health care system in serious jeopardy. This deficit must be 
addressed in light of its $627 million request for FY2020.

Medical and Prosthetic Research

    The VA Medical and Prosthetic Research program is widely 
acknowledged as a success on many levels, and contributes directly to 
improved care for veterans and an elevated standard of care for all 
Americans. The research program is an important tool in VA's 
recruitment and retention of health care professionals and clinician-
scientists to serve our nation's veterans. By fostering a spirit of 
research and innovation within the VA medical care system, the VA 
research program ensures that our veterans are provided state-of-the-
art medical care.
    For VA research to maintain current service levels, the Medical and 
Prosthetic Research appropriation should be increased in FY2019 to go 
beyond simply keeping pace with inflation. It must also make up for how 
long the continuing resolution funding level for FY2018 has been in 
effect. Numerous meritorious proposals for new VA research cannot be 
funded without an infusion of additional funding for this vital 
program. Research awards decline as a function of budgetary stagnation, 
so VA may resort to terminating ongoing research projects or not 
funding new ones, and thereby lose the value of these scientists' work, 
as well as their clinical presence in VA health care. When denied 
research funding, many of them simply choose to leave the VA.

Emerging Research Needs

    IBVSOs believe Congress should expand research on emerging 
conditions prevalent among newer veterans, as well as continuing VA's 
inquiries in chronic conditions of aging veterans from previous wartime 
periods. For example, additional funding will help VA support areas 
that remain critically underfunded, including:

      post-deployment mental health concerns such as PTSD, 
depression, anxiety, and suicide in the veteranpulation;
      gender-specific health care needs of the VA's growing 
population of women veterans;
      new engineering and technological methods to improve the 
lives of veterans with prosthetic systems that replace lost limbs or 
activate paralyzed nerves, muscles, and limbs;
      studies dedicated to understanding chronic multi-symptom 
illnesses among Gulf War veterans and the long-term health effects of 
potentially hazardous substances to which they may have been exposed;
      innovative health services strategies, such as telehealth 
and self-directed care, that lead to accessible, high-quality, cost-
effective care for allterans; and
      leverage the only known integrated and comprehensive 
caregiver support program in the U.S. to help inform policy makers and 
other health systems looking to support informal caregivers.

Million Veteran Program

    The VA Research program is uniquely positioned to advance genomic 
medicine through the ``Million Veteran Program'' (MVP), an effort that 
seeks to collect genetic samples and general health information from 
one million veterans over the next five years. When completed, the MVP 
will constitute one of the largest genetic repositories in existence, 
offering tremendous potential to study the health of veterans. To date, 
more than 620,000 veterans have enrolled in MVP, far exceeding the 
enrollment numbers of any single VA study or research program in the 
past, and it is in fact one of the largest research cohorts of its kind 
in the world. The VA estimates it currently costs around $75 to 
sequence each veteran's blood sample.
    Accordingly, the IBVSOs recommend $65 million to enable VA to 
process begin processing the MVP samples collected. Congress must begin 
a targeted investment to go beyond basic, surface-level genetic 
information and perform deeper sequencing to begin reaping the benefits 
of this program.

Construction Programs

Major Construction

    Each year VA outlines its current and future major construction 
needs in its annual Strategic Capital Investment Planning (SCIP) 
process. In its FY2018 budget submission, VA projected it would take 
between $55 billion and $67 billion to close all current and projected 
gaps in access, utilization, and safety including activation costs. 
Currently, VA has 21 active major construction projects, which have 
been partially funded or funded through completion.
    In its FY2018 Budget Request, VA requested and Congress intends to 
appropriate a significant reduction in funding for major construction 
projects-between $410 million and $512 million. While these funds would 
allow VA to begin construction on key projects, many other previously 
funded sites still lack the funding for completion. One of these 
projects was originally funded in FY2007, while others were funded more 
than five years ago but no funds have been spent on the projects to 
date. Of the 21 projects on VA's partially funded VHA construction 
list, eight are seismic in nature. Seismic projects are critical to 
ensuring VA's facilities do not risk the lives of veterans during an 
earthquake or other seismic events.
    It is time for the projects that have been in limbo for years or 
that present a safety risk to veterans and employees to be put on a 
course to completion within the next five years. To accomplish this 
goal, the IBVSOs recommend that Congress appropriate $1.73 billion for 
FY2017 to fund either the next phase or fund through completion all 
existing projects, and begin advance planning and design development on 
six major construction projects that are the highest ranked on VA's 
priority list.
    The IBVSOs also recommend, as outlined in its Framework for 
Veterans Health Care Reform, that VA realign its SCIP process to 
include public-private partnerships and sharing agreements for all 
major construction projects to ensure future major construction needs 
are met in the most financially sound manner.

Research Infrastructure

    State-of-the-art research requires state-of-the-art technology, 
equipment, and facilities. For decades, VA construction and maintenance 
appropriations have not provided the resources VA needed to maintain, 
upgrade, or replace its aging research laboratories and associated 
facilities. The average age of VA's research facilities is more than 50 
years old, and those conditions are substandard for state of the art 
research.
    The IBVSOs believe that Congress must ensure VA has the resource it 
needs to continue world class research that improves the lives of 
veterans and helps recruit high-quality health care professionals to 
work at VA. To do so, Congress must designate funds to improve specific 
VA research facilities in FY2019 and in subsequent years. In order to 
begin to address these known deficits, the IBVSOs recommend Congress 
approve at least $50 million for up to five major construction projects 
in VA research facilities.

Minor Construction

    In FY2018, VA requested $372 million for minor construction 
projects. Currently, approximately 900 minor construction projects need 
funding to close all current and future year gaps within the next 10 
years. To complete all of these current and projected projects, VA will 
need to invest between $6.7 and $8.2 billion over the next decade.
    To ensure that VA funding keeps pace with all current and future 
minor construction needs, the IBVSOs recommend that Congress 
appropriate an additional $761 million for minor construction projects. 
It is important to invest heavily in minor construction because these 
are the types of projects that can be completed faster than other 
capital infrastructure projects and have a more immediate impact on 
services for veterans.

State Veterans Home Construction Grants

    Grants for state extended-care facilities, commonly known as state 
home construction grants, are a critical element of federal support for 
the state veterans' homes. The state veterans' home program is a very 
successful federal-state partnership in which VA and states share the 
cost of constructing and operating nursing homes and domiciliaries for 
America's veterans.
    State homes provide more than 30,000 nursing home and domiciliary 
beds for veterans, their spouses, and gold-star parents of deceased 
veterans. Overall, state homes provide more than half of VA's long-
term-care workload, but receive less than 22 percent of VA's long-term 
care budget. VA's basic per diem payment for skilled nursing care in 
state homes is significantly less than comparable costs for operating 
VA's own long-term-care facilities. This basic per diem paid to state 
homes covers approximately 30 percent of the cost of care, with states 
responsible for the balance, utilizing both state funding and other 
sources.
    State construction grants help build, renovate, repair, and expand 
both nursing homes and domiciliaries, with states required to provide 
35 percent of the cost for these projects in matching funding. VA 
maintains a prioritized list of construction projects proposed by state 
homes based on specific criteria, with life and safety threats in the 
highest priority group. Only those projects that already have state 
matching funds are included in VA's Priority List Group 1 projects, 
which are eligible for funding. Those that have not yet received 
assurances of state matching funding are put on the list among Priority 
Groups 2 through 7.
    With almost $1 billion in state home projects still in the 
pipeline, The Independent Budget recommends $200 million for the state 
home construction grant program to address a portion of the projects 
expected to be on the FY2019 VA Priority Group 1 List when it is 
released this year.

Grants for State Veterans Cemeteries

    The State Cemetery Grant Program allows states to expand veteran 
burial options by raising half the funds needed to build and begin 
operation of state veterans cemeteries. NCA provides the remaining 
funding for construction and operational funds, as well as cemetery 
design assistance. Funding additional projects in FY2019 in tribal, 
rural and urban areas will provide burial options for more veterans and 
complement VA's system of national cemeteries. To fund these projects, 
Congress must appropriate $51 million.

Office of Information Technology

Electronic Health Records

    We are pleased to hear Secretary of Veterans Affairs David 
Shulkin's decision to have the Department adopt the same electronic 
health care record (EHR) system as the Department of Defense (DoD), 
putting an end to the saga of not being able to efficiently integrate 
military treatment records into a veteran's treatment plan. This plan 
will greatly improve the delivery of care to ill and injured veterans, 
and ensure truly integrated care as service members transition from DoD 
to VA care.
    While improvements to information technology (IT) systems are an 
important part of VA's mission, the cost of doing so cannot come at the 
expense of health care veterans have earned. We call on Congress to 
balance the needs of an improved VA with the need to ensure high 
quality health care is provided to all eligible veterans. In VA's 
fiscal year (FY) 2019 budget request, VA states it will transfer $782 
million from its FY2018 medical care and Office of IT appropriations to 
its EHR modernization program. We support an integrated VA-DoD EHR, but 
we do not endorse taking critical funds away from health care to pay 
for it.
    We call on Congress to allocate the nearly $800 million VA needs in 
FY2018 for EHR modernization from the additional fiscal year 2018 
discretionary non-defense appropriations included in the recent 
bipartisan budget deal. Doing so would ensure VA can begin its work to 
provide a truly seamless transition for our service members and our 
veterans.

Administration Legislative Proposals

    VA's FY2019 budget request includes legislative proposals that 
would have budget implications.he Independent Budget supports the 
proposal to include in VA's medical benefits package the authority to 
pay for care only in VA-approved Medical Foster Homes and specifically 
for veterans who for whom VA is currently required to provide more 
costly nursing home care. VA estimates cost reductions that will 
increase annually from $12 million up to nearly $90 million over five-
years if Congress enacts this proposal.
    The Independent Budget opposes the proposal to end the current 
practice of offsetting a veteran's copayment debt with reimbursements 
it receives from that veteran's health plan.his will shift over the 
cost of over $50 million of care annually from the federal government 
on to the backs of ill and injured veterans.
    The IB also opposes the proposal to impose punitive enforcement to 
make veterans pay over $8 million annually of the care they receive 
from VA if the veteran fails to provide third-party health plan 
coverage information and any other information necessary to VA for 
billing and collecting from the third party payer.
    Mr. Chairman, thank you for the opportunity to submit testimony and 
to present our views regarding FY2019 and FY2020 advance funding 
requirements for medical care and construction programs to support VA's 
ability to deliver benefits and services to veterans, their families 
and survivors. We would be happy to respond to any questions that you 
or members of the Subcommittee may have regarding this statement or our 
recommendations.

                                 
          AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO
    Chairman Wenstrup, Ranking Member Brownley, Members of the 
Subcommittee,

    The American Federation of Government Employees (AFGE), appreciates 
the opportunity to submit a statement for the record for this hearing 
regarding President Trump's FY2019 budget request for the Department of 
Veterans Affairs (VA). AFGE represents nearly 700,000 federal 
employees, including 250,000 employees at the VA, and more 
specifically, the overwhelming majority of non-management frontline VA 
employees who provide direct medical and mental health services to our 
nation's veterans. It is imperative that Congress give VA employees the 
resources they need to succeed, and that means investing money into the 
VA and its staff instead of sending precious resources to the private 
sector.
    One issue that needs an immediate remedy is chronic understaffing 
across the VA system. AFGE has repeatedly raised the issue of the 
outrageous understaffing at the Department. It seems that VA has a 
policy of not filling positions that even they acknowledge should be 
filled. We would like to use this statement to once again point out 
that there are approximately 35,000 positions that need to be filled. 
But instead of seeking to hire for these positions, the Department 
proceeds without any sense of urgency. Pushing veterans to the 
unaccountable private sector while the Department needs 35,000 
additional front line personnel is a national disgrace. If the White 
House and VA want to fix internal problems at the Department they 
absolutely must get serious about staffing the agency. Anything short 
of a firm hiring commitment is yet another Band-Aid on a multi-year 
problem. As the Independent Budget Veterans Service Organizations state 
in the Independent Budget, every expansion in the temporary CHOICE 
Program has increased demand for VA in-house services. Front line 
clinicians and support staff now have additional demands to manage 
Choice referrals, assist overwhelmed veterans and ensure continuity of 
care as veterans are shuttled between the two systems.
    On January 17, 2018, Secretary Shulkin testified before the Senate 
Veterans' Affairs Committee and was asked directly about the 
Department's hiring plans. When asked about vacancies Secretary Shulkin 
said, ``I just want to understand what they are, 35,000 vacancies, we 
have 370,000 employees, a 9 percent vacancy rate which is not overly 
high. So you're always going to have 40,000 vacancies during the course 
of the year.'' We respectfully disagree with this sentiment. The VA 
provides critical care and services to a special population, our 
nation's heroes, and we should not accept the status quo when it comes 
to serving their needs. Surely, we can all agree that the brave men and 
women who have worn the uniform and borne the battle deserve more than 
simply the bare minimum when it comes to adequate staffing of health 
care providers. AFGE continues to urge Congress and the Administration 
to address VA staffing and hire 35,000 additional and necessary front-
line personnel.
    Sadly, instead of addressing the internal problems with 
understaffing, leadership at the VA has opted to privatize core 
functions of the VA. The Department is opting to send care and services 
to costly, unaccountable private contractors instead of hiring adequate 
staff to perform these functions at the VA. A central topic last year 
was the notion of ``accountability'' yet the VA continues to send 
veterans outside of the VA to contractors who are held to no 
accountability standard. While VA employees must meet quality standards 
and have their performance scrutinized, no such oversight is conducted 
on private providers who operate in the CHOICE program. As Congress 
considers the VA budget, it must demand that the Department stop 
outsourcing vital functions.
    AFGE continues to be concerned about the way money allocated to the 
VA is being spent. Specifically, as part of the larger budget deal in 
February there was a bipartisan agreement to allocate $4 billion to the 
VA over the course of two years. The intent was that this money would 
be used for the VA to address infrastructure needs. However, the White 
House has insinuated that they would like to see part of this money 
diverted from the VA and used to patch the CHOICE Program. We urge 
Congress to oppose any change in the way this funding is used and 
allocated. Leadership on both sides of the aisle agreed that the entire 
$4 billion - $2 billion in FY18 and $2 billion in FY19 - would be used 
for the VA and its internal needs.
    The Senate and House VA Committees have spent a considerable amount 
of time debating and considering CHOICE funding and possible 
replacements. It is inappropriate to use the appropriations process to 
circumvent the Committees and send VA-specified money to CHOICE. The 
Department and the White House must be transparent in their dealings 
with Congress, VA employees, and veterans. It's disingenuous to accept 
money for the Department but then attempt to syphon that money off for 
other purposes. This smoke-and-mirrors approach to funding the VA is 
inappropriate, bad for veterans, and bad for employees. We urge 
Congress to adequately oversee how appropriated dollars are spent by 
the Department.
    Finally, AFGE has serious reservations about using medical service 
dollars as a slush fund to subsidize unaccountable private sector care. 
Specifically, the President's Budget recommends ``combining the Medical 
Community Care and Medical Services accounts'' in order to, supposedly, 
streamline operations. AFGE unequivocally opposes this recommendation 
and urges Congress to reject it outright. These are two separate and 
distinct accounts that should not be forced together for the 
Administration's convenience. We further oppose any change in funding 
streams that could divert resources from the VA and send that money to 
contractors. As can be seen by the 35,000 positions the VA needs to 
hire, the agency must have funding devoted to its own direct 
operations; and Congress must hold the Department accountable in the 
way the VA spends taxpayer money entrusted to it.

    Thank you.

    American Federation of Government Employees, AFL-CIO

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