U.S. GOVERNMENT PUBLISHING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Publishing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001

98–570 2016

U.S. DEPARTMENT OF VETERANS AFFAIRS BUDGET 

REQUEST FOR FISCAL YEAR 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

WEDNESDAY, FEBRUARY 11, 2015 

Serial No. 114–7 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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


VACREP0180 with DISTILLER
(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

RALPH ABRAHAM, Louisiana 

LEE ZELDIN, New York 

RYAN COSTELLO, Pennsylvania 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

CORRINE BROWN, Florida, Ranking 

Minority Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

JERRY MCNERNEY, California 

JON TOWERS, Staff Director 

DON PHILLIPS, Democratic Staff Director 

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. 


VACREP0180 with DISTILLER
(III) 

C O N T E N T S 

Wednesday, February 11, 2015 

Page 

U.S. Department of Veterans Affairs Budget Request for Fiscal Year ............... 1 

OPENING STATEMENTS 

Jeff Miller, Chairman .............................................................................................. 1 

Prepared Statement ......................................................................................... 51 

Corrine Brown, Ranking Member .......................................................................... 3 

Prepared Statement ......................................................................................... 53 

WITNESSES 

Hon. Robert A. McDonald, Secretary, VA .............................................................. 4 

Prepared Statement ......................................................................................... 54 

Accompanied by: 

Dr. Carolyn Clancy M.D., Interim Under Secretary for Health, VA 

Hon. Allison A. Hickey, Under Secretary for Benefits, VA 

Mr. Ronald E. Walters, Interim Under Secretary for Memorial Affairs, VA 

Ms. Helen Tierney, Executive in Charge for the Office of Management, and VBA Chief Financial Officer, VA 

And 

Mr. Stephen Warren, Executive in Charge and Chief Information 

Officer, Office of Information and Technology, VA 

Mr. Carl Blake, Associate Executive Director, Government Relations, Paralyzed Veterans of American, On Behalf of the Co-Authors of the Independent Budget .................................................................................................... 40 

Prepared Statement ......................................................................................... 80 

Accompanied by: 

Mr. Joseph A. Violante, National Legislative Director, Disable American Veterans 

Mr. Ray Kelley, Director, National Legislative Service, Veterans of 

Foreign Wars 

Ms. Diane M. Zumatto, National Legislative Director, AMVETS 

Mr. Ian de Planque, Legislative Director, The American Legion ........................ 42 

Prepared Statement ......................................................................................... 87 

FOR THE RECORD 

The Independent Budget for the Department of Veterans Affairs ...................... 92 

Secure Sharing of Health Information to Improve Patient Care ......................... 113 

Question for the Record ........................................................................................... 118 

Part I Overview Information .................................................................................. 173 


VACREP0180 with DISTILLER

VACREP0180 with DISTILLER
(1) 

U.S. DEPARTMENT OF VETERANS AFFAIRS 

BUDGET REQUEST FOR FISCAL YEAR 2016 

Wednesday, February 11, 2015 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, D.C. 

The committee met, pursuant to other business, at 10:35 a.m., in 

Room 334, Cannon House Office Building, 

Hon. Jeff Miller [chairman of the committee] presiding. 

Present: Representatives Miller, Lamborn, Bilirakis, Benishek, 

Huelskamp, Coffman, Wenstrup, Abraham, Costello, Radewagen, 

Brown, Brownley, Titus, Kuster, O’Rourke, Rice, McNerney, and 

Walz. 

OPENING STATEMENT OF CHAIRMAN JEFF MILLER 

The CHAIRMAN. The hearing will come to order. 

We are here to discuss the President’s fiscal year 2016 budget request for the Department of Veterans Affairs. 

Mr. Secretary, welcome to the committee. I understand that your 

testimony will be a little bit different today than what we are accustomed to with reference to charts to help us better understand 

what you are seeing in terms of the challenges that lay ahead. 

And I would say that is indeed a welcomed change. So, too, is 

the openness that you have had with me, with the Members of this 

committee, and this Congress about your plans to change the culture at VA. 

As your testimony illustrates, you have been extremely active in 

visiting VA facilities, I think it is well over 90 at this point, talking 

with employees, veteran groups, and your private sector colleagues 

with one aim in mind, putting everyone’s focus squarely on the 

needs of veterans. 

Thank you for your willingness to take the job of secretary and 

thank you for putting everything that you have into that job. 

Turning to the business of examining the VA budget request, I 

see some very positive things, but also there are some areas where 

we will have considerable question marks. 

The committee’s task will be to learn as much as possible in 

order to inform our views and estimates letter that is due next Friday. 

On the positive side, Mr. Secretary, you have boldly tackled a 

very sensitive issue of VA’s aging infrastructure coupled with a 

more realistic budget request for VA’s major construction program. 

Addressing the closure of unsafe, vacant, or underutilized facilities 


VACREP0180 with DISTILLER
2 

begins an important conversation about the future alignment of 

VA’s infrastructure. 

I have long argued that we needed a strategic reassessment of 

VA’s construction program. That is in part what the independent 

assessment and the Veterans Healthcare Commission established 

in last summer’s Choice Act were tasked with examining. 

You have my commitment and this committee’s commitment to 

work with you as this conversation begins in earnest. 

Now, I have several areas of concern that I hope you and our second panel can address. First, and I am going to be frank as I have 

in the past with you on this particular issue, the proposal to reallocate any portion of the $10 billion appropriation for the Veterans 

Choice Program is a non-starter. 

I understand there is a great degree of uncertainty about the 

program’s utilization. But in appropriating the money, the Congress had to work with the best estimates that we had at the time 

to stretch those dollars including limited eligibility criteria for veterans. 

So if there is going to be any reallocation, it is going to be to further improve and strengthen the program itself and not address 

other unspecified needs. 

Secondly, the budget requests an additional $1.3 billion for VA 

medical care on top of the advanced appropriation for fiscal year 

2016, bringing the total proposed increase to 7.4 percent. 

At a threshold level, I do not understand how this request interacts with the $15 billion that Congress provided last summer for 

non-VA care and infrastructure as part of the Veterans Access, 

Choice and Accountability Act. 

It would appear that there are considerable unknown variables 

in this area such as the degree to which the Choice Program alleviates the workload and resource pressure on VA, the productivity 

standards that VA should expect from its clinical workforce, and 

the ability for VA to hire medical professionals in the face of an already large vacancy rate and a national shortage of healthcare professionals. 

I hope to expand on this a bit more during questioning. 

Thirdly, I note the 6.5 percent increase for the Veterans Benefit 

Administration principally to hire additional staff to address the 

workload. 

Mr. Secretary, there are several of us on this committee, the 

ranking member included, who have long memories on this issue. 

We know the disability claims staffing has doubled in ten years 

and nearly tripled since I arrived in Congress in 2001. We have invested over a half a billion dollars in VBMS, millions more in other 

systems, and we have provided tools to encourage veterans to file 

fully developed claims which in turn enables a quicker decision. 

All of these investments were made with a promise that productivity would markedly improve and shift the department away from 

the usual trend of relying on an ever-increasing workforce and 

overtime to deal with the workload. 

Although I note the production improvement in the backlog over 

the last two years, it is a far cry from seeing individual worker productivity improve given the resources that have already been proVerDate Aug 31 2005 13:32 Mar 15, 2016 Jkt 000000 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 Y:\98-570.TXT PAT

VACREP0180 with DISTILLER
3 

vided to the department. Again, this is another area I hope to address in questioning. 

And, finally, a big lesson learned last year is that veterans are 

better served with constant and aggressive oversight. Ms. Brown 

and I have asked for a larger committee budget towards that end. 

One thing that you and I have talked about is the Office of Inspector General. I, too, believe that they need an increase larger 

than the .3 percent increase provided in the budget. The proposed 

amount is not even enough to cover inflationary costs, let alone the 

increased oversight we all rely on so heavily. 

Again, Mr. Secretary, thank you for what you are doing. I look 

forward to your testimony and I look forward to hearing from the 

veteran service organizations on the second panel. The VA system 

is for them and those they represent, so their input on budgetary 

matters is critical in informing the committee and the Congress on 

VA’s budget request. 

[THE PREPARED STATEMENT OF CHAIRMAN JEFF MILLER APPEARS

IN THE APPENDIX] 

And with that, I recognize Ms. Brown for her opening remarks. 

OPENING STATEMENT OF RANKING MEMBER CORRINE 

BROWN 

Ms. BROWN. Thank you, Mr. Chairman. 

And welcome, Mr. Secretary. I want to say that I am very happy 

that you are here this morning and I am looking forward to hearing how this budget request will meet the needs of our veterans. 

The President has proposed a large increase for VA. For fiscal 

2016, the President has proposed nearly an eight percent increase 

in funding for VA healthcare, personnel, construction, research, 

and claim processing. 

Given this large request, I am looking forward to our discussion 

today and how it will assist our work as a committee to make sure 

that this proposed budget gives you the dollars that you need but 

also assures us how in Congress that every dollar you receive will 

be spent wisely. 

I certainly wish that my bill, H.R. 216, the Department of Veterans Affairs Budget Plan and Reform Act of 2015, was the law of 

the land. It is an important tool to assist us and you in matching 

resources to the needs of our veterans and ensuring that we are 

planning for the future to make sure that we don’t let our veterans 

down. 

Mr. Secretary, the first question I will ask is does your proposed 

budget give you all of the dollars you need to fix the problems that 

you face, meet the goals and initiatives the department has laid 

out, keeping in mind that funding provided by the Choice Act. 

I hope that we can discuss whether you have enough resources 

to ensure that veterans do not face intolerable delays in getting access to healthcare. I hope we can discuss how you are looking down 

the road to ensure that veterans have the access to VA care in the 

future. 

I always hear from veterans how they prefer VA care when it is 

available. I hope that we are going to all work together to make 

sure that healthcare our veterans prefer is available to them when 

they need it. 


VACREP0180 with DISTILLER
4 

This is the first year that VA benefits programs will be fully 

funded under advanced appropriations, how veterans won’t have to 

worry about what we are doing in Congress, and it won’t affect how 

we operate. 

Finally, I want to hear about your reform and reorganization efforts and how this budget request will support these efforts. 

I also want to hear about how you are making progress in an effort to reform and re-energize, invigorate the VA. Too often all we 

hear about is the problems VA is having. I would like us to also 

consider what we can do to fix those problems and to point out 

what VA is getting right. 

I am pleased with this budget request and I hope these dollars 

can fix what is wrong and strengthen what is right with the VA. 

And with that, Mr. Chairman, I yield back the balance of my 

time. 

The CHAIRMAN. Thank you very much, Ms. Brown. 

[THE PREPARED STATEMENT OF RANKING MEMBER CORRINE

BROWN APPEARS IN THE APPENDIX] 

I would like to welcome our first panel to the table this morning. 

Accompanying the Honorable Robert McDonald, Secretary of the 

Department of Veterans, is Dr. Carolyn Clancy, Interim Under Secretary for Health; the Honorable Allison A. Hickey, Under Secretary for Benefits; Mr. Ronald Walters, Interim Under Secretary 

for Memorial Affairs; Ms. Helen Tierney, Executive in Charge for 

the Office of Management, and VA Chief Financial Officer; and Mr. 

Stephen Warren, Executive in Charge and Chief Information Officer with the Office of Information and Technology. 

Mr. Secretary, again, thank you for being here and please proceed with your statement. 

STATEMENT OF ROBERT A. MCDONALD, SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY 

CAROLYN CLANCY, INTERIM UNDER SECRETARY FOR 

HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS; ALLISON A. HICKEY, UNDER SECRETARY FOR BENEFITS, U.S. DEPARTMENT OF VETERANS AFFAIRS; RONALD E. WALTERS, 

INTERIM UNDER SECRETARY FOR MEMORIAL AFFAIRS, U.S. 

DEPARTMENT OF VETERANS AFFAIRS; HELEN TIERNEY, EXECUTIVE IN CHARGE FOR THE OFFICE OF MANAGEMENT, 

AND VA CHIEF FINANCIAL OFFICER, U.S. DEPARTMENT OF 

VETERANS AFFAIRS; STEPHEN WARREN, EXECUTIVE IN 

CHARGE AND CHIEF INFORMATION OFFICER, OFFICE OF INFORMATION AND TECHNOLOGY, U.S. DEPARTMENT OF VETERANS AFFAIRS 

STATEMENT OF ROBERT A. MCDONALD 

Secretary MCDONALD. Thank you. 

Chairman Miller, Ranking Member Brown, Members of the committee, thanks for the opportunity to discuss VA’s 2016 budget and 

2017 advanced appropriations request. 

Thank you as well for joining me at 810 Vermont last week for 

a groundbreaking town hall meeting. 


VACREP0180 with DISTILLER
5 

We deeply appreciate the President’s and Congress’s steadfast 

support for veterans, their families and survivors, as well as the 

advocacy of veteran service organizations. 

Our Nation is emerging from the longest war in its history. VA 

is emerging from one of the most serious crises the department has 

ever experienced. We now have before us the greatest opportunity 

we have ever had to improve care for veterans and to build a more 

efficient and more effective system. With your support, VA intends 

to take full advantage of this remarkable timely opportunity. 

Members of this committee and VSOs share my goal to make the 

VA a model agency with respect to customer experience and stewardship of taxpayer resources, an example for other government 

agencies. 

With efficient and effective operations, we look to be comparable 

to the very top private sector businesses. This is how we best meet 

the Nation’s obligations to all veterans. 

The cost of fulfilling those obligations to our veterans grows and 

we expect it will continue to grow for the foreseeable future. We 

know that services and benefits for veterans do not peak until 

roughly four decades after a conflict ends. 

[Chart] 

Secretary MCDONALD. This chart demonstrates the number of 

veterans receiving service-connected disability benefits from World 

War I peaked in 1958. For World War II, it peaked in 1985. For 

Korea, it peaked in 1993 and for Vietnam veterans, it was just last 

year, 2014, when it peaked. 

It is worth remembering that today, almost 150 years after the 

Civil War ground to a halt, VA is still providing benefits to the 

child of a Civil War veteran. We still have troops in both Iraq and 

Afghanistan. And in the last decade, we have already seen dramatic increases in the demand for benefits and care. 

[Chart] 

Secretary MCDONALD. This chart shows how for 40 years, from 

1960 to 2000, the percentage of veterans receiving compensation 

from VA was stable at about eight and a half percent. But in the 

last 14 years, since 2001, the percentage has dramatically increased to 19 percent, more than double. 

Simultaneously, the number of claims and the number of medical 

issues in rating related claims that VA has completed has soared. 

[Chart] 

Secretary MCDONALD. As this chart shows, in 2009, VBA completed almost 980,000 claims. In fiscal year 2017, we project we 

will complete over 1.4 million claims. That is a 47 percent increase. 

But there has been even more dramatic growth in the number of 

medical issues in claims, 2.7 million in 2009 and a projected 5.9 

million in 2017. That is a 115 percent increase over just eight 

years. 

These increases were accompanied by the dramatic rise in the 

average degree of disability compensation granted to veterans. For 

45 years, from 1950 to 1995, the average degree of disability held 

steady at 30 percent. But since the year 2000, the average degree 

of disability has risen to 47.7 percent as this chart shows. 

[Chart] 


VACREP0180 with DISTILLER
6 

Secretary MCDONALD. So while it is true that the total number 

of veterans is declining, the number of those seeking care and benefits from VA is increasing. Fueled by more than a decade of war, 

Agent Orange related disability claims, an unlimited claims appeal 

process, increased medical claim issues, far greater survival rates 

among those wounded, more sophisticated methods for identifying 

and treating veterans’ medical issues, demographic shifts, veterans’ 

demands for services and benefits has exceeded VA’s capacity to 

meet it. 

It is important that Congress and the American people understand why this is happening. The most important consideration is 

that America’s veterans are aging. As with any population, 

healthcare requirements and the demand for benefits both increase 

as veterans age and exit the workforce. 

[Chart] 

Secretary MCDONALD. This chart reveals an astounding shift. In 

1975, the year I graduated from West Point, just 40 years ago, only 

2.2 million American veterans were 65 years old or older, 7.5 percent of our veteran population. In 2017 here on the far left, we expect 9.8 million will be 65 or older or 46 percent of veterans. That 

is 7.5 percent to 46 percent, an astounding increase. 

So today we serve a population that is older with more chronic 

conditions and less able to afford private sector care. We predict 

that benefits for veterans of recent conflicts will peak around 2055 

if we assume that Afghanistan and Iraq are winding down this 

year. 

And it is fair to imagine that Members of Congress, the President, and the secretary of Veterans Affairs in 2175 will be debating 

resources that will in part help care for the family members of Iraq 

and Afghanistan veterans. 

Currently 11 million of the 22 million veterans in this country 

are registered, enrolled, or use at least one VA benefit or service. 

Veterans are demanding more VA services than ever before. The 

number of all veterans who are seeking VA medical care is steadily 

growing. 

The requirement for women veterans, a very important issue for 

us, and mental health, another very important issue for us, have 

increased dramatically. Over 635,000 women veterans are now enrolled in VA healthcare and over 400,000 actively use VA for care. 

That is double the number using VA care in the year 2000. 

We see annual increases in women veterans seeking care of 

about nine percent and this trend will continue and probably even 

go higher. Our women veteran call center now connects with over 

100,000 women veterans per year. 

Over 1.4 million veterans with a mental health diagnosis are enrolled in VA, an increase of 64 percent from the year 2015. There 

were approximately 19.6 million mental health outpatient encounters in 2014. That is an increase of 72 percent from 2005. 

Since its inception in 2007 through 2014, the veterans’ crisis line 

has answered over 1.6 million calls and assisted in over 45,000 rescues. Over one million veterans received services through the primary care mental health integration program begun in 2007 

through November 2014. The annual number of encounters has 


VACREP0180 with DISTILLER
7 

grown from about 182,000 in fiscal year 2008 to over one million 

in 2014. 

As veterans witness the results of the positive changes VA is 

making and regain trust in the VA and as the military simultaneously downsizes, the number of veterans choosing VA services 

will continue to rise. It should and our veterans have earned it. 

We are listening hard to what veterans, Congress, employees, 

VSOs, and other stakeholders are telling us. And what we hear 

drive us to a historic, unprecedented department-wide transformation changing VA’s culture and making the veteran the center of everything that we do. 

That transformation we call MyVA because that is the way we 

want veterans to think about VA. It is theirs. It is personalized. It 

is customized. And this transformation entails many organizational 

reforms to better unify the department’s efforts. 

MyVA focuses on five objectives, which I have shown here on the 

bottom. First is improving the veteran experience so that every veteran has a seamless, integrated, and responsive customer service 

experience every single time. 

Second, improving the employee experience and eliminating barriers to customer service to achieve people excellence so employees 

can better serve veterans. We have no hope of taking care of veterans if we don’t take care of the employees of VA. 

Third, improving our internal support systems and services. 

Fourth, establishing a culture of continuous improvement so local 

levels can identify and correct problems more immediately and 

then replicate proven solutions across our entire network. 

And, fifth, enhancing strategic partnerships. MyVA revolutionizes VA’s culture and reorients the department around the needs 

of veterans, measuring success by veterans’ outcomes as opposed to 

some kind of internal metrics. 

We intend every veteran to have a seamless, integrated, and responsive customer service experience every single time. 

Reorganizing the department geographically is a first substantial 

and important step in achieving this goal. 

In the past, VA had nine disjointed geographic organization 

structures, one for each line of business. So imagine a business 

with nine different businesses, nine different sub-businesses each 

having a different organization structure and a different middle 

management. 

Our new unified organizational framework has one national 

structure as shown in this chart. 

[Chart] 

Secretary MCDONALD. This new structure has just five regions 

aligning VA’s disparate organization boundaries into a single 

framework. This facilitates internal coordination and collaboration 

among business lines, creates opportunities for integration at a 

much lower level, and promotes effective customer service. Veterans will see one VA rather than individual disconnected organizations. 

Last, MyVA is also about ensuring VA is a sound steward of taxpayer dollars. We will integrate Lean Six Sigma systems and efficiencies across our operations to ensure we balance veteran-centric 


VACREP0180 with DISTILLER
8 

service with operational efficiency, but we need the help of Congress. 

VA cannot be a sound steward of the taxpayers’ resources with 

the asset portfolio that we are currently carrying. No business 

would carry such a portfolio. Veterans deserve much better. It is 

time to close the VA’s old substandard and underutilized infrastructure. 

Nine hundred VA facilities are over 90 years old and more than 

1,300 are over 70 years old. VA currently has 336 buildings that 

are vacant or less than 50 percent occupied. That is 10.5 million 

square feet of excess, which costs us an estimated $24 million a 

year to maintain. These funds could be used to hire roughly 200 

registered nurses for a year or to pay for 144 primary care visits 

for veterans or to support 41,900 days of nursing home care for veterans in community living centers. 

We need your support to do the harder right rather than the 

easier wrong. These MyVA reforms will take time, but over the 

long term, they will enable us to better provide veterans the services and benefits they have earned and that our Nation promised 

them. 

Our 2016 budget will allow us to continue this critical transformation to meet the intent of MyVA. The 2016 budget for VA requests $168.8 billion, $73.5 billion in discretionary funds and $95.3 

billion in mandatory funds for benefit programs. 

The discretionary request is an increase of $5.2 billion or 7.5 percent above the 2015 enacted level and it provides the resources necessary to continue to serving the growing number of veterans who 

have selflessly served our Nation. The budget will increase access 

to medical care and benefits for veterans. It will address infrastructure challenges including major and minor construction, modernization and renovation. It will end the backlog of claims and 

veterans’ homelessness by the end of calendar year 2015. It will 

fund medical and prosthetics research and it will address the IT infrastructure and modernization. 

We know this is a large request, but it is not sufficient to meet 

all the requirements for either 2016 or 2017. Therefore, the President will transmit a legislative proposal to allow flexibility as necessary to reallocate, if needed, a portion of the Veterans Choice Act 

funds to improve VA operations within a fiscally responsible, budget-neutral approach to best care for veterans. 

[Chart] 

Secretary MCDONALD. As this chart demonstrates, this proposal 

is largely driven by our uncertainty of what resources we need to 

fund the new Veterans Choice Program. It is difficult to predict 

veterans’ use of the program or its interaction with the medical 

care base budget because it is all new. 

We have no long-term data to draw upon yet. Our current estimates of demand range from a low of about $4 billion to a high of 

about $13 billion over the three-year program. We want and need 

the flexibility to move resources if veterans decide to stay inside 

VA rather than move outside VA. 

This is about ensuring every veteran receives the care they have 

earned and deserve regardless of where they choose to get it from. 


VACREP0180 with DISTILLER
9 

Mr. Chairman, Members of the committee, we meet today at a 

historically important time for VA and the Nation. March will 

mark the 150th anniversary of President Lincoln’s solemn promise 

to those who had fought the most devastating war in our country’s 

history. He promised that we would care for those who shall have 

borne the battle and for their families and their survivors. 

That is VA’s primary mission. It is our only mission. It is the noblest mission supporting the greatest clients of any agency in the 

country, and we count on your support to uphold that sacred commitment. 

Thank you again for your unwavering support for veterans, for 

working with us on these budget requests, and for making things 

better for all of our great Nation’s veterans. We look forward to 

your questions. 

[THE PREPARED STATEMENT OF ROBERT A. MCDONALD APPEARS IN

THE APPENDIX] 

The CHAIRMAN. Thank you very much, Mr. Secretary, for 

your—— 

Secretary MCDONALD. Thank you, sir. 

The CHAIRMAN [continuing]. Testimony. And as we approach 

President Lincoln’s birthday tomorrow, we are ever mindful of his 

commitment to the veterans of this Nation and our responsibility 

as a Congress and as an administration. Can you tell me a little bit about how the $15 billion that was 

appropriated last year in addition to the budget, how that is accounted for in this budget? 

Secretary MCDONALD. Well, sir, as you know, that money gets 

obligated only when veterans use the program. So, so far in terms 

of Veterans Choice Program, we have had nearly a half a million 

calls from veterans about the program, veterans and providers. So 

far, we have had roughly 24,000 veterans make appointments on 

the program and go outside. So we obligate that money as it is. 

Also, we are in the process of leasing 27 new facilities and that 

work is already underway. And we are using the money to hire 

more doctors, more medical professionals. We have a net new increase of over 8,000 medical professionals. That is in the last nine 

months. November was our biggest month of hiring. We hired over 

2,000 more medical professionals than we lost. 

Our turnover rate is about eight percent, 8.9 percent. The turnover rate in the industry is about 18 percent, so we are trying everything we can do to retain the medical professionals and hire 

those that we need. 

Let me ask Helen. Is there anything I missed, Helen? 

Ms. TIERNEY. Thank you. 

Yes, we did have a shift of just over $500 million where we think 

the costs will shift to the Choice Program. 

The CHAIRMAN. Yeah. Could you explain that a little bit further? 

I know there was a telephone conference with staff, but talk about 

the shift. 

Ms. TIERNEY. So understanding the program is still very new, we 

thought that some of the costs that we normally see in the Fee Program would be picked up by the Choice Program. Right now, 

though, our actual results are we are seeing much more demand 

for the Fee Program on the VA side of the budget. 


VACREP0180 with DISTILLER
10 

The CHAIRMAN. Yeah. I would say that is a critical component to 

knowing whether this request is adequate or not. That is why the 

hesitance to do anything, Mr. Secretary, with the Choice piece. 

Again, we arrived at the 40-mile criteria because we wanted to 

have zero. Any veteran out there had a choice. That number came 

back from CBO at about 50 billion. We couldn’t do that, so that is 

where the 40 got. 

But there has to be some savings, I would suspect, that are derived by alleviating some of the pressure within the system by 

those that are going outside because of the Choice Program. 

Ms. TIERNEY. And we are going to be looking at that very carefully. What we also don’t understand is what level of suppressed 

demand that we had from veterans who did want to use the services who weren’t using the services because of long wait times, distance. So there is still a lot to understand about Choice. 

Secretary MCDONALD. Mr. Chairman, I don’t know that now is 

the time to make a move of any funds. What I am trying to do is 

sensitize the committee to the fact that there is a lot of uncertainty. And in our budget, we have roughly 70 line items where we 

have inflexibility. We can’t move money from one line item to another. 

And what I am asking is that we work together to have flexibility so no matter where a veteran goes, we can move the appropriate money there and make sure that veteran receives care. 

The CHAIRMAN. I will commit to helping you have flexibility, Mr. 

Secretary, in just about everywhere within your agency except 

within that Choice piece because of the uncertainty that is there. 

That is what is interesting about this budget request. 

You talk about, Ms. Tierney, about all the uncertainty that is out 

there, yet we are asking for increases in FTEs. We are asking for 

increases in dollar amounts. 

Let me get back real quick. I have got one other question and 

then I need to give it to Ms. Brown. 

One of the things that I think a lot of us have asked, I know the 

physicians on this committee have asked over and over again, have 

never really gotten an answer, it is twofold, number one, how much 

does it cost for a veteran to be seen within the VA versus the private sector? The private sector, Mr. Secretary, you know could answer that right away. We have a hard time answering that within 

the department. And then the other issue is, do we know whether 

the clinical workforce is operating at its maximum capacity and efficiency based on the workload that is out there? There has just 

been a lot of anecdotal evidence that has been presented to this 

committee that would say that it is not, that physicians are seeing 

as few as two patients a day which is just absolutely unheard of. 

Dr. Clancy. 

Secretary MCDONALD. Let me ask Dr. Clancy to comment on 

that. But before she does, let me say that, as you know, my first 

trip was to Phoenix. And when I arrived in Phoenix, I discovered 

we were short 1,000 people and each primary care doctor had one 

clinical room. And in the private sector today, a primary care doctor has three clinical rooms. 

So we have an issue of both staffing, which the committee helped 

with the Choice Act, but we also have an issue on infrastructure. 


VACREP0180 with DISTILLER
11 

It is an old infrastructure. We have got women veterans and we 

don’t have the clinical rooms that are currently the situation today. 

In Boston, I would visit operating rooms where operating rooms 

are 35 percent smaller than they need to be. If you have an operating room which is 90 years old, they didn’t use robots or computers in operating rooms 90 years ago. We need that equipment 

today to be able to provide our veterans the best operating surgery 

that we can possibly do. 

Dr. Clancy. 

Dr. CLANCY. Yes. So just on the productivity issue which I think 

is incredibly important, we have a tool, and we have discussed this 

and briefed Representative Wenstrup, called SPARC where facilities can look at the productivity of different types of clinics understanding that it is both about what the clinician is doing about the 

space issues that Secretary McDonald just mentioned and also 

about the efficiency and capabilities of the people around them who 

are supporting those needs. 

That tool has been deployed system wide. We are right now examining some of the data quality issues and very importantly are 

having that externally reviewed. So we would be happy to come 

back and brief you in more depth. 

We think it is a good tool. At this point, it is more diagnostic 

than it is kind of in a place where we could give people grades, for 

example, but we also want to make sure that some of the best and 

brightest minds have taken a look at it, have kicked the tires and 

so forth so that we are confident as we measure productivity. 

And I just want to reinforce what the secretary just said a 

minute ago. Some of our clinics, some of the better clinics, it would 

bring tears to your eyes in terms of how well they are doing, but 

they are really, really landlocked. One room almost feels like a gift 

much less the two or three that you would see in the private sector. 

The Chairman. Ms. Brown. 

Ms. BROWN. Thank you, Mr. Chairman. 

Before I begin my questions, Mr. Secretary, I understand that 

you were down in Orlando last Wednesday meeting with the 

Nurses Association. Can you give us an update of how that went? 

And also you made an announcement about the opening of a hospital in Orlando. Can you give us an update on that also? 

Secretary MCDONALD. Yes, ma’am. 

I was in Orlando. I spoke to the American Nurses Association 

and I was there to tell them about how exciting it would be to work 

in VA today. And just like you and the chairman went with me to 

the medical schools in Florida to recruit, we were recruiting. We 

picked up quite a few people who were interested in coming to 

work for VA. 

The VA is the largest employer of nurses in the country and it 

is important. Our nurses are very important to us and they do a 

great job. So that is why I was there. 

Separately I did visit the Orlando hospital, Orlando Medical Center. There are now patients being seen. We are in the process of 

moving in. We expect to have a commemoration ceremony of sorts 

by Memorial Day. 

But between now and then, there will be new clinics being set 

up every single week there. It is a fantastic facility and I think the 


VACREP0180 with DISTILLER
12 

citizens of Orlando and the area of Florida will really enjoy going 

there. 

Ms. BROWN. Thank you. 

Dr. Clancy, it is a lot of discussion on this committee about, you 

know, we have doctors on this committee and they talk about the 

duties and responsibilities. It is a little different working with the 

VA because what we expect of the VA physicians is a little more 

comprehensive. 

When a person goes in, let’s say I am going into the podiatrist, 

but they can’t just go in and deal with a podiatrist. It is comprehensive. I mean, it is the blood pressure. It is a whole different 

casework. 

Can you explain that to us? 

Dr. CLANCY. So we believe that primary care and care for the 

whole veteran, if you will, is really the foundation of the system. 

So for the most part, we don’t have people just coming in for podiatry or for a hearing aid, for example, a very popular use of our facilities, without also checking some of their other risks to their 

health and so forth. 

We are taking a very, very hard look because our two overarching goals for this year are getting access right, whether it is 

within our facilities, whether it is virtually by telehealth or something like that, fee care, or with the Choice Program, that all of 

that is seamless, and our equally high second goal is exceptional 

veteran experience. 

We recognize that some veterans actually might choose to simply 

come in for podiatry and skip the rest. So we are going to be looking at different options for doing that by way of maximizing efficiency and, frankly, making the veteran experience very satisfactory. 

But in general, we have an incredible opportunity because of the 

entirety of the department to actually have an impact on health 

that no other healthcare system has because a lot of things affect 

health besides medical care. That is income. It is education. It is 

whether you have a place to live and so forth. 

And the department has tools through VBA and so forth to actually address all of those needs. So we take that very, very seriously. 

Ms. BROWN. The last question I have, what are we doing working 

with the Department of Defense as veterans transition to make it 

seamless and, you know, the bumps in the road? 

I just met a veteran who has been out two years and only ten 

percent disability. But the point is he can’t get his paperwork from 

DoD. What are we doing? And we have asked this question for 

years. 

Secretary MCDONALD. It is a great question. I have to say that 

Secretary Hagel and I are totally aligned that we want to have a 

seamless handoff from the Department of Defense to VA. That is 

why we have instituted programs like TAP while the person is on 

active duty. 

Maybe I will ask Allison to talk about that. 

Ms. HICKEY. So, Congresswoman Brown, some good news to report on this front, though it didn’t obviously help that particular 

veteran two years ago. 


VACREP0180 with DISTILLER
13 

We are actively engaged now in the mandatory TAP Program for 

all of our separating servicemembers including national guard and 

reserve for which there are now nearly a million who qualify for 

benefits that did not previously. 

Another thing that is starting literally right now is the mandatory separation health assessment. The choice to the veteran told 

at the TAP session is that if you are going to make a claim to VA 

for anything, then VA will do a complete separation health assessment on you top to bottom before you leave service so that we capture absolutely everything service connected right there on the 

spot. 

The next thing I will tell you is we have moved substantially forward with DoD on the new Haines System where they give us the 

complete service treatment record, all the parts and pieces we have 

talked about before that we used to call the gold standard. 

For a while there, the numbers of late ones were really high, but 

they have come down to now about 21 percent of them are overdue. 

So they are getting better and we are getting them faster. And we 

have built all the IT connections now such that we simply note in 

VBMS that we have got a claim. The system tells the DoD system 

we are asking for the records and then the records come back automatically into VBMS and are instantly loaded up into our VBMS 

system for the raters to do it. That has helped substantially. 

The last thing I will share with you that we have also done is 

we have reduced substantially those folks waiting in the IDES 

process and now are getting much better in our timeliness in the 

IDES process. 

And I can tell you also that the Benefits at Discharge Program, 

the backlog has been reduced by a significant amount. There is 

only about five or ten percent of those who are now over 125 days. 

Ms. BROWN. Thank you very much. 

And I yield back the balance of my time. 

The CHAIRMAN. Mr. Secretary, I just want to read a text that I 

just got from a friend of mine. Said had a reason to deal with the 

VA in Jacksonville this morning on a home we just finished for a 

veteran. A guy named X handled my request and was very efficient 

and friendly. I left the conversation warm and complete. Very good 

experience. Never had that before. Thank you. 

Secretary MCDONALD. Mr. Chairman, may I get the name so I 

can send a note of recognition? 

The CHAIRMAN. Yes, you may. 

Secretary MCDONALD. No, I am serious. I do that. 

The CHAIRMAN. Unsolicited. It just came in while I am sitting 

here. 

Secretary MCDONALD. As you know, I have given out my cell 

phone number publicly and nationally and I get about 120 contacts 

a day. And right now I would say 30, 35 percent are positive. That 

is not enough. All of us sitting here at this table want 100 percent 

of those to be positive and we are working on it. 

The CHAIRMAN. You bet ya. I will be glad to provide you his 

name. 

Ms. Brown. Mr. Chairman. 

The CHAIRMAN. Yes, ma’am. 

Ms. BROWN. You did say Jacksonville. 


VACREP0180 with DISTILLER
14 

The CHAIRMAN. Yeah, I did. 

Ms. BROWN. All right. 

The CHAIRMAN. Maybe that is why they never had a good experience before. 

Mr. Lamborn. 

Mr. LAMBORN. Thank you, Mr. Chairman. 

And thank you for being here, Secretary McDonald. 

I am pleased to see that you have focused a portion of your budget on construction efforts. Can you tell me the status of the southern Colorado National Cemetery Project and when you anticipate 

that they will begin accepting earlier burials? I am very concerned 

that this project stays on track. 

Secretary MCDONALD. We are as well. We are in the design 

phase right now and we think that design phase will take about 

a year, year and a half. 

Ron, would you like to provide more detail? 

Mr. WALTERS. Yes. 

Congressman Lamborn, as you know, we have made progress, 

significant progress on establishing the cemetery in southern Colorado. We acquired the 374 acres at Rolling Hills Ranch in El Paso 

County. We do have sufficient funds in the budget right now to 

complete the design, complete it through construction documents, 

the final phase of design. 

Once that is completed, we will begin the solicitation phase for 

construction of phase one. Assuming construction funds are provided in the next budget cycle and that is, you know, yet to be determined, we would expect the first burials to occur sometime in 

calendar year 2018. 

Mr. LAMBORN. Well, I am disappointed that the time line seems 

to be slipping. I will do everything I can to make sure that those 

funds are in the budget and I will work with other folks to try to 

achieve that, but it sounds like there has been some slipping to the 

right and that is disappointing. 

Secretary MCDONALD. We are going through a complete review 

right now of our construction management process. As you know, 

Sloan Gibson, the Deputy Secretary, is leading that. And we have 

asked the Corps of Engineers help. We have got to find a way to 

shorten these time lines that we face. And so we will be looking 

at that and obviously any work we can do to accelerate it, we 

would like to do. 

Mr. LAMBORN. And I will work with you if any amendments are 

necessary or any other legislative action to help you have the authority to make faster progress in the future on this or other 

projects. 

Changing subjects, Secretary McDonald, you mentioned that 

there are five proposed regions as opposed to 21 VISNs. I guess 

that is more efficient. Does that mean that you will have fewer personnel doing the same job as before which to me is a hallmark, a 

result of more efficiency? 

Secretary MCDONALD. Well, as I said in my remarks, this organization is focused on productivity improvement. We don’t feel like 

we can come to you and ask for more money unless we are demonstrating that we are saving money at the same time. That is why 


VACREP0180 with DISTILLER
15 

we have identified the buildings that are empty that cost us money 

every year. 

Think of nine different geographic maps, each one for a different 

line of business, whether it is insurance or disability—— 

Mr. LAMBORN. And I have one other question, so if you could just 

summarize. 

Secretary MCDONALD. Okay. It goes to five regions and we 

haven’t yet determined how many VISNs we will have, but they 

have to fit those five regions. 

Mr. LAMBORN. Okay. 

Secretary MCDONALD. And we have a team of directors looking 

at that now. Everybody is trying to fit into that structure. The 

point is there will be more efficiency at the middle management 

level. 

Mr. LAMBORN. Good. And I hope that means fewer people doing 

the same job which means less budget dollars going to personnel. 

Secretary MCDONALD. We are trying to put every budget dollar 

we can against the veteran experience—— 

Mr. LAMBORN. Okay. Thank you. 

Secretary MCDONALD [continuing]. Making the veteran experience better. 

Mr. LAMBORN. Thank you. 

And lastly, I know we have touched on this, but the transition 

between DoD and VA, and I have 100,000 veterans in my district 

and almost that many dependents and other family members. And 

the Military Compensation and Retirement Modernization Committee has just come out with recommendations. They have said 

there needs to be better transition. 

You have mentioned some things that you are working on. That 

is good to hear, but what can be done in the future, what could be 

improved to make that transition better? 

Secretary MCDONALD. We met with that committee throughout 

their work. I think they have done some excellent work. Some of 

the ideas that Allison mentioned are brand new and before that 

committee wrote its report. In fact, when they gave us the report, 

we mentioned some of these things and they missed the report. The 

report was already in printing. 

But this idea of the medical exam before the servicemember 

leaves the service, that is the biggest idea. And I think the problems that we have had in the past we will be able to resolve with 

that and also with the way we strengthen the TAP Program. So I 

think we are getting better, but we are going to continue to look 

and see if there are other things we can do. 

Mr. LAMBORN. Okay. Thank you so much. 

The Chairman. Ms. Titus. 

Ms. TITUS. Thank you, Mr. Chairman. 

Thank you, Mr. Secretary. It is nice to see you again. 

Secretary MCDONALD. Good to see you, ma’am. 

Ms. TITUS. We appreciate you being here. Before I ask kind of 

my general question, I am going to bring up what I always bring 

up and that is the Reno office. You know, we have been without 

a permanent director for about two years. We are on our second interim. 


VACREP0180 with DISTILLER
16 

I understand they haven’t started to recruit yet. But if you 

moved it to Las Vegas, it would be a lot easier to recruit a person 

to come and take that position. So that is my first point. 

Second, you know, the hospital built in Las Vegas was too small 

by the time it was completed because they didn’t anticipate the increased usage. We heard Deputy Secretary Sloan say they were 

going to move some resources to help with the hospital that is out 

from Denver, I believe it is, Aurora. I want to be sure that you 

aren’t moving any resources from the Las Vegas hospital to fix the 

problem in Aurora. So if we could just follow-up with that. 

Now, my general question is, for the last couple of years, we have 

focused on the backlog, fixing that problem and also problems with 

our hospitals. So I would like to see us as we move into the next 

two years look at other areas, of benefits and make the VA more 

relevant to our 21st century veterans. 

And I appreciated the things that you mentioned in your testimony. One is women, second is LGBT veterans, and third is the 

issue of medical marijuana. These are all big issues during these 

times. You talked about how many more women veterans you expect to have, but really what we don’t know is what we don’t know. 

And the Women Veterans Task Force recommended two positions 

that are data gathering positions so we can get a better handle on 

this, a performance analyst and a demographics and research analyst. So I would like to know if the VA is making those two positions a priority and if we have your commitment that those would 

be positions that would be funded and utilized. 

Second, I would ask you, Mr. Secretary, if you would commit to 

whether you think the law needs to be changed that prevents the 

VA from giving LGBT veterans the same benefits that other veterans get. They earned them. They deserve them. They just happen 

to live in the wrong state. I don’t think that is fair. 

And, third, with the medical marijuana, as more and more states 

are legalizing medical marijuana, VA doctors aren’t able to make 

any kind of recommendations concerning that. I wonder how VA 

policy might be moving to address that issue. 

Secretary MCDONALD. Thank you for the questions. 

First on women, I took down a painting in my office that had 

probably been on the wall since Omar Bradley was the administrator of VA and I put up a poster that says women in the military. 

And it has a picture of a woman in service in each branch of the 

military. And I did that on purpose because this is going to be a 

defining issue for those of us leading the VA right now. 

You already heard that our buildings are old. We need space to 

be able to create the women’s clinics. We just opened a women’s 

clinic here in Washington, DC, at our facility. I would encourage 

you to go see it. It is a beautiful clinic, but it is different than 

where the men would want to go. 

Ms. TITUS. Yes. 

Secretary MCDONALD. And, of course, the care is different because we have gynecologists and other kinds of care. So this is a 

very important issue for us and we are working very hard to identify where can we put women’s clinics with women care. 


VACREP0180 with DISTILLER
17 

We just got a building from DoD in Fort McPherson, Georgia, 

where we have set up a women’s clinic. This is a very big issue for 

us and we are going to stay after it. 

Relative to LGBT, we are following the law. You know, if the 

couple is married in a given state, we will give them benefits. We 

need a new interpretation in the law or a change in the law. We 

are following the law. 

There is an exception to that. In national cemeteries, if we are 

able because of the legal authority I have to be able to bury partners together when they so choose, and in every case that we have 

done that, we have looked at the relationship and we have granted 

that, so—— 

Ms. TITUS. If I may interrupt you. I appreciate that. But in state 

cemeteries, it still remains a problem as I understand it. 

Secretary MCDONALD. Yes, ma’am. I don’t control those. 

Ms. TITUS. Yeah. But they get funding from the VA, the 

state—— 

Secretary MCDONALD. Some. Some. 

Ms. TITUS [continuing]. Veteran cemeteries. 

Secretary MCDONALD. Some. 

On the medical marijuana, let me ask Dr. Clancy to comment. 

Dr. CLANCY. Sure. So a fair number of our clinicians have veterans who use marijuana, I will put it medically in quotes. They 

live in areas where this is legally possible and so forth. It is very, 

very early for us to have medical policies, but there are active discussions going on now and trying to learn from what we know 

about treating it for different conditions which, by the way, are not 

necessarily identical with those conditions for which veterans believe that they are helpful. 

I actually think that there is an incredible opportunity for us to 

learn from some of those experiences, but I think that we have to 

be careful given the variation in legal issues. But we would be 

happy to provide more detail for the record. 

Ms. TITUS. Thank you. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you. 

I yield to Ms. Brown for 30 seconds. 

Ms. BROWN. Yeah. On the area of medical marijuana, we have 

constantly passed the bill saying that the VA doctors cannot administer even if the state in the area says it is legal and they could 

be charged with a felony. So it passed last year on the floor. I 

didn’t vote for it. And it is an issue for Congress. I mean, so if you 

feel strongly about it, then I think maybe you should introduce a 

bill. But as we speak, it is illegal for a VA doctor to administer 

marijuana. 

Dr. CLANCY. Yeah, that is correct, Representative Brown, and I 

was not clear enough on that point. That said, again, trying to be 

responsive to veterans’ experiences and what they are telling us. 

We are trying to learn from that and understand and anticipate 

what a different future might look like. 

Ms. BROWN. Oh, absolutely. There are all kinds of additional 

kind of therapy, but as we speak now, it is illegal for a physician 

to administer it. Am I correct? 

Dr. CLANCY. [Nonverbal response.] 


VACREP0180 with DISTILLER
18 

Ms. BROWN. And last year, we passed a bill on the floor saying 

it was illegal for a VA physician. 

I yield back. 

The CHAIRMAN. Thank you. 

Mr. Bilirakis. 

Mr. BILIRAKIS. Thank you, Mr. Chairman, very much. Thank 

you. 

First of all, I wanted to thank you, of course, Mr. Secretary, first 

of all, for taking the position and being so accessible to us, but 

more importantly to our veterans. And, again, you have made a 

great deal of progress and we want to help you make more 

progress, so thank you for your cooperation and we are here for 

you. 

First of all, I have some questions with regard to lease authorizations. First of all, I want to thank you for working with me to ensure veterans and community stakeholders in my area are being 

engaged regarding the Pasco County lease consolidation located in 

central Florida. 

To ensure the success of its utilization, it is important that their 

opinions on potential locations and what specialty services should 

be offered are considered. I know you agree. 

I am pleased to hear that there will be a potential site visit. Can 

you give me an idea of when that might be? 

Secretary MCDONALD. Our staffs are meeting. They met this 

morning actually. So I don’t know the outcome of that meeting, but 

I think it should be imminent, tomorrow or the next day. 

Mr. BILIRAKIS. Thank you. 

Again, is there something we can work with you on to expedite 

the activation of these leases in general, the leases in general? I 

am talking about the 27 leases that were authorized last year. 

Secretary MCDONALD. Right. As I said, Sloan Gibson, our Deputy 

Secretary, is going through a process right now to understand how 

can we speed up our ability to design, lease, construct. And as we 

go through that, if it looks like there is an opportunity for legislation, we will come back to you and ask you for your help. Right 

now we are not ready for that, but we are taking a close look at 

it. 

Mr. BILIRAKIS. All right. My next question has to do with the future lease authorizations. I understand that there is an issue between VA and GSA with future lease authorizations, not the 27 

that were authorized last year. 

Can you discuss what options are being considered and if there 

is enough requested in the budget, should funds for the full extent 

of the lease be required? It is so very important that we plan 

ahead. 

Secretary MCDONALD. I will start and then maybe Helen can 

help. 

At one time, over a year ago now, we had a blanket lease authorization from GSA which would allow us to enter into leases quickly, 

easily with our authority. That has been revoked and it requires 

us to go to GSA for them to study our leases. In some cases, if the 

cost of the lease exceeds, I think it is $2.85 million, then they actually have to take it to a committee which takes even more time. 


VACREP0180 with DISTILLER
19 

They have been very helpful. We have been working with them 

to speed up the process, but we are also trying to see if there is 

a totally different way that we can do it. We are applying Lean Six 

Sigma technically to see if there is a way we can improve the process even more. 

Helen. 

Ms. TIERNEY. GSA has been working very cooperatively with us. 

We are working on getting those processes right and making sure 

that we all are working under the same standards for scoring. So 

I think that is progressing well right now. 

Mr. BILIRAKIS. Okay. Very good. 

Anyone else. 

[No response.] 

Mr. BILIRAKIS. Thank you very much. 

I do want to discuss with you in the future, Mr. Secretary, expanding dental healthcare for our veterans within the VA and 

some of the clinics. 

But I yield back at this time. Thank you, Mr. Chairman. 

Secretary MCDONALD. We would be happy to do that. 

Mr. BILIRAKIS. Thank you. 

The CHAIRMAN. Ms. Kuster, you are recognized. 

Ms. KUSTER. Thank you very much, Mr. Chairman. 

I want to start by commending you, Secretary McDonald, for the 

efforts that your team has done to settle the lawsuit out in west 

Los Angeles. 

We had a hearing yesterday in the Oversight and Investigation 

Committee and we had a discussion about the steps that will be 

taken. 

A couple of things in follow-up and I will be working with our 

subcommittee chair, Mr. Coffman. But one is we want to stay in 

very close touch with your team about the plan for the west LA facility, particularly addressing homelessness of veterans in west LA, 

and then we have suggested to have a follow-up hearing next fall 

when you come back with your report so that we can stay closely 

engaged with that. 

Secretary MCDONALD. We would love to do that. I think what we 

demonstrated in west LA more than anything else is this is a team 

sport and we all need to play together on the same team. And it 

is just silly to think that we have a national issue with veterans 

being homeless. And in the city with perhaps the largest homeless 

population in the country, we had a lawsuit going for four years 

that prohibited us from making progress. 

Ms. KUSTER. Yeah. And the representative from The American 

Legion said it had been 30 years that they have been working on 

this problem which obviously goes through a number of administrations, so—— 

Secretary MCDONALD. We got the land in 1880 something. 

Ms. KUSTER. 1888, yeah. I wanted to go to the opposite end of 

the country to my district in New Hampshire and talk briefly about 

the Veterans Choice Program. My colleagues in the Senate, Senator 

Ayotte and Senator Shaheen, have introduced a bill to make sure 

that the Veterans Choice Program, whatever happens elsewhere, 

will continue in the states that do not have a full service VA hospital. 


VACREP0180 with DISTILLER
20 

This is critical for us because we have got folks that, and I know 

they don’t travel the distances that my colleague, Beta O’Rourke’s 

constitutes travel, but with weather and such particularly of late, 

that is important. 

Can I ask about how the Veterans Choice Act is working in those 

states? And you mentioned briefly about hiring new physicians and 

medical personnel for filling the gap. I am particularly interested 

in mental health provider and if you could comment on that, it 

would be very helpful. 

Secretary MCDONALD. First of all, I want to make sure that we 

are clear that the leadership of VA believes that the system of the 

future will be a network of both VA and outside care. Already we, 

in the last year, we did about 550 million appointments in outside 

care. That was up 48 percent above a year ago. So that is even before the Choice Program. 

So we are believers in that because that is the way our veterans 

will get served the best. It was misinformation. There was never 

intent to either gut the Choice Program or somehow eliminate the 

Choice Program. It was simply I was asking for recognition that we 

have 70 line items of budget that we can’t move money from. 

Imagine your household. You have a checking account for gasoline. You have a checking account for groceries. The price of gasoline goes down by half. You are hungry, but you can’t move the 

money from the gasoline account to the food account. Well, that is 

the situation I face. I am trying to serve veterans and I don’t have 

the flexibility to do that. I ran a relatively large business. You 

know, it is very hard to achieve customer satisfaction when you 

have all these strictures and restrictions on how you can take care 

of customers. So that was the only point I was making. 

The Choice Program is a good program. It is very early days. As 

I said, we have had nearly 500,000 calls and about 24,000 appointments, but we are going to be watching it very closely every single 

day and we will let you know what we see. 

Ms. KUSTER. Yeah. Again, that is something that I would assume 

the Oversight Committee would want to stay in close contact. 

Secretary MCDONALD. We invited over, and I will make this invitation to everyone, we invited over Congresswoman Brown, Chairman Miller. They came over. They went through our daily—we 

have something we call a daily standup. It is a Lean Six Sigma 

technique. We review the data from that day and you make 

changes to the next day. 

Deputy Secretary Gibson leads it. And I would invite any Member to come over and watch us do that. I would argue that it might 

give you confidence in the data that we are giving to you and you 

can also see the trend lines. 

Ms. KUSTER. Thank you very much. My time is expired. 

Secretary MCDONALD. You are welcome. Thank you. 

Ms. KUSTER. I yield back. 

The CHAIRMAN. Mr. Coffman. 

Mr. COFFMAN. Thank you, Mr. Chairman. 

Mr. Secretary, in the budget submission for the Office of General 

Counsel, you list as recent accomplishments, and this is a quote, 

‘‘Defending against complex litigation such as the construction 


VACREP0180 with DISTILLER
21 

projects in Orlando and Denver,’’ end quote. How is that a success? 

You lost that case on every single point. 

For the hospital in my district that is hundreds of millions of dollars over budget and years behind schedule and the only way the 

construction could continue was that the general contractor demanded that the VA construction management personnel be kicked 

off the project and that the Army Corps of Engineers come in and 

take over the project. 

And so, you know, I think that is just characteristic of your 

glossing over the extraordinary problems confronted by your department. This is a department mired in bureaucratic incompetence and corruption. 

And I have got to tell you I think the public relations is great 

today, but there is no substance. There is no substance. And I—— 

Secretary MCDONALD. I am highly offended by your comments, 

Mr. Coffman. 

Mr. COFFMAN. Let me finish first because I fundamentally believe that as unfortunate as it is that at the end of the day, at the 

end of this President’s term that you will not have made a difference in changing the culture of this organization by virtue of the 

fact that you continue to gloss over its problems. 

Secretary MCDONALD. I am offended by your comment. Actually, 

I have been here six months. You have been here longer than I 

have. If there is a problem in Denver, I think you own it more than 

I do. 

I found it ironic that when I went out to LA to solve a four-yearold lawsuit, you were busy calling for a hearing to discover what 

happened five years ago. I am working on the future, sir, and I am 

going to correct the past. But I am working on the future because 

that is what our veterans want. 

Mr. COFFMAN. For you to say that you are going to the Army 

Corps of Engineers to advise you as to how to correct the extraordinary problems, let me tell you I think what you need to do is 

focus on providing the healthcare benefits and the other benefits 

that veterans have earned and get out of that construction management business and to cede it to the Army Corps of Engineers. 

Secretary MCDONALD. We know that is your point of view 

and—— 

Mr. COFFMAN. Each major construction project is hundreds of 

millions of dollars over budget and years behind schedule. That is 

a problem. 

Secretary MCDONALD. I think we work very closely with the 

Corps of Engineers. General Bostick is a good friend. He has also 

been very helpful. He has told us he does not want total responsibility for all of VA’s construction. 

We are going to work with him. We are going to find out the 

right balance of that. We are doing it in Denver, as you know, and 

we appreciate your help to get that building finished and get it finished for a good value for taxpayers. 

Mr. COFFMAN. I hope you can make a difference. I hope you can. 

Secretary MCDONALD. I would just say maybe if you want, I will 

give you my cell phone tonight and you can answer some of the 

calls and see if I am making a difference for veterans and see what 


VACREP0180 with DISTILLER
22 

they say or go on the Web sites, see what the veterans are saying 

on the Web sites. Ask the VSOs in the next group. 

Mr. COFFMAN. The fundamental challenge—— 

Secretary MCDONALD. I run a large company, sir. 

Mr. COFFMAN. The fundamental challenge is for this organization 

to reflect your values and I am not sure that that is going to happen. And I hope that it does. 

Secretary MCDONALD. I want your help to do that. 

Mr. COFFMAN. Mr. Chairman, I yield back. 

Secretary MCDONALD. I need your help. 

The CHAIRMAN. Thank you, Mr. Secretary. 

Mr. O’Rourke. 

Mr. O’ROURKE. Thank you, Mr. Chairman. 

Mr. Secretary, let me begin by thanking you for your service. I 

have only been in Congress a little over two years. But in that 

short time, I really feel that you personally have set a new bar for 

leadership and accountability and responsibility for the problems 

that you encountered that you are turning around and, in fact, facing the future so that we build a better VA and do better for the 

veterans whom we serve. 

Case in point, two days after the tragic murder of Dr. Fjordbak 

in El Paso, Texas, you were there on the ground meeting with VA 

leadership, the incredible staff that works under Mr. Dancy. You, 

in fact, ensured that we had Mr. Dancy there to begin with. You 

replaced leadership and ensured that we had someone there who 

could be transformational and that is what we need in El Paso 

right now. So I want to thank you for that. 

I also want to thank you for your willingness to work with us to 

do better in El Paso. I mean, again, no need to focus on the past. 

We are not a top-tier performer. We want to be and I want to figure out how we are going to do that. 

To some of the points that Mr. Coffman just raised and a, you 

know, six or eight hundred million dollar facility now projected to 

be $1.1 billion or 1.4 at the high end, we can’t do that anymore. 

In El Paso, we have partners like Texas Tech and the four-year 

medical school there, University Medical Center, the public hospital, private providers, Tenet and ACA, all of whom are desperate 

to work with us. 

I would like your commitment that we are going to in the short 

time that we know that you have within this administration, 22 

months, put together a plan and get it to a point where it is 

unstoppable so that should we be lucky enough to have you as secretary in the next administration or your successor will be able to 

work with us to implement that. 

Can I have that commitment from you publicly to work with me 

on that? 

Secretary MCDONALD. As you and I talked when we were there 

and we went to the Texas Tech site, what we want to do in El Paso 

is exactly what we did in Los Angeles which was we got everybody 

together. We looked at all the options and we are going to make 

the decision together. We are going to work together to get this 

done. 

This is a team sport. We can’t do it by ourselves and we know 

that. And so I look forward to working with Texas Tech. I look forVerDate Aug 31 2005 13:32 Mar 15, 2016 Jkt 000000 PO 00000 Frm 00026 Fmt 6633 Sfmt 6633 Y:\98-570.TXT PAT

VACREP0180 with DISTILLER
23 

ward to talking to Department of the Army because, as you know, 

currently our facility is connected to Beaumont, but Beaumont is 

closing. But, yes, we will work together to develop a plan for El 

Paso. 

Mr. O’ROURKE. Thank you. 

And I also want to thank you for the presentation you made at 

the outset of this meeting. I think you placed our current problems 

in context. And they, not all of them, some of them originate in the 

VA, but the wars that we choose to engage in, and you mentioned 

that, you know, hopefully we are at the conclusion of our commitment in Afghanistan and Iraq and we are going to peak in terms 

of commitments to those veterans in 2055. 

I would argue the point that we are still at war in Afghanistan. 

We have 10,000 servicemembers there whose lives are on the line. 

The NATO commander says expect more U.S. casualties. We are 

about to consider an authorization for the use of military force in 

Iraq and Syria. We are and have been in a state of perpetual war 

and there is a cost to that beyond sending the servicemember over, 

funding the assets that follow him or her. It is the cost to care for 

them and their family and their children when they return. 

And I just hope that we are all keeping that in mind as we go 

forward. There is a much larger cost than the immediate one that 

we consider. 

The Veterans Choice Act passed this August included a component to assess VA healthcare processes and it was supposed to be 

an independent assessment. 

What do you have in this 2016 budget that would fund implementing the findings from those assessments, if any? And I don’t 

know when that assessment is supposed to conclude. 

Dr. CLANCY. Thank you, Representative O’Rourke. 

As you said, the Choice Act actually has required a number of 

assessments which, frankly, we think are an incredible gift. 

I last weekend spoke to a Blue Ribbon panel that they have assembled who will take a look across all of the assessments. They 

will be finished their work by this August and are working very, 

very hard, weekends, evenings, whatever they need to make sure 

that that happens. And they are looking at all aspects of our operations. 

Mr. O’ROURKE. You have dollars in this budget to implement the 

recommendations that are made? 

Dr. CLANCY. I don’t think that we have explicit dollars. I think 

what we have is we expect that this will be a core part of management and how we do business. And we are providing them with all 

of the data that they need to actually make the recommendations 

as actionable and relevant to VA as possible. So we are very much 

looking forward to those. 

Mr. O’ROURKE. Okay. My time is expired, but I would love to follow-up with you on that—— 

Dr. CLANCY. Great. 

Mr. O’ROURKE [continuing]. To find out what that might cost. 

Thank you. 

Thank you, Mr. Chair. 

The Chairman. Dr. Wenstrup. 

Dr. WENSTRUP. Thank you, Mr. Chairman. 


VACREP0180 with DISTILLER
24 

And thank you all for being here today. 

If I may, I am going to go back to something I touched on briefly 

the last time that we met and that is what we actually spend for 

the care that is delivered. 

And I had asked about knowing the number of how many RVUs 

per year does the VA generate with their caregivers, the relative 

value units. And that is a common term used both in private sector 

and in the VA, and then what the total cost is. And then by total 

cost, I don’t mean just what the doctor is getting paid, but you are 

including everything, administration, physical plant. 

And Mr. Gibson said, oh, we are a long way from coming up with 

that number. And my question is, how do you come up with a 

budget if you can’t say what that number is today? So how much 

did we spend on everything to do with healthcare per RVU that 

was generated? 

And so I am curious why we can’t come up with that number for 

one because I wonder sometimes when we look at Choice, are we 

really determining is it more cost effective and a patient benefit in 

some regions to refer out rather than build out, you know? 

And because the cost per RVU to the outside doc is pretty easily 

defined. You know what you paid that doctor, but that doctor is 

then paying for their physical plant and their staff and their malpractice and all those other expenditures. So that is pretty well defined, but we are not being realistic if we don’t look at the overall 

picture of what we are spending per RVU. 

So if you could comment to those issues. 

Secretary MCDONALD. As Sloan said, that is a system we have 

to develop. We are in the process of doing that. It is not perfected 

yet. The numbers aren’t as valuable yet. 

The department has had a history of working to a budget. It has 

not worked to a demand or to a customer focus. As a result of that, 

Congress would provide a budget and that is what the department 

would work toward. That budget would be allocated throughout the 

department. 

So we are actually, contrary to what Congressman Coffman 

thinks, we are actually making some relatively large changes here 

to focus the organization on the customer and to be able to get that 

data. 

Dr. Clancy can talk about the process of doing that, but this is 

a big undertaking. 

Dr. WENSTRUP. So if we know what the budget is for all the 

health administration costs and what that is, can’t that give us 

something to start with? In other words, I feel like we need a baseline. We can start to look at that more closely at different facilities 

as we project out. 

I am looking down the road, you know. I am here for the same 

reason I think you are, is to make a difference and to make good 

decisions, but we have got to come up with those numbers because 

you can’t decide if Choice is working better or worse and effectively, especially when it comes to the dollars. 

Secretary MCDONALD. Yeah. 

Dr. CLANCY. Thank you. 

That is part of the independent assessments that we will be getting as well. One of the wild cards here that I am sure you are 


VACREP0180 with DISTILLER
25 

quite familiar with in terms of comparing how efficient and productive we are, cost per RVU versus the private sector is that there 

is a big difference in terms of fixed costs versus variable costs. 

If you have got a building where you have to keep a cafeteria 

running and all that kind of stuff, that is the point that was in the 

overall opening statement from Secretary McDonald. In the private 

sector, they have got a lot more flexibility. 

But we will be looking at that very, very hard because as we look 

to a future where, as Secretary McDonald said a few minutes ago, 

it is going to be both about what we provide in VA as well as what 

we send out to community partners through non-VA or fee care and 

Choice and so forth or something like it possibly with a different 

name. 

We have got to be very, very smart and as strategic as possible 

about make or buy decisions and—— 

Dr. WENSTRUP. Well, I look forward to seeing those types of numbers because that has got to be our guide—— 

Dr. CLANCY. Yes. 

Dr. WENSTRUP [continuing]. As we try to decide what is best for 

the veteran and the VA itself as we go down the road. 

Dr. CLANCY. Absolutely. And those answers are probably going to 

be different in some communities than in others depending on local 

capacity and so forth. 

Dr. WENSTRUP. Sure. No, I think you do have to evaluate locally, 

but you can start with what it is in the big picture—— 

Dr. CLANCY. Yes. 

Dr. WENSTRUP [continuing]. And then take a look locally, because 

every place is going to have a little different demand based on VA 

population, et cetera. So I look forward to working with you on that 

and, thank you, I yield back. 

Dr. CLANCY. Great. 

The Chairman. Mr. McNerney. 

Mr. MCNERNEY. Well, thank you, Mr. Chairman. 

Hey, I am really glad to be back on the committee. I was here 

for three terms starting with the 110th Congress. It is a pleasure 

to be back. 

I want to thank you, Mr. Secretary and the Under Secretaries for 

your dedication. This is an enormous challenge, as you pointed out 

in your opening remarks. A lot more service is required, a lot more 

veterans seeks help and so on. So, I think we are making progress, 

but there is still a long ways to go. 

My first question will go to Ms. Hickey, who I have had that lot 

of dealings with in the past. I would like to just give a brief update 

on the backlog, specifically focusing on some of the California ROs 

who had such a problem a few years ago, and please kind of be 

brief, if you would. 

Ms. HICKEY. Absolutely. So let me just start, for all of you, the 

backlog is down nationally sixty-two percent and we are on target 

to hit our 2015 goal. 

Our productivity is up 25 percent, per FTE. We are producing 

now, at the claim’s perspective, 47 percent more than we did before 

we started this transformation effort; a 101 percent from a 

claims—from a medical issues’ perspective. 


VACREP0180 with DISTILLER
26 

Our quality, we have not traded for; in fact, it is up eight percentage points at the claim level at 91 percent, and at the medical 

issue level, it is now up at 96 percent. 

What I will tell you—a non-rating, by the way, we have not put 

off non-rating; we just have a lot of it, it is volume, it is need. 

When we do more regular, you know, first-time claims, it opens the 

door to more follow-on non-rating opportunity for our veterans. So, 

by exactly, when we did record breaking, never done in our history 

before, at 1.32 million claims last year, and as you saw on the 

chart, the disability level is now on average at 47.7 percent, you 

have a wider opportunity for many more veterans to get that additional benefit as well. 

Oakland, since we last saw you here in the room—glad to have 

you back, Congressman—phenomenally much better. Their backlog 

is down 67.3 percent. Their quality is up at 90 percent on issue 

basis and they are doing much better than they were. They also 

have done much better on the mail issues, which we are doing nationally, so I thank this whole Committee, both now for the funds 

that you have invested in centralized mail. We are really starting 

to see the benefit of that, moving mail timeliness down from 32 

days down to eight days; that is a phenomenal saving to our veteran, in getting that mail associated with that client. 

Mr. MCNERNEY. Okay. Well, you know President Reagan had a 

saying, ‘‘Trust, but verify.’’ I am really glad to hear these numbers, 

and you know that we are going to be looking into them to be sure. 

Ms. HICKEY. Absolutely. 

Mr. MCNERNEY. Thank you. 

The next question goes to Mr. Secretary. Following up on Mr. 

Bilirakis’ questioning, I would like you to comment a little bit on 

meeting construction challenges. You said in almost a quote that 

the VA is not ready for legislative help on this issue. But I would 

like to see if you think private partnerships would be beneficial in 

moving forward with the construction backlog or where do you 

stand on that sort of issue? 

Secretary MCDONALD. First of all, as I said in my remarks, on 

my VA, strategic partnerships is one of the five planks. This is a 

really big deal. Historically, VA has not had as many strategic 

partnerships as had been possible, and one of the first things I 

found as secretary is I had a lot of people willing to offer help that 

we did not accept. 

So we set up an office of strategic partnerships. We have somebody leading it. They came from the private sector. We are hoping 

to making good progress there. 

Secondly, relative to construction, a lot of changes have been 

made over the years, probably since the last time you were on the 

committee. Number one, originally, a lot of the times, the design 

was done by architects. Engineers have now been added to the design committee and there is a whole design committee now that reviews it. 

Many of the structures that we are building now, frankly, as an 

engineer—I am an engineer—I would not have built, because they 

are architects’ dreams, but they are very expensive and they will 

be very expensive to operate. 


VACREP0180 with DISTILLER
27 

Secondly, we have looked at that entire process. We are training, 

do a better job of training the project managers. We will implementing GAO recommendations, about how to make the process 

more efficient. So there are a number of steps being taken. 

As Congressman Coffman said, we are now also working with the 

Corps of Engineers and we have asked them to do a complete review for us from A to Z of our process and see if we can improve 

it, as well as what part of the process could they help us in. 

Mr. MCNERNEY. Well, thank you. 

On a parochial issue, in the French Camp Project there is been 

some temporary structures put up, but some of the basic requirements such as disability-accessible bathrooms have not been met 

yet, even though the project has been up there for more than year. 

Can I get your commitment to take strong action to make sure 

that those basic requirements are met, sir? 

Secretary MCDONALD. We will get into that. 

Mr. MCNERNEY. Thank you, Mr. Secretary. 

Secretary MCDONALD. Thank you. 

The Chairman. Dr. Abraham. 

Mr. ABRAHAM. Mr. Secretary, first, if you for your effort and your 

attitude, and that of your staff, for trying to help our veterans, as 

great as they are. 

Two quick questions. One, on the—we have hit this before on 

some of the electronic health record issues, the VA budget states, 

and I will quote this, ‘‘In addition to VistA improvements, the VHA 

2016 investment supports our commitment to achieve interoperability with the Department of Defense electronic health record and 

community health care providers, including those who are participating in the new Veterans Choice Program.’’ 

My question is this: With a 136 percent increase in EHRs and 

VistA funding from fiscal year 2015 to 2016, and given your stated 

emphasis on making seamless transition possible, can we now expect to see third-party administrators and non-VA providers get access to these systems? 

Secretary MCDONALD. Let me talk on the high level and then I 

will ask Steph to talk about specifics. 

Mr. ABRAHAM. Okay. 

Secretary MCDONALD. I believe that the electronic medical record 

that will win in the future will be a record which is open-source, 

free to everyone—— 

Mr. ABRAHAM. Right. 

Secretary MCDONALD [continuing]. As well as crowd-sourced in 

terms of the innovation. Crowd-sourced innovation occurs in a 

much more rapid pace than any company with protect their own 

innovation rate. So our record is open-source. It is crowd-sourced 

in terms of innovations. We get innovations back—I was at the 

AMA convention talking about the importance of private sector providers using our record so we could do a really warm handoff of our 

veterans to the private sector and back under the Choice Program. 

Mr. ABRAHAM. Is that working pretty good, the warm handoff? 

Secretary MCDONALD. It is early days. It is early days. But we 

have more work to do to make sure that the veteran’s record is 

there when they get there and to make sure that we get the annoVerDate Aug 31 2005 13:32 Mar 15, 2016 Jkt 000000 PO 00000 Frm 00031 Fmt 6633 Sfmt 6633 Y:\98-570.TXT PAT

VACREP0180 with DISTILLER
28 

tations back from the doctor in the private sector who works on 

them, and that is part of the work that we are doing. 

Mr. ABRAHAM. You know, heretofore, some of the private providers were getting the veteran’s health records, but it was the entire record and sometimes it was hundreds and maybe even thousands of pages—— 

Secretary MCDONALD. Yes. 

Mr. ABRAHAM [continuing]. Whereas that provider only needed 

maybe the last discharge summary, and it would have taken two 

to three hours to get through that stack. 

So we need something certainly more seamless, certainly more 

efficient—— 

Secretary MCDONALD. Yes. 

Mr. ABRAHAM [continuing]. For the outside Choice providers. 

Secretary MCDONALD. In a sense, the good news is that we need 

that interoperability too, with DoD, too. 

Mr. ABRAHAM. Right. 

Secretary MCDONALD. So we need the interoperability back and 

we need it forward, and Steph can talk about the steps that we are 

taking. 

Mr. WARREN. Thank you, Mr. Secretary. 

If I could submit for the record, actually, four charts that walk 

through what is the sharing that we are doing today? 

[Chart] 

The CHAIRMAN. Yes. 

Mr. WARREN. And it includes sharing with third-party providers. 

So we have 31 partners, UC Davis Medical Systems in terms of 

where we are sharing data already. There also is a way of sending 

the email as—or sending the information to the third-party provider as an email. 

The other piece that we are doing, to recognize your point about, 

we would send the full medical record. 

Mr. ABRAHAM. Right. 

Mr. WARREN. We are taking the Janus Viewer which shows a VA 

record and the DoD record together and we are going through and 

modifying it so we can actually provide that to the third-party provider. So when we send the veteran out for that third-party care 

or through Choice, we are able to send a URL. The provider can 

click on the URL and the record comes up. 

Mr. ABRAHAM. Do you have a timeline when this might—is this 

going to happen within six months? Twelve months? 

Mr. WARREN. Again, these documents are what is happening 

now. It will give you the record in terms of using the existing systems. The one where we are sending the provider a link so they 

can look at, we are about a year away. 

Mr. ABRAHAM. Okay. 

Mr. WARREN. Because we need to make sure when we do it—we 

have a Choice issue with respect to veterans opting in to us sharing that information to somebody outside of the system, and that 

is one of the systems that we are working through programatically. 

So, the technology piece, the team is looking at it. We are using 

the viewer that we deployed last year to add in the capability out 

to third-party providers. 


VACREP0180 with DISTILLER
29 

Mr. ABRAHAM. Okay. My second question real quickly, because 

my time is limited, going back to the efficiency of the providers, 

whether it be a physician, a PA or an NP, and I understand the 

limitation of space being one or two exam rooms, but even with 

that, is there a measurement for a provider on a daily basis that 

we can access or you can access and give it to us that shows how 

many patients they are seeing a day? Like Chairman Miller said, 

two patients a day, even with one exactly room is not anywhere 

close to being acceptable. As a physician, I know what one exam 

room can see during a day. And I understand the complications 

that VA patients have, as having multiple-organ system issues, so 

can you address that, please? 

Mr. WARREN. The answer is and I will let Carolyn talk about it. 

Dr. CLANCY. So, the great news, and as a few of you got to see 

last weekend, the secretary invited anyone else who wants to come, 

we literally go over these data every single morning, so it is much 

more visible how many patients per day providers are seeing. Understand that some of our providers are also teaching or doing research and so forth, but we have to be as transparent about all aspects of that as possible. So this entire exercise not only gives us 

close to realtime information—and we post this publicly every two 

weeks, in terms of—— 

Mr. ABRAHAM. Are we doing anything with the information? 

Dr. CLANCY. Yes. 

Mr. ABRAHAM. Are we incentivizing or maybe—and punishment 

is the wrong term—but if that physician or that provider is not 

pushing himself a little bit, are you guys pushing him or her a little bit more? 

Dr. CLANCY. I think the word would be ‘‘motivating.’’ 

Mr. ABRAHAM. That would probably be a better word. 

Dr. CLANCY. Yes. Yes. 

Secretary MCDONALD. Given the issues on access, that is not a 

problem. Everybody is looking at this data locally and regionally 

and nationally because of our issues on access. 

Mr. ABRAHAM. Okay. Thank you. 

The Chairman. Mr. Walz. 

Mr. WALZ. Thank you, Mr. Chairman and Ranking Member, and 

thank you for the opportunity to be back on this committee. It truly 

is one of the greatest honors that I have experienced in my life. 

Mr. Secretary, thank you for being here for numerous reasons. 

I say thank you as a veteran. I am glad to know you are there and 

that means a lot. 

I think this room, when I look around, I mean back here, is filled 

with some of the most honorable, patriotic and professional people 

I know, at this table, those behind you, the VSOs, members here. 

I have to say it is certainly somewhat objective, but over the last 

year we have had difficult conversations, all of us, and we have 

worked closely together. They were difficult because all of us understood the implications of our actions impacted veterans, and if 

it was Phoenix or wherever—but trying to find solutions. 

And I can say from my experience, and I think it is the one that 

you are hearing here, the professionalism and the willingness to fix 

this amongst this team has been greatly gratifying, and I say 

again, maybe subjectively, but it feels to me like for the first time 


VACREP0180 with DISTILLER
30 

in a while, the Department has its feet back under it. That this 

idea of moving towards solutions—and it is not that we will ever 

going to stop having accountability of where we are going to stop, 

whether it is problems as they bring up, but trying to find those 

solutions. 

So I, for one, accept that and I believe that your challenge is 

right; we all are in this together. We have responsibilities to get 

this. And when we bring up these things, these parochial issues, 

those are the things that our constituents are talking about. Those 

are the things. 

But I go back to what you said, Mr. Secretary, I do believe this 

is a unique opportunity for transformational change, and this window will close over a certain amount of time, just the nature of politics and everything else that goes with it, so I think we need to 

seize on it. The feeling I have gotten is that there is a desire. 

And I can tell you from the folks that work out there—and I just 

came from a meeting with a group of your fantastic VA nurses and 

they are committed. They want to get this right. Their morale is— 

I care about that, because if we freeze their pay and we hammer 

them and we tell them that the VA is not working, they know that 

is not true in the cases where they are out there on every case. So 

I think when we hear from them, I hear this feedback, I hear from 

the different groups and we try to get it right. 

And I just wanted to go on, on this providing solution things, 

that I think there are new ideas out there. I think this new model 

is starting to get there and I want to tie it all together. When I 

first got here eight years ago, the first thing I worked on was 

VHA’s pain management issue, and this comes back to me again 

and again, mainly because it ties in on so many levels of veterans 

care, especially mental healthcare. 

And I think it is timely in that yesterday we signed in and tomorrow it will be signed by the President, the Clay Hunt Bill 

which is—we recognize one step. I recognize the incredible work 

that is already being done at VA, but I think it might be a new 

way at looking at this, a new approach, and it ties in with, again, 

why we bring these solutions and why we want to interact with 

you is, is the Tomah situation with the opiates. These are all connected. And I agree with you, if I had been here eight years and 

Tomah’s in my area of operation, I own some of that, and I get 

that. 

So what I ask is, when we provide and we move forward on 

something like Clay Hunt, if we figure out a new model on how 

that Act is going to—and before we wait for it to run its course, 

we correct and self-correct. So I know it is a—I am throwing it out 

to you because I, for one, have bought into your vision of transformation. I, for one, want to be that partner and I, for one, want 

to make sure that I didn’t pass a piece of legislation that added 

more to your plate and didn’t improve the care of veterans. 

Secretary MCDONALD. We are very much in favor of the Clay 

Hunt act or the SAV Act, as it is called. We partnered with everybody who wants to do it. We are very much in favor of it. 

I had the opportunity to be on the Charlie Rose show last night 

with the writer of American Sniper with the leader of Team Rubicon, and I talked about the fact that we at VA are the canary in 


VACREP0180 with DISTILLER
31 

the coal mine for American medicine. We see things because of the 

battlefields that our veterans go on way before the American public. Mental health is a big issue in this country. Any veteran committing suicide is disastrous. 

And the work that you have done on the Clay Hunt Act, it gives 

us more residencies. It gives us the ability to pay back student 

loans. The average medical school student is graduating with about 

$185,000 in debt. The Care Act moved it—we can repay from 

$60,000 to $120,000. This is $30,000, additionally. I am working 

hard to try to get more residencies for mental health and to get 

greater throughput for mental health. 

But of those 22 veterans who we estimate commit suicide today, 

17 of them aren’t committed to the VA, aren’t connected to the VA. 

Mr. WALZ. That’s right. 

Secretary MCDONALD. So one of the things I am working on is 

how do we get more people connected, because we do have treatments for post-traumatic stress. We do know how to alleviate it, 

and we just need to get those people connected. So we are working 

very, very hard on that. 

Mr. WALZ. Well, to all of you, again, I am thankful, and thank 

you for working as partners in this, and as I said, they are difficult 

conversations because our veterans are counting on us to have 

those difficult conversations. 

I yield back. 

The Chairman. Ms. Radewagen. 

Ms. RADEWAGEN. Thank you, Mr. Chairman. 

Mr. Secretary, I first want to thank you for the opportunity to 

have breakfast last week and share with you the concerns of some 

of our American Samoan veterans, who, because of our geographic 

and economic isolation, don’t share in all the benefits that they are 

entitled to. And I want to thank you for presenting me with the 

seal, the beautiful seal of the Department. 

Our veterans, who make up ten percent of our entire population, 

have issues that are basic and comparatively small, but they are 

generally taken for granted, here in the States. In a nutshell, they 

need a cemetery. We have no map flights. We need access to better 

health care. Our local hospital has no CAT scan, no cancer specialists, so our veterans must always seek care off-island. 

ObamaCare, most of our veterans do not understand. Our troop 

store is always out of merchandise and there is always complaining 

as to why it is that we don’t get merchandise and services provided 

to the PXs off-island. 

Our veterans have difficulty getting their medical records to even 

apply for benefits. 

But, Mr. Secretary, what I would like to ask you is: The VA’s 

budget submission has identified an expected increase in claims receipts for fiscal year 2015 at $1.3 million and fiscal year 2016 at 

$1.4 million. These figures represent an increase of 17 and 20 percent, respectively, over the 1.14 million claims received in 2014. 

Can you please explain what factors and information you considered in determining the anticipated volumes of claims receipts for 

these two years? 

Ms. HICKEY. Congressman [sic], absolutely. 


VACREP0180 with DISTILLER
32 

Let me just tell you that the largest portion of that is not going 

to be the brand-new veteran who is now leaving service, 

transitioning to us; it is going to be the fact that we have done so 

many veterans claims, 1.32 million, and every veteran is entitled 

to come back for any supplemental claim, which, by the way, is 

about 67 percent of our workload, meaning it is the majority of our 

workload is not our original claim, it is the, it has been aggravated, 

it got worse, and so as a result, you can come back and get another 

one. That growth largely attributed to the increased expectation for 

supplemental claims, and that is where the majority of it is. 

Ms. RADEWAGEN. Thank you, Mr. Chairman. 

Secretary MCDONALD. Ma’am, I would like to—if we can, I would 

like to bring our leadership over and sit down with you and go 

through all the issues on Samoa and see if we can help and fix it. 

We care very much about every veteran and we care about those 

in Samoa. 

Ms. RADEWAGEN. That would be great, Mr. Secretary. 

Secretary MCDONALD. We would love to do that. 

Ms. RADEWAGEN. Thank you, Mr. Chairman. 

The Chairman. Ms. Brownley. 

Ms. BROWNLEY. Thank you, Mr. Chairman. 

And, Mr. Secretary, I, too, want to thank you for your extraordinary leadership over the last six months, and I feel very confident that the rudder of the VA is being repaired and we certainly—I believe we are on a good trajectory for really righting the 

ship, and I really want to thank you for that leadership. And I 

want to thank you also for today’s presentation and the analysis 

in the presentation, because I do think it absolutely demonstrates 

what the challenges are within the VA, both in the short and the 

long-term, and the fact that all of the challenges that we all must, 

collectively, tackle for our veterans. So thank you very, very much 

for that. 

I appreciate the meeting that we had in our office last week and 

I was very excited to go home this weekend and talk to my veterans in Ventura County and to let them know an important milestone has occurred here, including a new clinic in Oxnard for our 

veterans. It was quite clear to me that our veterans were underserved when I was first sworn into Congress, and I think this clinic 

will, indeed, right a wrong, and our veterans will be better served. 

And so I just wanted you to speak to that because I wanted my 

veterans in Ventura County to hear from you directly your agreement for the need of this clinic and what you think the time estimates will be to acquire the lease and build out the facility. If you 

could comment on that, I would really appreciate it. 

Secretary MCDONALD. Well, first of all, I apologized to you for 

not visiting Ventura County when I was in Los Angeles. That was 

a relatively quick trip and I was there for one reason, which was 

to get a settlement with the community and get the homeless veterans off the streets of skid row in Los Angeles. But I will come 

to Ventura county and get together with you and perhaps this 

would be a good topic to talk. 

As Deputy Secretary Gibson goes through and looks at our construction leasing process, I am hoping that the kind of time we 

have seen in the past to get something like Oxnard going will be 


VACREP0180 with DISTILLER
33 

shortened, and we will work together with you on that. Right now 

I don’t have any estimates, but we will get together with you and 

we will work on that, and I want to meet the needs of the veterans 

in Ventura County. 

Ms. BROWNLEY. Very good. 

And just as a follow-up, could you just describe, briefly, what the 

process will be in terms of—are stakeholders, are veterans being 

included in this process? 

Secretary MCDONALD. Absolutely. Absolutely. 

Just like I have done everywhere else I have gone, I bring together all of the stakeholders, members of Congress, veteran service organizations, mayors. Because as I said earlier, and I really do 

mean this, this really is a team sport. 

And, particularly, in the case of homelessness as an example, we 

can’t do the right thing unless—we can have all the HUD house 

vouchers we want, but if there is not a landlord in the City of Los 

Angeles willing to rent at that rate, we are still going to have a 

homeless veteran. So, for me, what we did in Los Angeles is going 

to be a prototype of what I hope to do everywhere else in the country, which is VA can be the lightning rod to call the community together with the local mayor and work to improve the situation. In 

this case, we will work with you on the Oxnard facility. 

Ms. BROWNLEY. Thank you very much. 

And I think we are making progress on the VHA side, and I 

think there is more progress to be done on the benefits side. This 

year is 2015. I was just curious to ask—we set an ambitious goal, 

your predecessor set an ambitious goal in terms of the backlog— 

just your comments in terms of meeting that goal? 

Secretary MCDONALD. As Allison said earlier, we think the goal 

is doable, so we are not changing the goal. But one thing that is 

really clear is we do need more people. Even though the productivity is up, the inflow is so great, the inflow has grown so much 

and the repetitive appeals has created a workload issue, that we 

have had to work mandatory overtime. Mandatory overtime is a 

prescription for disaster with a workforce—I do have some experience leading large organizations—and as a result of that, we have 

got to get more people or find either further productivity improvements, which we are working on. 

But going to the entire digital record has been a big, big improvement, and one of the nice things about it is we don’t need any more 

space. We can hire additional people and all the space that used 

to be taken up with paper can now be people working on digital 

files. 

Ms. HICKEY. In fact, Congresswoman, I want to thank the entire 

committee for increasing VBA’s budget. We would not have been 

able to accomplish this without the support of this committee and 

every person on it. 

You saw the growth in the requirement from 2000, so thank you, 

Chairman, and thank you Ranking Member for being here long 

enough to really see us through that growth. I really appreciate 

that. 

But one of the things I wanted to tell you is there is a savings 

implication to this, we are not yet ready to be able to realize because we have got—working through the agreements with DoD on 


VACREP0180 with DISTILLER
34 

what we do with half a million cubic feet of paper we no longer 

touch, and that is 5,000 tons, and equal to ten Mt. Everests and 

200 Empire State Buildings, just to give you a visual. We don’t 

touch that anymore. Ninety-five percent of what we are doing now 

is in a paperless environment. We are working with DoD on a solution to get that out of the buildings. When we do, we have some 

potential lease savings in the tune of $30 million a year that we 

can bring back to you and say, ‘‘This is what the benefit is by our 

not needing to house all of those cabinets and all those things anymore.’’ 

We are already realizing a $2.4 million savings in simply shipping costs of not moving all that paper around on a regular basis. 

Ms. BROWNLEY. Thank you. 

And my time is way out, and I yield back. 

The Chairman. Mr. Huelskamp. 

Dr. HUELSKAMP. Thank you, Mr. Chairman. 

I appreciate the opportunity to visit with you, Mr. Secretary, particularly last week, and I would like to ask you a few questions and 

discuss the Choice Program, which is very important to me. 

As we discussed last week, my district includes 63 counties; it 

touches four different VISNs, and that creates some problems. But 

distance is the main problem and access; there is no VA hospital 

in the district. I just had an email contact from a veteran who 

drives 340 miles one way for cardiology. If the VA Choice Program 

can’t provide something closer for him, then we need to relook at 

how we are implementing that. 

One thing I would like to ask you, and there is some concern, 

particularly with providers, with veterans that are looking into taking advantage of that, is the fact that it is only a temporary program. Are you and the Administration committed to making this 

a permanent option for our veterans? 

Secretary MCDONALD. As you know, we have had an external 

program, and so I think an external program is necessary as we 

look forward to a future where the network is both VA care and 

outside care. We are also going through an analysis right now— 

given the relatively low take rates, but, again, I don’t want to assume that is going to continue, we are talking about how can we 

do a better job marketing it, and also, should we look at that 40 

miles and change the interpretation of it, get CBO to score something differently so we can make sure the program is robust. 

Dr. HUELSKAMP. And your thoughts on making the Choice Program permanent, Mr. Secretary? 

Secretary MCDONALD. I am all for it. I am all for whatever it 

takes to satisfy veterans, to aid veterans. 

Dr. HUELSKAMP. And I appreciate and thank you for that. I appreciate the 40-mile discussion, because that creates problems. If 

you were in a place, for instance, that a CBOC was implemented 

sometime in the last 20 years, all of a sudden, that keeps you out 

of the Choice Program. And as I understand, the interpretation is 

even if the services aren’t provided at the CBOC, that restricts that 

access. 

So for the gentleman in Dodge City, Kansas, that is asked to 

drive to Kansas City, again, 340 miles one way, it is only because 

there is a CBOC there and they are never going to provide the carVerDate Aug 31 2005 13:32 Mar 15, 2016 Jkt 000000 PO 00000 Frm 00038 Fmt 6633 Sfmt 6633 Y:\98-570.TXT PAT

VACREP0180 with DISTILLER
35 

diology services that we need. So is that something that you are 

willing to look at interpretation or you are going to require us to 

pass some changes in the law? Because I think that can be interpreted that you would have that flexibility to make that determination. 

Secretary MCDONALD. Actually, it is pretty straightforward in 

the law, at least that is what we have heard from CBO and from 

others. 

But we are going to work on different options. Each option will 

have a different estimated price and we will come back to you and 

let you know what those options are and together we will decide 

what is the best thing to do. I agree with your point of view that 

distance from a place you can’t get the service seems like a relatively weak measure, but that is what has resulted in the current 

appropriations. So we have got to work with CBO to score all of 

those opportunities and decide together. 

Dr. HUELSKAMP. And I can follow some of that, but as the crow 

flies versus as a real person drives, I think that is an interpretation that can be changed. 

But even with the 40 miles that is in the Choice Program, there 

is nothing that would prohibit you from using a fee-for-service approach in this exact same situation, which has created many of 

these problems. 

Secretary MCDONALD. Correct. 

And that is the marketing that we have to do, too; we have got 

to get the word out that that is possible. 

Dr. HUELSKAMP. Well, the word, I think needs to go with the 

folks answering the phone at the VA Regional Medical Center, because that is not what they are told, that you could get your cardiologist services and drive a hundred miles to Hays, no. You can go 

to Wichita, which by the way is only 157 miles, but he wanted 

services that were a little bit better, and so they said you can drive 

340 miles when he probably could have gotten those right in his 

own hometown. 

The answer always should be, Yes, we can, we are going to look 

at a way. And if it is not the Choice Program, we have got the feefor-service that we should be using—should have been using all 

along. And I know it varies if you are in an urban area, but, again, 

when I am in a rural area, I actually have 70 community hospitals 

that are coming to my office and say, Tim, we would like to serve 

those veterans and we are not able to. And the Choice Program, 

if we can make that permanent and then expand our understanding of the fee-for-service approach to that, I think we are 

going to serve veterans better and give them access to the care 

they deserve. 

So I appreciate your efforts on that, Mr. Secretary. Appreciate 

your commitment to making these programs permanent, because I 

think they are critical to making sure that the VA works long-term, 

so thank you. 

I yield back, Mr. Chairman. 

The Chairman. Ms. Rice. 

Ms. RICE. Thank you, Mr. Chairman. 

So, Mr. Secretary, I wanted—as everyone here has thanked you, 

I thank you for spending time with me yesterday. I think it is inVerDate Aug 31 2005 13:32 Mar 15, 2016 Jkt 000000 PO 00000 Frm 00039 Fmt 6633 Sfmt 6633 Y:\98-570.TXT PAT

VACREP0180 with DISTILLER
36 

credibly informative, and I, personally—all the brave men and 

women that work so hard to protect our freedoms deserve the help 

right now. But what they don’t—and I know that is what you are 

working towards and your whole team is working towards—but 

what they don’t deserve is a ‘‘knee-jerk, try to Band-Aid on a gaping wound fix,’’ and so I appreciate, as I am sure everyone on this 

committee does, the thoughtful way that you are approaching all 

of these reforms. Because I think that they are going to serve the 

brave men and women that protect us in the long run. 

So I just have a couple quick questions. You mentioned the 22 

veterans who commit suicide every day. I think you said 17 of them 

had not accessed any service within the VA. How are you going 

to—and we had spoken briefly about this yesterday—but how are 

you going to reach out to them? 

Secretary MCDONALD. There are a number of things we have to 

do. Number one, we have to eliminate the stigma in this country, 

but it exists across the world, around mental health care. I am 

thinking that this is a fortuitous moment in time because American 

Sniper, the movie, the largest-selling war movie, is starting to do 

that. That is why I went on the Charlie Rose show last night was 

to talk about this. 

When Congressman O’Rourke and I were together in El Paso— 

I will never forget it—we were looking at a private sector hospital 

and there was a neon sign at the top of this one building that said 

mental health clinic, and there wasn’t a car in the parking lot. And 

I turned to him at the time and I said, well, of course, there is 

not—it wasn’t his hospital; it wasn’t our hospital—but, of course, 

there is not a car in the parking lot. 

What we do is we take our veterans, through the primary care 

physician, into the mental health treatment, and as a result of 

that, the stigma doesn’t exist, and they may not even know that 

they are talking to a psychiatrist. So we have got to get rid of the 

stigma. 

Number two is we have to reach all of the veterans. We have the 

ability to put on the TV, a public service campaign that the Ad 

Council is working with us pro bono to get people signed up, but 

I don’t feel, yet, that we are ready for that. That our capacity is 

so strained that if we were to get a lot more people into the system 

not for mental health, that we might have issues. 

And, third, we have to train the American public. If you see 

somebody who you think has an issue—we have an algorithm or 

not an algorithm—an acronym called SAV. S is about seeing and 

recognizing that the individual may have an issue. We have a hotline, a 1–800 hotline that you can call to get that person help and 

then we go immediately into action. 

Those are some of the things we are doing. It is not everything. 

The medical exam when you leave DoD is also a big help, but we 

have got to get our arms around the 17 veterans and care for them. 

Ms. RICE. Now, I know that there is discussion in terms of the 

facilities in California that are vulnerable to earthquakes. The VA 

is just outside my district, but I still claim it as my own, obviously, 

on behalf of the veterans that live in my district and have to travel 

out there. 


VACREP0180 with DISTILLER
37 

Superstorm Sandy hit my congressional district harder than any 

other place in New York state, and I was wondering if part of your 

construction plan included—I mean I understand the focus on 

earthquakes in places like California, but in similarly fragile and 

vulnerable areas like Long Island, is there a plan to have some 

emergency preparedness to prevent any—— 

Secretary MCDONALD. Yes. 

Ms. RICE [continuing]. Interruption in services? 

Secretary MCDONALD. When we do our construction management 

process, we call it SCIP; it is another acronym. I owe you that acronym dictionary. 

Ms. RICE. We need an encyclopedia of acronyms in Washington. 

Secretary MCDONALD. But safety is number one, and we consider 

seismic and other natural disasters as safety, so that is always the 

first priority. 

In the case of Sandy, for example, we have a facility near the 

Battery, near Battery Park in Lower Manhattan, and it was devastated. The entire first floor was water. I visited the facility. 

We are now building a wall that can help us keep out higher levels of water should another storm occur. So express safety is always number one—and I don’t have the specific facts on the facility 

in Long Island, but we can get together with you, and we can go 

through that. 

Ms. RICE. I would appreciate that. 

Again, thank you so much, Mr. Secretary and to your entire 

team. 

Secretary MCDONALD. You’re welcome. Thank you. 

Ms. RICE. And I yield back my time. 

Thank you, Mr. Chairman. 

The Chairman. Dr. Benishek. 

Dr. BENISHEK. Thank you, Mr. Chairman. 

Thank you, Secretary Vilsack [sic], for being here with your 

team. I think a lot of the members this morning, we asked a lot 

of great questions and touched upon a lot of the issues that I want 

to talk about. I want to commend Dr. Wenstrup there for bringing 

up the costs of care. 

And that is something that I am very concerned about, and I 

wanted to ask a few more questions about when you think that you 

are going to have an idea of when that is going to be or is this 

independent review of the VA system, is that going to help look at 

that number? Because I know I am very concerned about it in continuing to implement access to care locally. 

Can you just elaborate on that a little bit? 

Ms. HICKEY. Sure. In addition to the external independent assessments, which we anticipate will be here around August or before then, we are also commissioning some internal work, internal 

contracts and so forth from some of the leaders in industry just to 

figure out how do we get to some of the questions that you raised 

in your recent hearing when Dr. Tuchschmidt presented and so 

forth. 

One of the issues that we struggle with in terms of cost is this 

reliance factor, you know, where some veterans use VA for some 

of their needs, but they go outside for others. My uncle recently 

proudly told me he got his hearing aid, but by and large, given 


VACREP0180 with DISTILLER
38 

where he lives, does not actually go to VA for most of his care; he 

goes closer to home. So that is part of the issue that we have got 

to work through, as well as this issue of fixed and variable costs. 

And, again, I think this is why the secretary raising this issue 

of fixed costs that are kind of a drag on the budget in terms of getting to the issues of access and veteran experience are so important. 

Dr. BENISHEK. I think that is what Dr. Wenstrup was talking 

about, is that, you know, the cost of these half-a-billion-dollar hospital overruns, that all adds to the costs of taking care of a patient 

who walks into the clinic. I just want to make sure that all of these 

costs are included in that because we are supporting a bureaucracy 

that—are we supporting way too much of a bureaucracy for the 

care that we are getting out of it. I mean that is my concern. 

Ms. HICKEY. That is a fair question and it is one that—— 

Dr. BENISHEK. Let me just ask another question here, and this 

is something else that we have talked about in our subcommittee 

as well, is this management of pain within the VA. Because I know 

it has been over a year that we have talked about this in my subcommittee and this opioid medication and the high doses and the 

number of prescriptions written, and then this recent troubling incident with the IG in Tomah. What has been going on in the VA 

recently to try to address pain management; is there a better pain 

management system? Is there a referral to a pain management 

specialist? 

Tell me a little bit more about what is happening more recently, 

and how are we going to put an end to this, you know, the practice 

of using opioids on a chronic basis for people with chronic pain. 

Secretary MCDONALD. I will ask Dr. Clancy to give you the specifics, but one of the things that I wanted to say at the beginning 

is we take this opioid use very, very seriously, and we track it very 

closely. 

And one of the things that I am very proud of that we do in the 

VA that I don’t see as much of in the private sector is we use a 

lot of alternative approaches, alternative medicines. We use acupuncture. We use yoga. We have used electronic devices that have 

shown to be effective amongst some of our veterans. Anything we 

can do to get that veteran off of opioids is something we want to 

do. And we are developing quite a broad array of tools that we can 

use that allow us to reduce the opioid use. 

Dr. BENISHEK. Well, I mean that sounds great, Mr. Secretary, 

but I think if you look at the numbers of people who are not on 

the alternate treatment versus the opioids, you would find that 

there are a lot of people on opioids compared to the number of people that are getting alternate therapies. 

Secretary MCDONALD. There are. 

Dr. BENISHEK. And it is great that you mentioned those things, 

but it seems like there should be a lot more people having access 

to pain management specialists than are being treated by their 

family physician or their primary care physician with narcotics. 

Dr. CLANCY. So, really an incredibly important and serious issue. 

I think, as you know from your prior hearing—and we, again, 

would be happy to brief you in more detail—we actually track 

opioid use per facility. Each facility has a dashboard, and nationVerDate Aug 31 2005 13:32 Mar 15, 2016 Jkt 000000 PO 00000 Frm 00042 Fmt 6633 Sfmt 6633 Y:\98-570.TXT PAT

VACREP0180 with DISTILLER
39 

wide since we launched this safety initiative, we have seen the 

trend line go down, which is a good thing. But we are also looking 

at the prescribing patterns of individual physicians to see—to make 

sure that an overall positive trend that is going down isn’t masking 

some practices that we would consider suboptimal. 

We are supporting a lot of research in this area as well, because 

the combination of non—— 

Dr. BENISHEK. Well, again, that is great, but it is unfortunate 

that apparently the situation in Tomah sort of contradicts what 

you are saying here today, and we just want to make sure that we 

maintain a high vigilance on this problem. 

So, I am out of time, but I certainly appreciate your efforts. 

Dr. CLANCY. Thank you. 

The CHAIRMAN. Thank you very much. 

Members, Ms. Brown has one final question. 

Ms. BROWN. Thank you, Mr. Secretary, and thank you for your 

service. 

I have one question. Just a few minutes ago, the congressional 

audit came out, and I don’t know whether you have seen the article, VA health care is at high risk, and I guess they do this audit 

every two years. In reading it, it seems like they were rehashing 

a lot of the stuff that is going on. 

You know, I appreciate you going on television, I just think we 

need to respond in our town hall meetings. You know, we see about 

seven million people a year that once they get in the system, they 

are happy with the service. 

So, can you speak to the article that is just coming out today and 

whether or not you would be willing to do an updated piece to USA 

TODAY, because I think it is important that veterans are not sidetracked. We are definitely headed in the right direction. 

Secretary MCDONALD. Yes, ma’am. 

I actually met with the comptroller general, and we were talking 

about whether or not he should put VA on the high-risk list. I actually encouraged him to, and the reason I did that is because we are 

a healthcare system, and we are going through a large amount of 

change right now. And during the time that any organization goes 

through a large amount of change, we need to make sure that we 

have the appropriate oversight, the leadership, as well as those responsible for it. 

So while I think the VA system is absolutely essential to American medicine—we train 70 percent of U.S. doctors. We have developed innovations that are absolutely critical for American medicine, 

the first liver transplant, first implantable pacemaker, nicotine 

patch, first time bar code is used to connect patients with medicine. 

We have got to make sure we have a robust VA. 

And so as we go through this change, I am thankful that you in 

your oversight role and others will be helping us get through this 

change and develop this robust system that this country and our 

veterans need. 

Thank you. 

Ms. BROWN. I want to, again, thank you all for your service. 

The CHAIRMAN. Mr. Secretary and everybody at the table, thank 

you for being here today. You are excused. 


VACREP0180 with DISTILLER
40 

If we could go ahead and have the second panel come to the 

table, we need to continue. 

I invite the second panel to the table and welcome Mr. Carl 

Blake, Associate Executive Director of Government Relations at 

Paralyzed Veterans of America who is going to be testifying to the 

committee on behalf of the co-authors of the Independent Budget. 

Accompanying Mr. Blake is Mr. Joe Violante, National Legislative 

Director, DAV; Mr. Ray Kelley, Director, National Legislative Service, Veterans of Foreign Wars; Ms. Diane Zumatto, national legislative director, AMVETS, and we are also going to be having testimony from Mr. Ian de Planque, Legislative Director, The American 

Legion. 

Mr. Blake, you are now recognized for five minutes. 

STATEMENTS OF MR. CARL BLAKE, ASSOCIATE EXECUTIVE DIRECTOR, GOVERNMENT RELATIONS, PARALYZED VETERANS 

OF AMERICA, ON BEHALF OF THE CO—AUTHORS OF THE 

INDEPENDENT BUDGET, ACCOMPANIED BY MR. JOSEPH A. 

VIOLANTE, NATIONAL LEGISLATIVE DIRECTOR, DISABLED 

AMERICAN VETERANS; MR. RAY KELLEY, DIRECTOR, NATIONAL LEGISLATIVE SERVICE, VETERANS OF FOREIGN 

WARS; MS. DIANE M. ZUMATTO, NATIONAL LEGISLATIVE DIRECTOR, AMVETS, AND MR. IAN DE PLANQUE, LEGISLATIVE 

DIRECTOR, THE AMERICAN LEGION 

STATEMENT OF CARL BLAKE 

Mr. BLAKE. Thank you, Mr. Chairman, Members of the Committee. 

On behalf of the co-authors of the Independent Budget seated 

here at the table, I would like to thank you for the opportunity to 

testify today on the VA’s fiscal year 2016 and 2017 budget. I ask 

that our report, the Independent Budget for the Department of Veterans Affairs for fiscal year 2016 and fiscal year 2017, be admitted 

into the official hearing order. 

The CHAIRMAN. Without objection. 

Mr. BLAKE. Thank you, Mr. Chairman. 

Let me begin by saying we believe this is probably the best VA 

budget we have seen in my many years of being up here on the 

Hill. That being said, recent media reports have pointed out that 

the VA has had hundreds of millions of dollars in unspent resources carried over in recent years. The IB does not dispute that 

fact. In fact, the VA has done a questionable job of managing the 

insufficient resources it has been given in the past. We believe that 

the access problems and the long waiting lists identified over the 

last year clearly affirm that point. 

However, we also believe that the VA, prior to this year, has continuously requested insufficient funds to adequately provide 

healthcare and benefit services to veterans. Yes, Congress has 

given the Administration virtually everything it has requested 

yearly, but that certainly does not mean that the VA has requested 

what it truly needs. Perhaps the Office of Management and Budget 

would have something to say about this. 

This does not mean that the VA should not be properly scrutinized for what it spends or does not spend; in fact, we wholeVerDate Aug 31 2005 13:32 Mar 15, 2016 Jkt 000000 PO 00000 Frm 00044 Fmt 6633 Sfmt 6633 Y:\98-570.TXT PAT

VACREP0180 with DISTILLER
41 

heartedly support this notion. But it should be scrutiny grounded 

in facts, not in rhetoric or poorly formulated assumptions. 

The Independent Budget recommendations represent our view of 

the actual resource needs of the VA to provide services across the 

entire spectrum of programs. Our views are not clouded by a particular agenda or by politics. Despite the closeness of our recommendations, the IB is an independent assessment of the VA 

budget requirements developed before the Administration even released this most-recent budget request. 

It is not bloated with unnecessary resources and administrative 

support. I would call your attention to the clear differences between 

our recommendations for such line items as medical support and 

compliance, general of administration and IT to affirm that point. 

Our recommendations focus on the areas where service is the 

linchpin: medical services, major/minor construction, the Veterans 

Administration, the National Cemetery Administration, and other 

key areas. A couple of those key areas were recently identified in 

our policy agenda that we released back in January. Those include 

women veterans programs and Caregiver Support Programs. We 

appreciate the emphasis this Committee has put on these two 

areas. We certainly appreciate the fact that the Committee held a 

hearing back in December to review the Caregiver Support Program; it is a high priority for many of our members. Those two 

issues are particularly critical issues in this year’s Independent 

Budget. 

Clearly, there are wide-ranging opinions about how the VA manages its capital infrastructure. We have no doubt that VA construction and contract management has been a disaster. The only people 

to suffer the consequences of these failures are veterans seeking 

care, particularly in the Denver area. But none of this changes the 

fact that the VA has a huge backlog of valid building projects that 

are in various stages from initial planning to near completion. 

Nevertheless, we believe the VA has not shown the level or degree of commitment in its request for resources to get all of these 

projects moving in the right direction or to complete them. We 

stand with the Committee to resolve these VA construction management problems and we hope that that will be done quickly. 

Lastly, I would just like to comment on a couple of points that 

have been raised here. With regards to the question about cost for 

care, we are certainly not experts, but I would suggest that in all 

of the briefings I have received about the VA’s Enrollee Health 

Care Projection Model, that if one wanted to know how much it 

cost to do a particular procedure in any region in the United 

States, that that model would produce a number, at least that is 

what we have been told over the years when we have been briefed 

on this. 

So what I would expect that if the Committee wanted to know 

how much it cost to do a colonoscopy which came up over and over 

again in the cost for care hearing, that the VA can probably 

produce a number. We appreciate the fact that the VA is committed to providing better information with regards to the cost for 

care. We look forward to having an opportunity to review that information, as well. 


VACREP0180 with DISTILLER
42 

And then lastly, the question about the Choice Program, which 

the VA has brought right out into the light of day, I think the Independent Budget probably agrees with the principle that the secretary has laid out, that, you know, you shouldn’t be obligated to 

spend the money you have been given for one singular purpose. I 

thought the secretary’s analogy he used about gas versus food is a 

perfect way to describe the need to be able to shift money around. 

That being said, I’m not sure that we also agree with taking 

money from a program right now that is clearly in its infant stage. 

I think that program clearly has to be given time to flush itself out 

and see what actually occurs. Three months is certainly not enough 

time to do a thorough evaluation of utilization of the Choice Program. So until there has been more time to really fully evaluate 

what will happen, I’m not sure that we fully support what the Administration is requesting. 

With that, Mr. Chairman, I would like to thank you again for the 

opportunity to testify, and I would be happy to answer any questions that you or the members of the committee may have. 

[THE PREPARED STATEMENT OF CARL BLAKE APPEARS IN THE AP- PENDIX] 

The CHAIRMAN. Thank you, Mr. Blake. 

Mr. de Planque. 

STATEMENT OF IAN de PLANQUE 

Mr. DE PLANQUE. Good afternoon, Chairman Miller, Ranking 

Member Brown, Members of the Committee. 

I would also like to thank Secretary McDonald and his staff for 

their words today. 

I am very fortunate to sit here and speak on behalf of The American Legion for our National Commander Mike Helm and the 2.4 

million members in over 14,000 posts across the country, who make 

up the backbone of the world’s—the nation’s largest wartime service organization. 

We are focused on getting things right, not just for our over two 

million members, but for over twenty million members beyond that 

who are veterans, people who have worn this. I was struck by 

something that Secretary McDonald said earlier today, ‘‘This is a 

team sport; we can’t do it by ourselves.’’ I think everyone agrees 

that the country owes a great service to the veterans, that the 

country owes a lot of things to the veterans. The country is not just 

the federal government. The VA is a piece of that, but I think everyone here, everyone here at this table, everyone here in this room 

is also a piece of that. We all have to work together on this. 

I spent two of the last four weekends out at various grassroots 

events for The American Legion in Nebraska and Kansas out there 

with blue cappers like myself, you know, who were there, actually 

out there wanting to go out and go into VA hospitals and help out 

in whatever way they can. We had over 7,000 legionnaires donating 

almost a million hours of volunteer service to the VA. This only 

works if we are all on the same page, if everyone is on the same 

page. 

And, Ranking Member Brown, you mentioned earlier that you 

wished H.R. 216 was the law of the land, as an important resource 

and tool that would help with that. I think we agree very much, 


VACREP0180 with DISTILLER
43 

and I know in the legislative hearing earlier when it was discussed, 

I think there was a lot of agreement on both sides of the aisle on 

that. We have to be able to look back and forth and compare these 

things. 

I was speaking with a colleague of mine about VA’s Strategic 

Capital Investment Plan and whether or not they are putting 

enough money into these things. The American Legion about four 

years ago was talking about looking at VA’s construction figures. 

It was going to take them 60 years to complete the 10-year plan 

in SCIP if they went forward with those numbers. But trying to 

compare the figures together and what are still there, you are pulling up a budget from one year and you are trying to hold it next 

to another—having it all laid out there, right for you where all 

stakeholders can participate in that—I know, Chairman Miller, 

when that bill was up in a legislative hearing, you spoke about the 

importance of the transparency for it and how you had seen in 

Armed Services that they are transparent with that. We need to 

have that same kind of transparency with the planning for the VA 

budget so we can maximize the resources that everyone is putting 

into this. 

We have a lot of great organizations. We have a lot of great veterans who are out there trying to make this a better system. We 

believe in a VA system. We believe the Choice card is important 

because we have to get access to care for veterans, but we want to 

make sure that the veterans still have access to that system. 

It is there because Secretary McDonald talked about the demand 

expanding beyond VA’s capability to meet that. Well, we need to 

make sure the resources are allocated to meet those demands, but 

we can’t lose sight of the focus that it is the VA that we want to 

be needing that. The VA that we want to be the leader that is pioneering medicine, that is the utmost expert in so many conditions. 

You look at a traumatic brain injury, you look at post-traumatic 

stress disorder, you look at amputation injuries, there is no reason 

that the VA should not be the world’s leading authority on that 

and we need that to happen, and that comes from everybody working together, and that comes from everyone being on the same 

page. 

The American Legion is absolutely devoted to that. We need to 

be able to look at these pieces. I think VA’s request for an additional 700, 770 full-time employees to work on the claims backlog, 

it is important. I think there is a very good point that they have 

been given more staff and that they were supposed to have been 

increasing their productivity, but you can’t deny the fact that they 

have been on mandatory overtime for four years. Going through 

four weeks on mandatory overtime says you might have a little bit 

of a problem. Going through four years on mandatory overtime 

says you might not have enough people to do that. Now, we don’t 

know exactly how many people we need in every office, and that 

is why we all need to be able to look at these figures on the same 

page together. 

I think working together we can do that. We are very committed 

to being a major partner in that and helping to drive that. We 

want this system to be the best system that can be for veterans. 

I think the Committee has been very generous in giving budgets 


VACREP0180 with DISTILLER
44 

to the VA to work with, we just need to keep everyone working on 

the same page and I think we can accomplish that. 

Again, I thank you for having The American Legion here to 

speak on this. Thank you for having all the veterans’ groups to 

speak on this, and I look forward to any of your questions. 

[THE PREPARED STATEMENT OF IAN DE PLANQUE APPEARS IN THE

APPENDIX] 

The CHAIRMAN. Thank you very much for your testimony. I 

would like to ask either of you, if you would, kind of one of the critical components and probably one of the toughest things that the 

secretary is confronted with is going to be closing outdated, old 

substandard, or particularly underutilized facilities. It is not easy 

politically. It is not easy, as the secretary has already alluded, but 

I would like to know if you feel like that is an important step that 

the secretary has to look at. 

Mr. BLAKE. Mr. Chairman, I am going to defer to my colleague, 

Crandall Construction, for the IB. 

Mr. KELLEY. Mr. Chairman, absolutely. 

If VA is holding property that it no longer uses or is underutilized, they need to find out how to get rid of that property. But in 

the process of figuring out how to get rid of it, they also need to 

have that conversation with the community to ensure that those 

veterans understand there are going to be services still there. 

That is the fear in the community, is my hospital is going away, 

therefore, my services are going away. They need to understand 

that full continuum of care is still going to be in the community 

and it is just going to be right-sized for that community. There is 

no need to spend three dollars per square foot to maintain a building that is no longer being used, just to keep it mothballed. 

Mr. DE PLANQUE. If I could dovetail onto that, the thing that 

comes to mind is Hot Springs which The American Legion has been 

very involved in, and that community desperately wants to keep 

their medical center. I can absolutely understand if you have an 

underutilized building and it is just taking up empty money that 

is not serving any veterans in the community. And certainly there 

are probably regions where it is just not effective, but we have to 

make sure that those veterans are included as a part of that planning process and that they are being listened to. 

I know there has been a tremendous amount of frustration in 

Hot Springs, that the community is adamant, it is vehement, and 

it has been organized and has tried to voice its opinion at every 

step along the way, that we need this facility here, this is serving 

the veterans in this area, and they are very concerned that that is 

not being heard. 

So, yes, I think that it is important to be able to open up to some 

possibilities with that, but let’s make sure that we are also still 

serving the veterans. 

The CHAIRMAN. Any other comments? 

Mr. BLAKE. Mr. Chairman, I would only add, too, one thing we 

would caution as they make a determination of where facilities are 

underutilized or unused, that they be innovative also. You know, 

we have talked for years about using some of these underutilized 

spaces for the homeless veterans issue. 


VACREP0180 with DISTILLER
45 

You know, one of the challenges of homelessness is having supportive housing that allows them to then transition into finding a 

job and being able to sort of become a productive member of society 

again. So before they choose to close a facility, I would hope that 

they would think outside the box in some of these areas where 

these facilities can serve a purpose. 

That doesn’t mean that some facilities shouldn’t just be closed, 

especially if they are sitting empty and have been sitting empty too 

long. 

The CHAIRMAN. Mr. Blake, where, specifically, do you think the 

administrative costs within VA could be reduced and where could 

those funds be reallocated? And, specifically, I guess we are talking 

about page 3 in your testimony. 

Mr. BLAKE. Well, I would suggest, Mr. Chairman, from the perspective of the recommendations we have made, we have sort of 

stuck to the same principle over the last couple of years, that we 

directed most of our recommendations at the medical services line 

where the rubber meets the road for providing healthcare. 

There has been some discussion about plussing up staff like in 

the general administration line items, which are a lot of the offices 

here in Washington, DC. We have also had some conversations 

with the Committee staff on the VHA side about the administrative 

costs that exist at the VISN level and across the various layers 

that exist within VHA. We were interested to see the plan to seemingly transition the regional framework of VA. What we would certainly hope to see—or hate to see, I should say, is we transition to 

a five-region alignment and where we go from 22 VISNs with 125 

to 150 staff to five regions that are just those people shifted into 

a regional alignment and you didn’t streamline your administrative 

support at all. 

The CHAIRMAN. If I could, the secretary asked Mr. Coffman to 

ask a question of the VSOs, and since Mr. Coffman is no longer 

here in the room, I will ask the question on behalf of the secretary: 

Have you seen a difference in the VA? 

Mr. VIOLANTE. Mr. Chairman, the fact that the secretary and his 

leadership team are still here I think answers that question. I 

think we have all been impressed of what he and Deputy Secretary 

Sloan Gibson have done in the short time that they have been here. 

So I would have to say that, yes, we appreciate what he is doing 

and what he is trying to do and hope that you will work with him 

to make sure that these changes happen. 

The Chairman. Mr. Kelley. 

Mr. KELLEY. Yes, we see a difference in spots. There are going 

to be areas that are slower to change than other areas, but we are 

seeing pockets of improvement. 

Just solving the problem in West LA, that land-management 

issue in a very short time, something that has been around for 

years, is indication that he is hands-on, he is going to get things 

done, and he expects people at all levels to do the same thing. 

The CHAIRMAN. And if I could—my time has expired, but could 

I just get a yes or a no, Mr. Blake? 

Mr. BLAKE. I will give a yes. 

The Chairman. Mr. de Planque. 


VACREP0180 with DISTILLER
46 

Mr. DE PLANQUE. Definitely a yes, and they are starting to own 

problems, too, which is a big change. 

The Chairman. Ms. Zumatto. 

Ms. ZUMATTO. I would agree with my colleagues. 

The CHAIRMAN. Okay. Very good. Thank you. 

I agree, too. There is a difference, and I would also say that Ms. 

Brown’s H.R. 216 is scheduled to be marked up tomorrow, and so 

we would expect to see that pass very quickly. 

Ms. Brown. 

Ms. BROWN. Thank you. 

I would like to associate myself with the remarks of the gentleman from Florida. I absolutely think there is a change in VA 

and it is headed in the positive direction. 

And when you talk about VA, I remember going to LA, and we 

had four brand new units sitting for over two years that we had 

built those units, 400 units, four separate buildings that stood vacant for two years because we built them, but the State of California did not have the money to operate it. We have got to make 

sure that that does not happen in the future, and I am very 

pleased that he was able to go in and resolve those issues. 

For the first time we have forwarding budget in all of the categories. Can you give me a response as to how you feel about how 

this is going to help VA move forward. I just want to hear from 

all three. 

Mr. BLAKE. Well, I would say Ms. Brown that, you know, we offered our support for the legislation at the legislative hearing a 

couple of weeks ago. I think Mr. de Planque hit on an important 

point, that this would allow for more transparency as they develop 

their needs going forward. 

I would also suggest that, you know, the secretary—what I appreciate seeing is I believe this is the first time that I have seen 

the VA take serious, this requirement, as part of the advanced appropriations process. You know, for the last several years since this 

was passed, one of our chief complaints has been that the Congress 

passes an advance appropriation, as requested by the VA, and then 

the next year, there is no real adjustment or no consideration given 

to how that should be adjusted. 

And this is certainly the first year that I can remember where 

a substantial analysis review and re-estimate for its need has 

taken place. So we appreciate the fact that this leadership team in 

particular seems to have taken this requirement far more seriously 

than in the past. 

Mr. DE PLANQUE. I also want to note I think the forward funding, 

you are not going to have veterans who are worried about not getting their checks if, for some reason, there is some friction between 

the Congress and they can’t get a budget passed. I am not as worried about that immediately, but I mean that is an important guarantee for them down the road, but I also think that that planning 

component that is going along with your legislation is a critical, 

like handshake with that bill. The ability to plan is critical as we 

are forward-funding things and to be able to look down the road 

and see the anticipated results beyond that. So I think they are 

kind of hand in hand with each other and very helpful. 


VACREP0180 with DISTILLER
47 

Ms. BROWN. One other thing. Let me mention that when I first 

came here, we were going through a bright process and, of course, 

we support closing some of the VA facilities, but keep in mind as 

meant, just as long as you don’t close any in Florida. But that is 

kind of the mentality of the members of Congress. So as we work 

through it, we have to keep in mind it is a team effort and that 

those communities need to have input and involvement as we 

evolve as to what we want the VA to look like. Because we are sitting up here saying, This is the right thing. This is the best thing 

for the country. 

But when we go to some little place in, what, high springs—Hot 

Springs? 

Mr. DE PLANQUE. Hot Springs. 

Ms. BROWN. Hot Springs. 

You know, that community feels that they are going to be 

disenfranchised, so the question is: How do we have these other 

communities and everybody involved in those decisions? 

And don’t think that politics doesn’t play a part, because when 

you get ready to close that, when the senators weigh in and, you 

know, some senators say, We don’t do that, we are just interested 

in what is best for the country. That is not always the case, as experienced it with brack. 

So I want to thank you all for your service and for your presentation. Any closing remarks? I have thirty seconds. 

Mr. BLAKE. I would say this, Ms. Brown, we have also—it has 

been nice to see that some of the folks in central office have been 

more open to deal with us on a regular basis. I have already had 

two briefings on VHA’s model and their cost for care since the cost 

for care hearing, which was two weeks ago. 

Prior to that, the last hearing or last meeting we had with VA 

employees on the healthcare model was back in 2009. So they are 

clearly more in tune with the concerns of the Committee, the concerns we raised and trying to get us more involved in the discussion so we know what they are doing. Whether we necessarily 

wholly support it or not, at least we have a better idea of where 

they are going and what they are doing. 

Ms. BROWN. Well, I feel the same way. 

I think I have been over there about four times at 8:00 in the 

morning or 7:00-something, and I want to get the entire committee 

over there to review like the town hall and the discussion so that 

we have a better feel as to what is going on over there, because 

I think it is very exciting to have the employees involved in what 

we are doing and it is not from top down, but it is the input of the 

employees, too. And one-third of them, I often see are veterans or 

more. 

So, thank you, Mr. Chairman. Thank you for the hearing, and I 

yield back the balance of my time. 

The CHAIRMAN. Thank you very much. 

Dr. Abraham. 

Mr. ABRAHAM. As a new Congressman and fortunately a new 

member of this Committee, I am very honored to be here. And just 

six weeks ago I was a practicing physician that was privileged to 

see veterans in my clinic. I am jumping up and down with joy for 

this Choice Program. 


VACREP0180 with DISTILLER
48 

And my question is, on these guys’ levels, are you, Members, are 

ya’ll getting feedback on the implementation of the Choice? Is it 

working? Is it fairly seamless? Where does it stand from ya’ll’s 

Members perspectives? 

Mr. KELLEY. The VFW commissioned a survey through our membership to get feedback and we are doing a two-part survey. We cut 

it off at the beginning of this month, so for a two-month period. We 

found that a good portion of veterans who called for an appointment to VA, when they interacted with VA to get an appointment, 

were not told that they had a choice. 

But now that we are in the second phase of this survey, we are 

finding more of those veterans are understanding that they have 

a choice, and VA employees are being educated to provide that 

choice. So we are seeing that trend of access go up, but at the same 

time, early on, the perception of choice was very positive or the experience of choice was very positive; there seems to be a trend that 

now that it has more people in it, that there is a slight down-tick 

in people’s opinion of it, of the care that they received. 

It is something that we are going to continue to monitor. We will 

have a report very soon that weighs out those analytics. 

Mr. ABRAHAM. Fair enough. 

Mr. DE PLANQUE. Likewise, I wanted to touch on that because, 

again, I just recently talked to a number of people. One of the biggest earlier concerns was there was a lot of confusion over whether 

or not people were eligible. There was a lot of confusion among the 

access. I mean we get calls in the office in DC all the time about 

this, as well, and so we have been working hard and I know that 

VA has been working hard as well to try and educate better about 

that. 

There is a lot, particularly the 40-mile straight line when you are 

in a rural area where the roads aren’t that accessible, the, well, I 

am close to a clinic, but the clinic doesn’t offer the services I need, 

as was mentioned I believe by Mr. Huelskamp in Kansas. You 

know, when you are driving 340 miles to get to something. So there 

was a lot of concern about that and we have heard a lot of bad 

feedback from the members. 

As far as, you know, whether they want to use the Choice Program or whether they want to use the VA, it has been mixed. We 

have some people that have been very happy with the care that 

they got at the VA, they just couldn’t get access to it and they were 

frustrated by that and they want to get back into the VA; on the 

other hand, some people were very excited about the options of 

looking out. 

So we are continuing to monitor that. The biggest part that we 

noticed early on has been a little bit of the confusion about eligibility, particularly with that sort of 40-mile circle and whether or 

not—how that interacted with facilities that didn’t treat the condition they had. 

Mr. ABRAHAM. Gotcha. 

Mr. BLAKE. I think the playing field is a little unlevel in trying 

to evaluate it right now, too, when you consider that, one, the VA 

doesn’t have the capacity to meet all the demand as we see it, and 

at the same time, we don’t know for sure that the private sector 


VACREP0180 with DISTILLER
49 

truly has the capacity to meet the demand that might come from 

the Choice Program. I think that is a great unknown. 

I think we forget that private healthcare is a business and they 

maximize their revenue for their business by not operating with excess capacity, and so it would stand to reason that when people try 

to access the private healthcare system that they might find challenges. I mean we find challenges using private insurance now. If 

I try to get an appointment for specialty care at George Washington University Hospital right here in town, it could be six 

months. 

So there are challenges. So the field is not level on the VA side 

or the private sector side yet. Until we have had a little more time 

to let the program itself even out, allow the VA to get its footprint 

more firmly planted by expanding its capacity, I am not sure that 

we can do a real thorough analysis. 

Mr. VIOLANTE. From DAV’s standpoint, we are getting ready to 

go out with a survey of our members to see what they are hearing, 

and we are not really hearing complaints. There is some confusion, 

as has been said, and I get X amount of miles for beni-travel, but 

then when I apply for this, they are telling me that I am not that 

far away and that is because of the way the law was written. 

But early on, our people were more concerned of being forced out 

of the system, thinking that if they lived more than 40 miles away 

or had to wait longer than 30 days that they wouldn’t be able to 

come into VA, and that concerned them greatly. 

Mr. ABRAHAM. But that has been dispelled, certainly—that misinformation has certainly, hopefully been dispelled. 

I think what we all envision here is that the veteran, when he 

needs primary care, such as a bronchitis—and I don’t mean to minimize a simple bronchitis—he can go maybe to a Choice doctor, and 

certainly if he needs specialty, he has the option to go to any VA 

facility he wants. We just want it as seamless for the veteran. 

And I guess my question was, are we slowly obtaining that goal? 

Mr. DE PLANQUE. I think right now it is a little early and that 

is why in terms of making an analysis of what utilization of the 

program is, and I understand that the secretary stated before that, 

you know, it wasn’t so much about what the utilization was right 

now, he was kind of trying to give a warning light that they might 

need to reappropriate things. 

For us, you know, it is a little bit early to make any decisions 

about that because people are just starting to get their feet wet 

with the program, but it is something that I know we are, and I 

know that all the other groups up here are watching very closely 

to see how this interacts and how this works—— 

Mr. ABRAHAM. Okay. Thank you. 

I am out of time. I just wanted to get ya’lls take. Thank you. 

The Chairman. Mr. O’Rourke. 

Mr. O’ROURKE. Thank you, Mr. Chairman. 

Mr. Violante pointed this out earlier, that the secretary and his 

team are here, and I really appreciate you saying that. I just want 

to make sure that it is noted for the record, because if we are going 

to be successful in this team approach, it is going to take all of us 

literally being in the same room and listening to each other. So I 

thought that was important that you pointed it out. 


VACREP0180 with DISTILLER
50 

I wanted to ask you, any person at the table to respond to this, 

that the secretary also mentioned working collaboratively in terms 

of how we build and offer medical care, beyond this question of the 

Choice Act. An example that we talked about last week in a hearing was this hospital in Aurora, Colorado, you know, $604 million 

now to $1.1 billion, originally supposed to be affiliated with an academic institution. That affiliation is broken. I couldn’t help but get 

the sense that veterans in that area and perhaps VSOs were insistent that that be flagged solely as a VA facility, and that might 

have had some cost and some consequences to that. 

What is your openness or what are your thoughts on this idea 

of working collaboratively and involving other non-VA institutions 

in the provision of healthcare or the development of facilities or organizing how we deliver that healthcare in a community like El 

Paso where I don’t know that we need a hospital—I don’t know 

that we are going to get a $1.1 billion facility, so we may have to 

work collaboratively. So, if I could start with you, Mr. Violante and 

work rightwards down the table, I would love to get your response. 

Mr. VIOLANTE. Sure. We have mixed feelings. I mean we have 

seen other facilities, particularly DoD facilities where VA and DoD 

have gone in together and sometimes there are problems because 

the troops that are stationed there get deployed and then the services really start lacking. But I think some of the facilities up in 

Great Lakes may be working fine with a federal VA kind of emphasis, so it just depends on the area and how it is structured. 

Mr. KELLEY. We have to look at every option. We have to look 

at building standalone VA hospitals. We need to look at public-private partnerships. We need to look at intergovernmental partnerships. We just have to. It has to be right-sized and the services 

need to be in place for veterans. And so every avenue, not just with 

university hospital partnerships, but with county hospitals, with 

city hospitals. I think that as they start planning what they are 

going to replace for their need, if there is room for VA at that same 

campus and it is purchased, it is a co-purchase, it is co-owned, and 

services are interoperable, then it is a smart move. 

Mr. O’ROURKE. To include, you mentioned city, county. To include private sector, potentially, if there is a capacity and expertise 

and a center of excellence in a particular area where there is a gap 

in VA care? 

Mr. KELLEY. Absolutely. 

Mr. O’ROURKE. Great. 

Mr. Blake. 

Mr. BLAKE. I think it would be unreasonable to think that they 

shouldn’t take advantage of affiliate opportunities and partnerships 

if it maximizes opportunity for healthcare. That being said, you 

mentioned Aurora, you know, part of the problem with that over 

the years was figuring out—I can remember a time when the vision 

for that was sort of a joint facility that had a mix of veteran patients and non-veteran patients, civilian patients, and you ran into 

challenges with something as simple as, you know, identification of 

two. And then you got into more complicated issues with like governance and priority of access and service. 

And so you have to be careful when you get into that sort of concept. The Denver issue is clearly—you know, I think it is even 


VACREP0180 with DISTILLER
51 

more unique than the problems that existed in Las Vegas and New 

Orleans that are still going on and Orlando. The Denver project 

has been going on for 20-plus years now and if nothing else, veterans are being unsatisfied there because there are many promises 

that have been made and still no access to healthcare there and 

that is a clearly under-served population. 

Mr. O’ROURKE. Thank you. 

Mr. DE PLANQUE. I think it clearly is a team sport. I think, clearly, it is a country that takes care of veterans, and we have certainly seen in the past, teaching hospitals working in conjunction 

with VA facilities and I think there are some great partnerships 

that can be achieved there. Obviously, the VA has to be the core 

of that and the taking care of veterans. There is a reason that a 

lot of our veterans like to go to the VA and that is because it is 

something that understands them. 

But at the same time, if they are going to be innovative, if they 

are going to be leading the way, like I was saying, you know, the 

leading authorities on TBI, PTSD, et cetera, that is beginning to 

involve partnerships. That is going to involve finding the best people out there, and I think it is absolutely within their grasp to be 

able to do that. 

Mr. O’ROURKE. Thank you. 

Mr. Chair, could I have 30 seconds for Ms. Zumatto to answer? 

Thank you. 

Ms. ZUMATTO. Thank you. 

I would say that while VA certainly has many fine doctors and 

experts, they don’t corner the market. There are lots of people in 

the civilian community who could bring new ideas, research and 

other possibilities. So to say that we shouldn’t be considering public-private partnerships I think would be a serious mistake. 

Mr. O’ROURKE. Thank you. 

Thank you all for your answers and for your work. 

The CHAIRMAN. Thank you very much. 

Ms. Brown, do you have additional comments or questions? 

Ms. BROWN. No, sir. 

Thank you very much for this hearing. 

The CHAIRMAN. Thank you very much for being here. Thank you 

for presenting the Independent Budget; we appreciate that. Expect 

questions to the second panel post-hearing questions and to the 

first panel. There are some issues that we were not able to bring 

up, given the time. 

But, Mr. Secretary, thank you, sir, for staying through the entire 

budget hearing, and with that, I request that all Members have 

five legislative days with which to revise and extend their remarks. 

Without objection, so ordered. 

This hearing is adjourned. 

[Whereupon, at 1:12 p.m., the committee was adjourned.] 


VACREP0180 with DISTILLER
52 

APPENDIX 

PREPARED STATEMENT OF CHAIRMAN JEFF MILLER

Good morning. This hearing will come to order. We are here to discuss the President’s Fiscal Year 2016 budget request for the Department of Veterans Affairs (VA). 

Mr. Secretary, welcome. I understand that your testimony will be a bit different 

than what the Committee is accustomed to, with references to charts to help us better understand what you’re seeing in terms of the challenges ahead. That’s a welcome change. So, too, is the openness that you have had with me, Members of this 

Committee and the Congress about your plans to change the culture at VA. 

As your testimony illustrates you’ve been extremely active in visiting VA facilities, 

talking with employees, veterans groups, and your private sector colleagues with 

one aim in mind . . . putting everyone’s focus squarely on the needs of veterans. 

Thank you for your willingness to take the job of Secretary, and thank you for putting everything you have in to it. 

Turning now to the business of examining the VA budget request, I see some very 

positive things but also some areas with considerable question marks. The Committee’s task will be to learn as much as possible in order to inform our ‘‘Views and 

Estimates’’ letter to the Budget Committee due next Friday. 

On the positive side, Mr. Secretary, you have boldly tackled the sensitive issue 

of VA’s aging infrastructure. Coupled with a more realistic budget request for VA’s 

major construction program, addressing the closure of unsafe, vacant, or underutilized facilities begins an important conversation about the future alignment of VA’s 

infrastructure. I have long argued that we needed a strategic reassessment of VA’s 

construction program. That is, in part, what the independent assessment and the 

Veterans Healthcare Commission, established in last summer’s Choice Act, were 

tasked with examining. You have my commitment to work with you as this conversation begins in earnest. 

I do have several areas of concern that I hope that you and our second panel can 

address. 

First, and I will be frank, the proposal to reallocate any portion of the $10 Billion 

appropriated for the Veterans Choice Program is a non-starter. I understand there 

is a great degree of uncertainty about the program’s utilization. In appropriating the 

money, the Congress had to work with the best estimates we had at the time to 

stretch those dollars, including limiting eligibility criteria for veterans. If there is 

to be any reallocation it will be to further improve and strengthen the program itself 

and not to address other, unspecified needs. 

Second, the budget requests an additional $1.3 billion for VA medical care on top 

of the advance appropriation for Fiscal Year 2016, bringing the total proposed increase to 7.4%. At a threshold level, I do not understand how this request interacts 

with the $15 Billion Congress provided last summer for non-VA care and infrastructure as part of the Veterans Access, Choice and Accountability Act. It would appear 

that there are considerable unknown variables in this area, such as the degree to 

which the Choice Program alleviates workload and resource pressure on VA, the 

productivity standards VA should expect from its clinical workforce, and the ability 

for VA to hire medical professionals in the face of an already large vacancy rate and 

a national shortage of healthcare professionals. I hope to expand on this a bit more 

in questioning. 

Third, I note the 6.5% increase for the Veterans Benefits Administration, principally to hire additional staff to address the workload. Mr. Secretary, there are several of us on the Committee who have a long memory on this issue. We know that 

disability claim staffing has doubled in 10 years and nearly tripled since when I 

first arrived in Congress. We’ve invested over a half-a-billion dollars in the VBMS 

system and millions more in other systems. And we’ve provided tools to encourage 

veterans to file fully- developed claims which, in turn, enables a quicker decision. 

All of these investments were made with the promise that productivity would 

markedly improve and shift the department away from the usual trend of relying 

on an ever-increasing workforce and overtime to deal with the workload. Although 

I note the production improvement in the backlog over the last two years, it is a 

far cry from seeing individual worker productivity improve given the resources that 

have already been provided. Again, this is another area I hope to address in questioning. 

Finally, a big lesson learned last year is that veterans are better served with constant and aggressive oversight. Ms. Brown and I have asked for a larger Committee 

budget toward that end. I believe the Office of Inspector General, too, needs more 

than a .3% increase. The proposed amount is not even enough to cover inflationary 

costs, let alone the increased oversight we all rely so heavily upon. 


VACREP0180 with DISTILLER
53 

Again, I look forward to hearing your testimony, Mr. Secretary. I also look forward to hearing the views of our VSO panel. The VA system is for them and those 

they represent, so their input on budgetary matters is critical to inform the Committee and the Congress on VA’s budget request. 

f 

PREPARED STATEMENT OF RANKING MEMBER CORRINE BROWN, 

Thank you, Mr. Chairman. 

Secretary McDonald, I want to welcome you this morning. I look forward to hearing how this budget request will meet the needs of our veterans. 

The President has proposed a large increase for VA. For FY 2016 the President 

has proposed nearly an 8 percent increase in funding for VA health care, personnel, 

construction, research, and claims processors. 

Given this large request, I look forward to our discussion today, and how it will 

assist our work as a Committee to make sure that this proposed budget gives you 

the dollars you need, but also assures us here in Congress that every dollar you receive will be spent wisely. 

I certainly wish that my bill, H.R. 216, the Department of Veterans Affairs Budget Planning Reform Act of 2015, was the law of the land. It is an important tool 

to assist us, and you, in matching resources to the needs of our veterans and ensuring we are planning for the future to make sure we don’t let down our veterans. 

Mr. Secretary, the first question I will ask is does your proposed budget give you 

all the dollars you need to fix the problems you face, meet the goals of the initiatives 

the Department has laid out? 

Keeping in mind the funding provided by the Choice Act, I hope that we can discuss whether you have enough resources to ensure that veterans do not face intolerable delays in getting access to health care. I hope we can discuss how you are looking down the road to ensure that veterans have access to VA care in the future. 

I always hear from my veterans how the prefer VA care when it is available— 

I hope that we are going to all work together to make sure that this health care 

our veterans prefer is available to them when they need it. 

This is the first year that VA benefit programs are to be funded under advance 

appropriations. Now veterans won’t have to worry as much if we here in Congress 

can’t do our job. 

Finally, I want to hear about your reform and reorganization efforts, and how this 

budget request will support these efforts. I also want to hear about how you are 

making progress in your efforts to reform and reinvigorate the VA. 

Too often, all we hear about is the problems VA is having—I would like us to also 

consider what we can do to fix these problems and to point out what VA is getting 

right. 

I am pleased with this budget request, and hope that these dollars can fix what 

is wrong and strengthen what is right with the VA. 

Thank you Mr. Chairman and I yield back the balance of my time. 


VACREP0180 with DISTILLER
54 


VACREP0180 with DISTILLERInsert offset folio 1 here 98570.001
55 


VACREP0180 with DISTILLERInsert offset folio 2 here 98570.002
56 


VACREP0180 with DISTILLERInsert offset folio 3 here 98570.003
57 


VACREP0180 with DISTILLERInsert offset folio 4 here 98570.004
58 


VACREP0180 with DISTILLERInsert offset folio 5 here 98570.005
59 


VACREP0180 with DISTILLERInsert offset folio 6 here 98570.006
60 


VACREP0180 with DISTILLERInsert offset folio 7 here 98570.007
61 


VACREP0180 with DISTILLERInsert offset folio 8 here 98570.008
62 


VACREP0180 with DISTILLERInsert offset folio 9 here 98570.009
63 


VACREP0180 with DISTILLERInsert offset folio 10 here 98570.010
64 


VACREP0180 with DISTILLERInsert offset folio 11 here 98570.011
65 


VACREP0180 with DISTILLERInsert offset folio 12 here 98570.012
66 


VACREP0180 with DISTILLERInsert offset folio 13 here 98570.013
67 


VACREP0180 with DISTILLERInsert offset folio 14 here 98570.014
68 


VACREP0180 with DISTILLERInsert offset folio 15 here 98570.015
69 


VACREP0180 with DISTILLERInsert offset folio 16 here 98570.016
70 


VACREP0180 with DISTILLERInsert offset folio 17 here 98570.017
71 


VACREP0180 with DISTILLERInsert offset folio 18 here 98570.018
72 


VACREP0180 with DISTILLERInsert offset folio 19 here 98570.019
73 


VACREP0180 with DISTILLERInsert offset folio 20 here 98570.020
74 


VACREP0180 with DISTILLERInsert offset folio 21 here 98570.021
75 


VACREP0180 with DISTILLERInsert offset folio 22 here 98570.022
76 


VACREP0180 with DISTILLERInsert offset folio 23 here 98570.023
77 


VACREP0180 with DISTILLERInsert offset folio 24 here 98570.024
78 


VACREP0180 with DISTILLERInsert offset folio 25 here 98570.025
79 


VACREP0180 with DISTILLERInsert offset folio 26 here 98570.026
80 


VACREP0180 with DISTILLERInsert offset folio 48 here 98570.048
81 


VACREP0180 with DISTILLERInsert offset folio 49 here 98570.049
82 


VACREP0180 with DISTILLERInsert offset folio 50 here 98570.050
83 


VACREP0180 with DISTILLERInsert offset folio 51 here 98570.051
84 


VACREP0180 with DISTILLERInsert offset folio 52 here 98570.052
85 


VACREP0180 with DISTILLERInsert offset folio 53 here 98570.053
86 


VACREP0180 with DISTILLERInsert offset folio 54 here 98570.054
87 


VACREP0180 with DISTILLERInsert offset folio 55 here 98570.055
88 


VACREP0180 with DISTILLERInsert offset folio 56 here 98570.056
89 


VACREP0180 with DISTILLERInsert offset folio 57 here 98570.057
90 


VACREP0180 with DISTILLERInsert offset folio 58 here 98570.058
91 


VACREP0180 with DISTILLERInsert offset folio 59 here 98570.059
92 


VACREP0180 with DISTILLERInsert offset folio 27 here 98570.027
93 


VACREP0180 with DISTILLERInsert offset folio 28 here 98570.028
94 


VACREP0180 with DISTILLERInsert offset folio 29 here 98570.029
95 


VACREP0180 with DISTILLERInsert offset folio 30 here 98570.030
96 


VACREP0180 with DISTILLERInsert offset folio 31 here 98570.031
97 


VACREP0180 with DISTILLERInsert offset folio 32 here 98570.032
98 


VACREP0180 with DISTILLERInsert offset folio 33 here 98570.033
99 


VACREP0180 with DISTILLERInsert offset folio 34 here 98570.034
100 


VACREP0180 with DISTILLERInsert offset folio 35 here 98570.035
101 


VACREP0180 with DISTILLERInsert offset folio 36 here 98570.036
102 


VACREP0180 with DISTILLERInsert offset folio 37 here 98570.037
103 


VACREP0180 with DISTILLERInsert offset folio 38 here 98570.038
104 


VACREP0180 with DISTILLERInsert offset folio 39 here 98570.039
105 


VACREP0180 with DISTILLERInsert offset folio 40 here 98570.040
106 


VACREP0180 with DISTILLERInsert offset folio 41 here 98570.041
107 


VACREP0180 with DISTILLERInsert offset folio 42 here 98570.042
108 


VACREP0180 with DISTILLERInsert offset folio 43 here 98570.043
109 


VACREP0180 with DISTILLERInsert offset folio 44 here 98570.044
110 


VACREP0180 with DISTILLERInsert offset folio 45 here 98570.045
111 


VACREP0180 with DISTILLERInsert offset folio 46 here 98570.046
112 


VACREP0180 with DISTILLERInsert offset folio 47 here 98570.047
113 


VACREP0180 with DISTILLERInsert offset folio 60 here 98570.060
114 


VACREP0180 with DISTILLERInsert offset folio 61 here 98570.061
115 


VACREP0180 with DISTILLERInsert offset folio 62 here 98570.062
116 


VACREP0180 with DISTILLERInsert offset folio 63 here 98570.063
117 


VACREP0180 with DISTILLERInsert offset folio 64 here 98570.064
118 


VACREP0180 with DISTILLERInsert offset folio 65 here 98570.065
119 


VACREP0180 with DISTILLERInsert offset folio 66 here 98570.066
120 


VACREP0180 with DISTILLERInsert offset folio 67 here 98570.067
121 


VACREP0180 with DISTILLERInsert offset folio 68 here 98570.068
122 


VACREP0180 with DISTILLERInsert offset folio 69 here 98570.069
123 


VACREP0180 with DISTILLERInsert offset folio 70 here 98570.070
124 


VACREP0180 with DISTILLERInsert offset folio 71 here 98570.071
125 


VACREP0180 with DISTILLERInsert offset folio 72 here 98570.072
126 


VACREP0180 with DISTILLERInsert offset folio 73 here 98570.073
127 


VACREP0180 with DISTILLERInsert offset folio 74 here 98570.074
128 


VACREP0180 with DISTILLERInsert offset folio 75 here 98570.075
129 


VACREP0180 with DISTILLERInsert offset folio 76 here 98570.076
130 


VACREP0180 with DISTILLERInsert offset folio 77 here 98570.077
131 


VACREP0180 with DISTILLERInsert offset folio 78 here 98570.078
132 


VACREP0180 with DISTILLERInsert offset folio 79 here 98570.079
133 


VACREP0180 with DISTILLERInsert offset folio 80 here 98570.080
134 


VACREP0180 with DISTILLERInsert offset folio 81 here 98570.081
135 


VACREP0180 with DISTILLERInsert offset folio 82 here 98570.082
136 


VACREP0180 with DISTILLERInsert offset folio 83 here 98570.083
137 


VACREP0180 with DISTILLERInsert offset folio 84 here 98570.084
138 


VACREP0180 with DISTILLERInsert offset folio 85 here 98570.085
139 


VACREP0180 with DISTILLERInsert offset folio 86 here 98570.086
140 


VACREP0180 with DISTILLERInsert offset folio 87 here 98570.087
141 


VACREP0180 with DISTILLERInsert offset folio 88 here 98570.088
142 


VACREP0180 with DISTILLERInsert offset folio 89 here 98570.089
143 


VACREP0180 with DISTILLERInsert offset folio 90 here 98570.090
144 


VACREP0180 with DISTILLERInsert offset folio 91 here 98570.091
145 


VACREP0180 with DISTILLERInsert offset folio 92 here 98570.092
146 


VACREP0180 with DISTILLERInsert offset folio 93 here 98570.093
147 


VACREP0180 with DISTILLERInsert offset folio 94 here 98570.094
148 


VACREP0180 with DISTILLERInsert offset folio 95 here 98570.095
149 


VACREP0180 with DISTILLERInsert offset folio 96 here 98570.096
150 


VACREP0180 with DISTILLERInsert offset folio 97 here 98570.097
151 


VACREP0180 with DISTILLERInsert offset folio 98 here 98570.098
152 


VACREP0180 with DISTILLERInsert offset folio 99 here 98570.099
153 


VACREP0180 with DISTILLERInsert offset folio 100 here 98570.100
154 


VACREP0180 with DISTILLERInsert offset folio 101 here 98570.101
155 


VACREP0180 with DISTILLERInsert offset folio 102 here 98570.102
156 


VACREP0180 with DISTILLERInsert offset folio 103 here 98570.103
157 


VACREP0180 with DISTILLERInsert offset folio 104 here 98570.104
158 


VACREP0180 with DISTILLERInsert offset folio 105 here 98570.105
159 


VACREP0180 with DISTILLERInsert offset folio 106 here 98570.106
160 


VACREP0180 with DISTILLERInsert offset folio 107 here 98570.107
161 


VACREP0180 with DISTILLERInsert offset folio 108 here 98570.108
162 


VACREP0180 with DISTILLERInsert offset folio 109 here 98570.109
163 


VACREP0180 with DISTILLERInsert offset folio 110 here 98570.110
164 


VACREP0180 with DISTILLERInsert offset folio 111 here 98570.111
165 


VACREP0180 with DISTILLERInsert offset folio 112 here 98570.112
166 


VACREP0180 with DISTILLERInsert offset folio 113 here 98570.113
167 


VACREP0180 with DISTILLERInsert offset folio 114 here 98570.114
168 


VACREP0180 with DISTILLERInsert offset folio 115 here 98570.115
169 


VACREP0180 with DISTILLERInsert offset folio 116 here 98570.116
170 


VACREP0180 with DISTILLERInsert offset folio 117 here 98570.117
171 


VACREP0180 with DISTILLERInsert offset folio 118 here 98570.118
172 


VACREP0180 with DISTILLERInsert offset folio 119 here 98570.119
173 


VACREP0180 with DISTILLERInsert offset folio 120 here 98570.120
174 


VACREP0180 with DISTILLERInsert offset folio 121 here 98570.121
175 


VACREP0180 with DISTILLERInsert offset folio 122 here 98570.122
176 


VACREP0180 with DISTILLERInsert offset folio 123 here 98570.123
177 


VACREP0180 with DISTILLERInsert offset folio 124 here 98570.124
178 


VACREP0180 with DISTILLERInsert offset folio 125 here 98570.125
179 


VACREP0180 with DISTILLERInsert offset folio 126 here 98570.126
180 


VACREP0180 with DISTILLERInsert offset folio 127 here 98570.127
181 


VACREP0180 with DISTILLERInsert offset folio 128 here 98570.128
182 


VACREP0180 with DISTILLERInsert offset folio 129 here 98570.129
183 


VACREP0180 with DISTILLERInsert offset folio 130 here 98570.130
184 


VACREP0180 with DISTILLERInsert offset folio 131 here 98570.131
185 


VACREP0180 with DISTILLERInsert offset folio 132 here 98570.132
186 


VACREP0180 with DISTILLERInsert offset folio 133 here 98570.133
187 


VACREP0180 with DISTILLERInsert offset folio 134 here 98570.134
188 


VACREP0180 with DISTILLERInsert offset folio 135 here 98570.135
189 


VACREP0180 with DISTILLERInsert offset folio 136 here 98570.136
190 


VACREP0180 with DISTILLERInsert offset folio 137 here 98570.137
191 


VACREP0180 with DISTILLERInsert offset folio 138 here 98570.138
192 


VACREP0180 with DISTILLERInsert offset folio 139 here 98570.139
193 


VACREP0180 with DISTILLERInsert offset folio 140 here 98570.140
194 


VACREP0180 with DISTILLERInsert offset folio 141 here 98570.141
195 


VACREP0180 with DISTILLERInsert offset folio 142 here 98570.142
196 


VACREP0180 with DISTILLERInsert offset folio 143 here 98570.143
197 


VACREP0180 with DISTILLERInsert offset folio 144 here 98570.144
198 


VACREP0180 with DISTILLERInsert offset folio 145 here 98570.145
199 


VACREP0180 with DISTILLERInsert offset folio 146 here 98570.146
200 


VACREP0180 with DISTILLERInsert offset folio 147 here 98570.147
201 


VACREP0180 with DISTILLERInsert offset folio 148 here 98570.148
202 


VACREP0180 with DISTILLERInsert offset folio 149 here 98570.149
203 


VACREP0180 with DISTILLERInsert offset folio 150 here 98570.150
204 


VACREP0180 with DISTILLERInsert offset folio 151 here 98570.151
205 

Æ 


VACREP0180 with DISTILLERInsert offset folio 152 here 98570.152