U.S. GOVERNMENT PUBLISHING OFFICE

29–687 WASHINGTON : 2018

FISCAL YEAR 2018 DEPARTMENT OF VETERANS 

AFFAIRS BUDGET REQUEST FOR THE VETERANS 

HEALTH ADMINISTRATION 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

THURSDAY, JUNE 22, 2017 

Serial No. 115–19 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

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COMMITTEE ON VETERANS’ AFFAIRS 

DAVID P. ROE, Tennessee, Chairman 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

BRUCE POLIQUIN, Maine 

NEAL DUNN, Florida 

JODEY ARRINGTON, Texas 

JOHN RUTHERFORD, Florida 

CLAY HIGGINS, Louisiana 

JACK BERGMAN, Michigan 

JIM BANKS, Indiana 

JENNIFFER GONZALEZ-COLON, Puerto 

Rico 

TIM WALZ, Minnesota, Ranking Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

J. LUIS CORREA, California 

KILILI SABLAN, Northern Mariana Islands 

ELIZABETH ESTY, Connecticut 

SCOTT PETERS, California 

JON TOWERS, Staff Director 

RAY KELLEY, Democratic Staff Director 

SUBCOMMITTEE ON HEALTH 

BRAD WENSTRUP, Ohio, Chairman 

GUS BILIRAKIS, Florida 

AMATA RADEWAGEN, American Samoa 

NEAL DUNN, Florida 

JOHN RUTHERFORD, Florida 

CLAY HIGGINS, Louisiana 

JENNIFER GONZALEZ-COLON, Puerto Rico 

JULIA BROWNLEY, California, Ranking 

Member 

MARK TAKANO, California 

ANN MCLANE KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

LUIS CORREA, California 

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. 

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C O N T E N T S 

Thursday, June 22, 2017 

Page 

Fiscal Year 2018 Department of Veterans Affairs Budget Request For The 

Veterans Health Administration ........................................................................ 1 

OPENING STATEMENTS 

Honorable Brad Wenstrup, Chairman ................................................................... 1 

Honorable Julia Brownley, Ranking Member ....................................................... 2 

WITNESSES 

Joy Ilem, National Legislative Director, Disabled American Veterans ............... 3 

Prepared Statement ......................................................................................... 35 

Carl Blake, Associate Executive Director, Government Relations, Paralyzed 

Veterans of America ............................................................................................. 5 

Prepared Statement ......................................................................................... 39 

Carlos Fuentes, Director, National Legislative Service, Veterans of Foreign 

Wars of the United States ................................................................................... 7 

Prepared Statement ......................................................................................... 43 

Matthew Shuman, Director, Legislative Division, The American Legion ........... 8 

Prepared Statement ......................................................................................... 46 

Poonam Alaigh M.D., Acting Under Secretary for Health, Veterans Health 

Administration, U.S. Department of Veterans Affairs ...................................... 10 

Prepared Statement ......................................................................................... 48 

Accompanied by: 

Mark W. Yow MBA, Chief Financial Officer, Veterans Health Administration, U.S. Department of Veterans Affairs 

STATEMENTS FOR THE RECORD 

Billy R. Maynard, President and CEO, Health Net Federal Services, LLC ....... 52 

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FISCAL YEAR 2018 DEPARTMENT OF VETERANS AFFAIRS BUDGET REQUEST FOR 

THE VETERANS HEALTH ADMINISTRATION 

Thursday, June 22, 2017 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

SUBCOMMITTEE ON DISABILITY ASSISTANCE

AND MEMORIAL AFFAIRS, 

Washington, D.C. 

The Subcommittee met, pursuant to notice, at 2:03 p.m., in Room 

334, Cannon House Office Building, Hon. Brad Wenstrup [Chairman of the Subcommittee] presiding. 

Present: Representatives Wenstrup, Bilirakis, Radewagen, Dunn, 

Rutherford, Higgins, Brownley, Takano, Kuster, O’Rourke, and 

Correa. 

Also Present: Representatives Roe and Sablan. 

OPENING STATEMENT OF BRAD WENSTRUP, CHAIRMAN 

Mr. WENSTRUP. The Subcommittee will come to order. Before we 

begin, I would like to ask unanimous consent for fellow Committee 

Member Congressman Sablan from the Northern Mariana Islands 

to sit on the dais and participate in today’s proceedings. 

Without objection, so ordered. Thank you. 

With that, good afternoon. We thank you all for joining us today 

to discuss the Department of Veterans Affairs fiscal year 2018 

budget submission, particularly as it pertains to medical and mental health care, community care, medical and prosthetic research, 

construction and infrastructure, and veteran homelessness. There 

is certainly no shortage of topics to address this afternoon, so I will 

keep my opening comments short so we can devote most of our 

time to questions. 

However, there are three points to discuss before hearing from 

Ranking Member Brownley and our witnesses. 

First, the President’s budget request includes $186.5 billion in 

budget authority for VA in fiscal year 2018, an increase of $6.4 billion over fiscal year 2017. 

Some have alleged that the increased funding for the Veterans 

Health Administration in this budget goes primarily to community 

care programs, like Choice, rather than traditional in-house programs, which some claim is a dangerous step toward privatization. 

This is not the case. And privatization is certainly not the goal. 

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As the Secretary clarified in testimony before the Senate just 

yesterday, the increase provided to medical services in this budget 

is three times as large as the increase provided to community care. 

Second, the elephant in the room this afternoon is the unexpected shortfall in the Choice Fund that the Secretary announced 

last week. 

In a letter sent to the Committee on Friday evening, Secretary 

Shulgin wrote that higher than expected utilization of the Choice 

Program this year has resulted in an acceleration of funds being 

expended from the Veterans Choice Fund and without significant 

changes to current Choice processes. The Choice Fund is expected 

to run dry by August 15th. 

There are a number of questions remaining today about the extent of the shortfall, the resources, and the actions the Secretary 

needs and when to address it and the consequences of inaction for 

veteran patients who, more than ever before, are relying on Choice 

to get the care that they need. 

Dr. Alaigh, I am hoping that you will be able to provide some 

clarity this afternoon on all of those things. Finally, as the Choice 

Fund shortfall clearly shows, we have challenges today, problems 

we cannot solve without the help of our veterans service organization partners. I am grateful to Disabled American Veterans, Paralyzed Veterans of America, the Veterans of Foreign Wars, and The 

American Legion for agreeing to testify this afternoon. 

We share a mutual sacred goal: meeting health care needs of veteran patients. We are relying on you to come to the table with actionable solutions with how we can move forward together given 

the fiscal realities that we all know exist. We can’t hide from them. 

I am grateful in advance for your candor and your cooperation, 

and I am very much looking forward to today’s discussion. 

And, with that, I will now yield to the Ranking Member 

Brownley for any opening statement that she may have. 

OPENING STATEMENT OF JULIA BROWNLEY, RANKING 

MEMBER 

Ms. BROWNLEY. Thank you, Mr. Chairman. 

And thank you, Under Secretary, for being here with us today. 

I look forward to hearing from you on how this budget request will 

meet the health care needs of our Nation’s veterans. I am also looking forward to testimony from the VSOs on whether or not this 

budget request meets the needs of their millions of veteran members. 

Dr. Alaigh, as Acting Under Secretary of Health, you have taken 

on more in the last few months of your tenure than many prominent Under Secretaries attempt in their entire period of service. 

Over the last few months, VHA has committed to the acquisition 

of a commercial electronic health care record system, the extension 

of the Choice Program to utilize all of the funds Congress provided 

in 2014, the consolidation of capital assets, the establishment of a 

White House hotline, and VA’s decision to drop the appeal of the 

Staab case. 

And while these commitments and decisions seem to be necessary on their face, I question whether VHA has been realistic in 

their request for the funds to support these costly commitments. 

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I hope today that you and the VSOs here can help my colleagues 

and myself understand how VHA plans to successfully execute 

these commitments while ensuring that quality and access to VHA 

care is improved and not sacrificed. 

Because Members of this Committee on both sides of the aisle 

want you to succeed and build the 21st century high-performing 

VHA our veterans deserve, I am especially interested in hearing 

more today about services and programs to improve women veterans health care. This cannot fall by the wayside. 

By 2035, the population of women veterans is expected to swell 

to 35 percent of the total veteran population. VHA must be prepared to meet these expanding populations’ needs. Women veterans 

deserve to receive care from professional providers in comfortable 

settings and in easily accessible manner. We need to keep working 

to break down barriers that may be preventing women veterans 

from receiving VA care, and I look forward to hearing from you, 

Doctor, and the VSOs about how we can do it better. 

I am also looking forward to hearing more about other programs, 

including the caregiver program, the future of the VA’s Care in the 

Community accounts, medical research, and services to address 

mental health and veteran suicide. While I am glad to see a general increase in the funding at VHA, we also want to hear more 

about some of the cuts and spending decisions included within the 

budget and how these could impact the care we provide to our veterans. 

Dr. Alaigh, yesterday, we had an opportunity to meet and talk 

about some areas of concerns I have regarding the services in my 

district and across the country, and I appreciate the dialogue that 

we have had on these issues. I hope today we can continue that 

open dialogue and work together and with the VSOs to determine 

what level of funding is necessary to ensure that VHA can accomplish its full mission. 

Thank you, Mr. Chairman. And I yield back the balance of my 

time. 

Mr. WENSTRUP. Thank you. 

Joining us this morning on our first and only panel is Joy Ilem, 

the National Legislative Director for the Disabled American Veterans; Carl Blake, the Associate Executive Director For Government Relations for the Paralyzed Veterans of America; Carlos 

Fuentes, the Director of the National Legislative Service for the 

Veterans of Foreign Wars of the United States; Matt Shuman, the 

Director of the Legislative Division for The American Legion; and 

Dr. Poonam Alaigh, the Acting Under Secretary for Health in the 

Veterans Health Administration in the Department of Veterans Affairs, who is accompanied by Mark Yow, who is the Chief Financial 

Officer for the Veterans Health Administration. 

I want to thank you all for meeting here this afternoon. 

Ms. Ilem, we will begin with you. You are now recognized for 5 

minutes. 

STATEMENT OF JOY ILEM 

Ms. ILEM. Thank you, Mr. Chairman, and Members of the Subcommittee. On behalf of DAV and as one of the coauthors of the 

independent budget, I am pleased to present our views on the 

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budgetary needs for a few of VA’s most critical health care programs. While DAV appreciates the increases recommended for VA 

in the President’s budget, we are concerned they are not sufficient 

for VA to meet significant increased demand for care and its goals 

of providing timely, high-quality care for veterans both in the VA 

and in the community. 

We applaud Secretary Shulkin for his leadership and efforts to 

restore veterans’ trust in VA and to improve their access to care 

and benefits as well as his focus on reforming inefficient business 

practices and modernizing the Department. We know the Secretary 

has also set forth a number of other priorities: building a high-performing health care network, addressing capital infrastructure 

needs, replacement of VA’s electronic health records and critical IT 

systems, expanding mental health services to veterans with other 

than honorable discharges, and the campaign to eliminate suicide 

in the veteran population. 

While we support all of these reforms, we want there to be an 

honest assessment and discussion about what the real costs are for 

accomplishing all of these important goals. 

Additionally, we ask that you reject the proposals included in the 

President’s budget that would eliminate individual unemployability 

benefits and ramp down veterans’ disability compensation cost-ofliving adjustments for millions of service-disabled veterans. 

Another important issue to veterans is timely access to VA mental health services. Veterans with serious mental health illness, 

post-deployment mental health challenges, including PTSD associated with combat or sexual trauma, are best served by VA’s highly 

skilled mental health providers and a comprehensive mental health 

care model. These services are also critical to VA’s suicide prevention efforts. 

We also note the Secretary proposed opening access to mental 

health care for veterans in crisis who have received a less than 

honorable discharge. While we support this initiative, we are concerned that no additional resources have been put forth in the 

budget to address a potential increase in workload, hire additional 

providers, or expand clinical space, if necessary. We also want to 

ensure appropriate funding is available to improve VA care and 

services for women veterans. 

DAV recommends an additional $110 million for women’s health 

programs to meet increased demand for services including coverage 

of gender specific care, hiring and training of women’s health providers, expansion of childcare pilot and days of care for newborns, 

as well as renovating VA’s facilities to resolve identified privacy 

and safety deficiencies. 

Additional funding is also essential to continue research on the 

health effects of wartime service on women veterans and to better 

address the high rates of homelessness, suicide, and unique transition challenges among this population. These services are especially critical for women veterans with service-connected disabilities, women veterans with wartime service, and women who 

have—and veterans who have experienced sexual trauma. 

Finally, we ask the Subcommittee to eliminate the inequity in 

the current caregiver law this year which limits essential services 

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tion left thousands of seriously disabled veterans’ families without 

the level of caregiver support and services that they desperately 

need and deserve. It is time now to recognize the selfless service 

and dedication of all our caregivers by including resources in the 

fiscal year 2018 budget to finally resolve this inequity. 

In closing, the new administration has pledged full support for 

our Nation’s veterans and a reformed VA. Secretary Shulkin has 

committed to carry out that promise by creating a system that is 

worthy of their service and sacrifices. 

As VA moves forward to rebuild trust with veterans, make needed reforms, and carry out modernization plans to strengthen and 

improve veterans’ health care, we must ensure VA has the resources and support needed to be successful. 

Mr. Chairman, that completes my statement, and I am pleased 

to answer any questions you may have. Thank you. 

[THE PREPARED STATEMENT OF JOY ILEM APPEARS IN THE APPEN- DIX]

Mr. WENSTRUP. Thank you. 

Mr. Blake, you are now recognized. 

STATEMENT OF CARL BLAKE 

Mr. BLAKE. Chairman Wenstrup, Ranking Member Brownley, 

Chairman Roe, and Members of the Subcommittee, on behalf of 

Paralyzed Veterans of America, our coauthors of the independent 

budget, the VFW, DAV, I would like to thank you for the opportunity to testify today. 

I think I would like to begin by applauding the VA and Secretary 

for a number of recent decisions that he has made with regards to 

the IU proposal and the need to use that money to fund the Choice 

Program. He has said he will drop the IU proposal as a means to 

fund it. That is the right decision. 

The Staab ruling, the decision to drop the appeal so that veterans can now get reimbursed for emergency care sought in the 

community, a decision in that case that is the right decision. 

The decision with regard to finally coming to a linkable, interoperable solution in EHR with the Department of Defense, that 

looks like it is the right solution. 

The decision as it relates to other than honorable discharges, it 

will serve veterans that need to be served; that is the right decision. 

The caregiver expansion, we all in this room know what the right 

decision is. It is yet to be made, but it needs to be made. 

Now let’s think about the financial impact of those right deci- sions. The IU proposal alone leaves $3.2 billion that must be addressed. You cannot be unequivocal about that: $3.2 billion that 

now has to be addressed in some fashion. 

The Staab ruling, that is $2 billion in outstanding obligations 

from the previous 2 years, plus what will likely be an average of 

$1 billion going forward under that requirement. 

We don’t even know yet what the EHR costs will be in the long 

term. There are estimates, but they vary. 

The same with the other than honorable discharge. 

We know that the caregiver expansion will cost significant 

money. That doesn’t mean that it is not the right thing to do. 

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I have heard in the last week or two a lot of discussion about, 

well, VA has its collections money available, has its carryover 

funds available, it needs transfer authority: all of these ways that 

they can presumably get to fixing these problems. But let’s be reminded: The IU and the Staab rulings alone are $5 billion. I don’t 

work in the VA, but I doubt that there is $5 billion laying around 

at central office or in the business available to fill those holes. 

The fact is that VA has not been fully forthcoming with what it 

needs for these purposes. And to keep saying, ‘‘Well, we have collections money available, we have carryover money available, just 

give us the transfer authority, we can make this work,’’ that is nonsense. We have grown weary of that nonsense. 

I will grant you that collections money is available, but it is already planned for some purpose in VA. It is built into VA’s budget 

baseline. If you take that money and fill the Choice hole, what did 

you take it away from? There are crosswalks that might demonstrate where those are taken from, but you better be able to justify where you are taking that money from. 

Carryovers, I will grant you the VA ends up with a significant 

amount of money that is available each year in carryovers. My understanding is some of what they have available is fenced for the 

hepatitis decision, and with some flexibility, they can repurpose 

that because they came in under cost to meet the hepatitis need. 

But, you know, we often get asked the question, why the hell 

does the VA still have carryover money at the end of the year, particularly when it is hundreds of millions of dollars? What are they 

spending their money on? Or, better yet, what are they not spending their money on? I understand that they can’t spend more than 

they are given. I fully understand that. But when the VA has hundreds of millions of dollars left in carryover every year, begs a lot 

of questions about how they are being efficient with their resources. 

The idea that they just need the transfer authority to move 

money around—the Secretary has really sort of harped on this, is 

give us the ability to transfer money out of the medical community 

care account to fill in the hole on Choice. Fine. If you want to do 

that, fine. But I ask you, what happens to the veterans being 

served in that medical community care account State currently? 

How are you going to address their needs—or if you take it from 

somewhere else? A perfect snapshot of this transfer authority issue 

is the NRM piece of medical facilities. For years, the VA requested 

approximately $500 million for NRM. I can tell you, and the VA 

knows, they actually spend about $1.3 billion to $1.4 billion a year. 

They actually spend that money. Where is that money coming 

from? What are they borrowing from to pay for that bill? What 

Peter are they robbing to pay Paul? 

We are tired of this. The VSOs, the veterans we serve, the veterans that seek care from the VA are tired of this. It is time to just 

do it right. Tell us what you need, let Congress act upon it. 

The Mil Con, VA Appropriations in the full Appropriations Committee just last week approved their bill to fund the VA. It is less 

than the administration’s request. Does that sound like it is a good 

idea? Because I certainly don’t think so. 

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Mr. Chairman, I would like to thank you again for the opportunity to testify. I would be happy to answer any questions you or 

the Members may have. 

[THE PREPARED STATEMENT OF CARL BLAKE APPEARS IN THE APPENDIX]

Mr. WENSTRUP. Thank you, Mr. Blake. 

Mr. Fuentes, you are now recognized for 5 minutes. 

STATEMENT OF CARLOS FUENTES 

Mr. FUENTES. Chairman Wenstrup, Ranking Member Brownley, 

Members of the Subcommittee, on behalf of the men and women of 

the VFW Auxiliary, I would like to thank you for the opportunity 

to present our views on VA’s budget request. 

The VFW is glad the administration has proposed a 6-percent increase in VA’s discretionary budget. We also strongly support the 

Department’s focus on increased access to high-quality health care 

for our Nation’s veterans; combating veterans suicide, including 

partnerships with organizations like the VFW to leverage our footprints in communities around the country and the world in an effort to eliminate the stigma associated with seeking mental health 

care; ensuring VA is ready and able to care for women’s veterans, 

who are the fastest growing cohort of the veterans’ population; and 

the continued commitment to end veterans homelessness. 

However, I would like to make it clear that the VFW strongly opposes efforts to claw back benefits from our most severely disabled 

veterans. In the past 2 weeks, more than 40,000 letters and emails 

from VFW members and supporters have been sent to Members of 

Congress opposing the administration’s proposal to revoke individual unemployability benefits for veterans who are unable to 

work because of their service disabilities. The VFW opposes the IU 

and the COLA ground-down proposals in the Department’s budget 

request. And we are glad to see Secretary Shulkin has agreed to 

look for other ways to fund the Choice Program. 

The continued failure by Congress to eliminate sequestration has 

forced the administration to propose cuts to veterans programs in 

order to expand the Choice Program under mandatory spending instead of including the program in discretionary spending. Sequestration and Budget Control Act spending caps limit our Nation’s 

ability to provide servicemembers, veterans, and their families the 

care and benefits they have earned. The VFW calls on this Subcommittee to join our campaign to end sequestration and do away 

with arbitrary and outdated budget caps. 

For more than a decade, the IB VSOs have warned Congress and 

the VA that perpetual underfunding has allowed VA’s infrastructure to erode while its capacity has swelled from 81 percent in 2004 

to as high as 100 percent to 2012. We continue to believe that this 

need for space and chronic underfunding of VA’s major construction 

projects could force VA to ration care. VA’s budget request says 

that improving the conditions of VA facilities through major construction projects accounts for the largest resource need to keep 

pace with the growing demand of VA outpatient care, yet the administration’s request only funds one VA major construction 

project. 

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The IB VSOs believe that VA has requested an adequate amount 

for major medical leases. However, Congress must find a way to 

quickly authorize leasing projects. There are now 27 major medical 

leases awaiting congressional approval. Delays in authorization of 

these leases have a direct impact on VA’s ability to provide timely 

care to veterans. The VFW urges the Committee to swiftly pass legislation that would streamline the authorization process for VA’s 

major medical leases. 

Mr. Chairman, this concludes my remarks. I am happy to answer 

any questions that you or the Members of the Subcommittee may 

have. 

[THE PREPARED STATEMENT OF CARLOS FUENTES APPEARS IN THE

APPENDIX]

Mr. WENSTRUP. Thank you, Mr. Fuentes. 

Mr. Shuman, you are now recognized for 5 minutes. 

STATEMENT OF MATTHEW SHUMAN 

Mr. SHUMAN. Earlier this week, a fellow veteran called The 

American Legion for help. She was seeking medical care from the 

VA, a mammogram specifically, but the VA employee told her that 

the request was denied because funds from the Choice Program 

were depleted. Fortunately, the VA employee was wrong. Our staff 

contacted Dr. Baligh Yehia, the Deputy Under Secretary for Health 

and Community Care at the VA, to determine if the funds were 

available so this veteran can receive the medical diagnostics she 

deserved. The bad news is the Choice Program seems to confuse 

even VA staff. The good news is The American Legion and Dr. 

Baligh Yehia were able to assure the veteran got the care she needed. 

Chairman Wenstrup, Ranking Member Brownley, Chairman Roe, 

and Members of the Subcommittee, on behalf of Charles E. 

Schmidt, the national commander for the largest veteran organization in the United States, representing more than 2.2 million members, we welcome this opportunity to comment on the President’s 

proposed budget. 

The American Legion has reviewed the President’s budget request, and while we fully support the administration’s proposal to 

increase the discretionary budget for the VA by $4.3 billion, we 

would like to draw this Committee’s attention to several components of this request that only Congress can address. 

In 2014, President Obama signed the Choice Act. The American 

Legion supported this program as a temporary emergency measure, 

provided it had a sunset date. Through increased emphasis on 

eradicating all hidden wait lists and ensuring that all veterans asking for VA medical appointments were seen within 30 days or less, 

VA quickly exhausted their community care accounts while the 

Choice funding remained largely untouched. Because of the way 

Choice was funded, VA couldn’t adjust the funding between their 

traditional contracting accounts. This created an unbalanced community care program. Then-Secretary McDonald mandated all appointments be pushed through the Choice Program to spend the 

money. This decision caused an artificial dependence on the Choice 

Program while preserving VA’s more established community care 

program accounts. 

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The American Legion calls on the President and this Congress to 

support VA medical infrastructure by reallocating the funding proposed in the 2018 Presidential budget toward current community 

care programs and allowing Choice to expire. 

Shifting from Choice to mental health, about one-third of returning servicemembers report mental health symptoms and suffer 

from major depression or post-traumatic stress disorder. Sixteen 

years of continuous conflict in Iraq, Afghanistan, and elsewhere 

has increased the demand for mental health services at VA. Unfortunately, there is a national shortage of mental health care providers, and this shortage is projected to grow over the next decade. 

Simply stated, there is an urgent need to respond and assist veterans in a timely and responsible manner. The American Legion 

calls on this President and this Congress to increase funding to 

eradicate mental health staffing shortages. 

Focusing on medical research and IT, I think we can all agree 

that medical research is essential to improving the quality of care 

for veterans. The American Legion noticed that in the President’s 

budget, $18 million has been stripped out of the IT appropriation 

for all VA research. We are very concerned about the long-term impacts of cutting research projects like the Million Veteran Program. 

Few people know that the VA has built the world’s largest and 

most robust genomic databases where medical investigators are 

currently studying Gulf War illness, PTSD, bipolar illness, and 

more. 

The VA’s medical research helps to advance VA health care and 

ensures the VA delivers world class, innovative services to veterans. A significant cut like this will negatively impact veterans. 

Secretary Shulkin, in his speech made at the White House, stated he plans drastic changes to VA IT. In fact, he mentioned this 

may be the only area in which he asks Congress for more funds. 

As previously stated, The American Legion is very concerned about 

the long-term impacts of an $18 million cut to the VA IT architecture, and we call the President and this Congress to fully fund 

medical research and modernization. 

Lastly, I will quickly address some ideas to pay for the increased 

budget at the VA. The American Legion aggressively opposes 

cannibalizing existing benefits earned by veterans to support benefits for other veterans. Without question, the proposal to eliminate 

the individual unemployability benefit is one of the worst ideas The 

American Legion has heard in years. We have received many calls 

and emails from our members expressing alarm. 

I personally spoke to a veteran who began crying as he explained 

to me that he would literally lose his home if his IU benefit was 

cut. Additionally, the President’s proposed budget would also round 

down to the nearest dollar the annual cost-of-living adjustment. 

Like IU, this is a bad idea, and The American Legion opposes this. 

The simple reality, we should not be asking veterans to pay for 

their own earned benefits. 

Chairman Wenstrup, Ranking Member Brownley, Chairman Roe, 

and Members of this Committee, it is my honor and duty to share 

the American Legion’s analysis of the President’s budget with you, 

and I very much look forward to answering any questions you may 

have. Thank you. 

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[THE PREPARED STATEMENT OF MATTHEW SHUMAN APPEARS IN

THE APPENDIX]

Mr. WENSTRUP. Thank you. 

Dr. Alaigh, you are now recognized for 5 minutes. 

STATEMENT OF POONAM ALAIGH, M.D. 

Dr. ALAIGH. Good afternoon, Chairman Wenstrup, Ranking Member Brownley, and Members of the Subcommittee. Thank you for 

the opportunity to appear before you to discuss the Veterans 

Health Administration’s fiscal year 2018 budget submission and 

fiscal year 2019 medical care advanced appropriation request. I am 

accompanied today by Mark Yow, our CFO at VHA. 

By way of introduction, I have served as a physician and a 

health care executive in both the private sector and the government sector for over 25 years. I have also served as a frontline physician at the VA medical center in New Jersey for over a decade. 

Then, as now, I have continued to learn a great deal from my patients. My respect for the selfless men and women only grows deeper each day. I am grateful to be here in support of veterans and 

VHA employees. I believe that it is my personal mission, responsibility, and privilege to support them in every way that I can. Because of their sacrifices and service, I am committed to making 

sure veterans receive the very best care anywhere. 

The 2018 budget request will allow VHA to continue on the path 

begun by then-Under Secretary Shulkin towards improving the 

timeliness and quality of care. This also fulfills the administration’s 

strong commitment to all of our Nation’s veterans by providing the 

resources necessary to support those who have earned this care 

through sacrifice and service to our country. 

This budget is not designed to privatize the VA but, rather, to 

get the veterans the best care when and where they need it. Our 

goal is to make VA strong. We are committed to making VA services best in class. 

Suicide prevention is our most important clinical priority at the 

VA, and it is critical that we make suicide prevention everybody’s 

priority. 

We have thousands of health care professionals helping save 

lives of veterans every day. Our veterans’ crisis line continues to 

do amazing work. Since its inception, the VCL has answered over 

2.9 million calls, dispatched priority services and rescues to over 

77,000 veterans, and referred 470,000 veterans to local VA suicide 

prevention coordinators. We have also launched REACH VET, a 

program that analyzes veteran data and identifies those veterans 

at increased risk for suicide and hospitalization. We are also training all the staff through Operation SAVE, teaching everyone to recognize the danger signs of suicide and the steps to be taken to prevent this tragic and unnecessary death. 

There are many examples of VA employees that have helped prevent a veteran suicide. For example, a VA employee saw a veteran 

on the ledge at the top of a VA parking garage. He looked depressed. This employee sent one of her colleagues to get the police 

while she calmly talked with him until they arrived and saved his 

life. This is just one story. We will continue to focus on these critical issues. 

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11 

Another one of our priorities to which I am deeply committed is 

ensuring veterans have timely access to care. VA is taking steps to 

expand capacity at our facilities by focusing on staffing, space, and 

productivity. We are also increasing transparency and empowering 

veterans to make more informed decisions about their health care 

through our new access and quality tool, accesstocare.va.gov. This 

tool will instill a spirit of competition and encourage our medical 

facilities to proactively address access and quality issues while empowering veterans to make choices according to what works best 

for them and their families. 

It also allows veterans to access the most transparent and easyto-understand wait times across the VA and quality care measures 

across the health care industry. 

We are in the process of redesigning and modernizing VHA, and 

this budget supports those efforts. We must recognize we must address community care access and are committed to streamlining 

and improving it. 

A redesigned community care program will not only improve access to veterans but will also transform how VA delivers care within our facilities. Community care access must be guided by principles based on clinical need and quality. VA will continue to partner with Congress and the other stakeholders to achieve our common goal of providing the best care we can for our veterans. 

Additionally, as you know, Secretary Shulkin announced that VA 

will start the process of adopting the same electronic health record 

as DoD to ensure continuity of care between the two Departments. 

We will incorporate the lessons learned through our pioneering 

work on VistA as we move forward. We will also be creating an integrated EHR product, that, by utilizing the same DoD platform, 

will require meaningful interface with other vendors to create a 

seamless system that serves the veterans in the best possible way. 

We believe that this product will serve as a model for the Federal 

Government and health care across the country. 

Finally, VA is committed to providing the highest quality of care 

which our veterans have earned and deserve. I appreciate the hard 

work and dedication of all of our stakeholders. We are all committed to making VA strong, and this budget does that. 

I look forward to continuing our partnership with this Subcommittee and the entire Congress and to work together to continue to enhance the delivery of health care services to our Nation’s 

heroes. I know you share my personal commitment to make sure 

veterans get the very best of care. 

Mr. Chairman, Members of the Subcommittee, thank you, again, 

for this opportunity to testify. My colleague and I are here to answer any questions. 

[THE PREPARED STATEMENT OF POONAM ALAIGH, M.D., APPEARS

IN THE APPENDIX]

Mr. WENSTRUP. Thank you all very much. 

I now yield time for myself for questions. 

I would like to start, Dr. Alaigh. In response, for the record, to 

our hiring hearing that was held in March of this year, we were 

told that there are currently 38,000 vacancies across VA as of April 

24, 2017. That is using data from VHA’s web HR system. So, when 

VA states that they have a certain number of vacancies, are those 

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12 

positions considered funded, and by that I mean appropriated 

funds that are available to fill those positions? Then, if they are not 

expended for the position, what happens with them? Does that 

money gets rescinded or rolled over if not used, or is it repurposed 

within a particular budget line? 

Dr. ALAIGH. Thank you, Mr. Chairman, for the question. Our 

goal at the VA is to make sure that our veterans are getting the 

highest quality of care with the greatest amount of access. 

In this year’s budget, we budgeted about 7,000 additional FTEs. 

And if those FTEs are not filled, those dollars go back to providing 

care through the discretionary funding. So, if our veterans have to 

go into the community, then those dollars go back in terms of ensuring that our veterans are getting care either inside the VA or 

outside the VA. 

Mr. WENSTRUP. So it goes back into caregiving specifically? 

Dr. ALAIGH. Yes. 

Mr. WENSTRUP. Thank you. 

Ms. Ilem, Mr. Blake, Mr. Fuentes, Mr. Shuman, I understand 

your expressed opposition to the proposals in the budget request to 

enact changes, especially rounding down the cost-of-living adjustment, COLA, to the nearest dollar, which, of course, at most would 

cost a veteran $12. I understand the principle of the whole thing. 

I get that. 

But at the same time, when I am in my district, and I am talking 

to veterans, and I ask them, and they are concerned about certain 

programs, certain benefits that we have been talking about and 

they would love to see enacted, I ask them, I said, ‘‘Would you be 

willing to round down,’’ and explained to them what that means, 

every one of them said yes. You know, they get it in principle. But 

you know what? Veterans do that for veterans. 

So I am a little confused on that one, because it is not what I 

am getting from the individual veterans, but we always get it from 

the VSOs. And it has been done in the past. 

And, you know, some of those very veterans may benefit from the program that at most would cost them $12 a year and at least 12 

cents a year. That is pretty good insurance policy for some of these 

types of benefits that they can receive. 

So I am feeling a little bit differently on that particular topic 

when I am out talking to veterans. And I think that that needs to 

be considered. 

We heard a lot of things you are concerned about, and I appreciate you bringing those up. And how do we go about funding and 

where do the moneys go, that is a big discussion to have. But I 

really didn’t hear many solutions, and I would really like to hear 

some viable solutions, some actual, realistic solutions you have as 

to how we can increase our funding and find pay-fors or get offsets 

within. So I would like to ask each one of you, if you can comment 

quickly—if you can discuss these with us. 

We can go down and start with Ms. Ilem. 

Ms. ILEM. I don’t have any specific offsets that we can share. I 

think one of the things, based on our resolutions that we receive 

from our membership was really put forth what we do legislatively, 

you know, talks about specific issues of offsetting veterans—you 

know, one benefit to a veteran to, you know, pay for another proLeonard.horne on VACREP0180 with DISTILLER

13 

gram. And I think the concern is, you know, throughout our organization, that we want to make sure that programs for disabled veterans are provided to them based on their military service, and we 

don’t want to see an interference or trying to take away another 

benefit from another group of veterans. 

Mr. WENSTRUP. Mr. Blake? 

Mr. BLAKE. Mr. Chairman, I think the question somewhat presupposes that in order to get to an increased level of funding you 

would have to offset or find a pay-for or something like that. I 

think the first thing we need to do is be honest with exactly how 

much it is going to cost to provide services, because I think we 

are—I think what we are missing here is, in the early part of the 

process of budget development, a lot of the cuts and reductions and 

figuring out ways to tamp down how much we are going to request 

takes place within the confines of the Office of Management and 

Budget, and we never get to, what does it actually take? 

I mean, the independent budget puts our recommendations forward, and our numbers are basically our belief of what it takes to 

provide care. I don’t sympathize with the position that you are in, 

that you have to figure out how to get to those numbers. But, 

truthfully, I see that as a congressional problem, not our problem. 

Our problem is we tell you this is what we think it takes, and you 

have to deal with the political consequences of cutting or offsetting. 

Mr. WENSTRUP. Yes. And that is the reality. 

Mr. BLAKE. Sure. 

Mr. WENSTRUP. Okay? So that is the reality we have. And since 

I have been here for 5 years, there are things that I know we are 

way overspending, and we have made some changes and working 

on some of those changes to bring costs down in other areas. And 

particularly near and dear to my heart is to get more care to the 

patients and to our veterans in that regard. That should be the 

highest priority, especially as we are dealing with this today. 

But you can’t ignore the reality. And so we are asking you for 

you to help, because you know what? We are all in this together. 

And that is the point I would like to make. So I am asking—you 

know, you talk to veterans. You represent veterans that are going 

through the process, and they do a lot of talking, and it is a good 

thing they do, but if they can come back with some evidence and 

say, ‘‘Hey, you know what I have observed and maybe this is the 

way we can do it,’’ we will take those solutions. So I understand 

the complaints and the concerns, but solutions are helpful to us. 

Mr. Fuentes. 

Mr. FUENTES. Just to add to what you were mentioning, Mr. 

Chairman. You know, there is fraud, waste, and abuse in the system that must be eliminated. There are inefficiencies that must be 

corrected. You know, there was just a release—I don’t know the 

number exactly off the top of my head—about $26 million or so 

that the Secretary estimates to be able to eliminate in terms of his 

fraud, waste, and abuse task force. That is certainly the right approach, finding where to do that without hurting veterans. 

But, frankly, you know, there are these improvements that are 

much needed. There is also nothing that says that it has to come 

from VA’s budget, right? You have congressional rules that say 

that discretionary funding, mandatory funding, needs to be offset, 

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14 

but that doesn’t say that it has to come from this Committee’s jurisdiction. 

Now, I understand that the complications that come with that. 

But, also, frankly, and it has been the VFW’s position for quite 

some time, sequestration has a lot to do with why VA is receiving— 

is not able to ask what they need and why Congress isn’t able to 

give them what they ask for. 

And we have said for quite some time, and hopefully you agree 

we need to end this, you know, setting arbitrary budget caps 10 

years ago that are no longer, you know, realistic. 

Mr. WENSTRUP. Mr. Shuman. 

Mr. SHUMAN. Thank you, Mr. Chairman, for the question. You 

are absolutely right. We are absolutely in this together. 

The first thing I want to sort of point out here is that this country has made a promise to veterans. And my colleagues here are 

right in that the money does not always have to come from the jurisdiction of this Committee. 

During his campaign, the President made a promise that he was 

going to do the right things for veterans, and we want to hold him 

to that. So we are standing by willing to work with you and the 

White House to get the funds necessary to be able to take care of 

the veterans. 

To go back to the first point—and sorry the time is over—our 

members, thousands of them, have to vote on our resolutions, millions, in order to get where we are. And, currently, our members 

are telling us that they are not supportive of the COLA round 

down. So I would love to talk you, to the constituents you have, 

and I would love to make sure that our members are speaking with 

your office as well. 

Mr. WENSTRUP. I am telling you that anecdotally. It is not a scientific study, and it is a not a poll or anything like that, but I just 

ask the question. I appreciate the input. 

And you might understand that it is difficult for any one committee to tell another committee of jurisdiction that they have to 

start giving up things. So I think you appreciate that. 

Mr. SHUMAN. We will tell them for you, Mr. Chairman. 

Mr. WENSTRUP. Ms. Brownley, you are now recognized. 

Ms. BROWNLEY. Thank you, Mr. Chairman. 

I think Mr. Blake pretty much laid it out in his testimony about 

where the challenges are here in terms of ensuring that we maintain and improve upon the programs we have promised to our veterans and to be able to fund all of the programs. 

And with regards to some of these offsets and we—Ms. Alaigh 

talked about the IU benefit as one example. And, certainly, the 

Secretary did, in his testimony, kind of back off of that as a way 

in which to help finance the Choice Program. 

But in your testimony, you still state that it is potentially still 

on the table as an offset. So I just wanted to clear that up. If we 

can clear that up today, or I am wondering if you have a different 

perspective. 

Dr. ALAIGH. Thank you, Congresswoman. As the Secretary has 

said, he would never do anything that puts our vulnerable veterans 

in a compromising position, and so he has committed to looking for 

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15 

another solution besides the IU at this point and working with all 

of you on that. 

Ms. BROWNLEY. And so are—is that something that you and your 

staff and Secretary are all are working on? 

Dr. ALAIGH. Yes, we are all going to work together on it. 

Ms. BROWNLEY. And do you have some sense of when—you know, 

when you will be able to share that with the Committee so we actually know kind of what we are really dealing with here? Because, 

right now, it just seems like we are going to figure it out. But— 

I think this is the time when we are supposed to be really reviewing and digesting a budget so that we can respond to it. So it is 

difficult when we do not know. 

Dr. ALAIGH. Absolutely. We will share it with you as soon as we 

are ready to share what our alternatives are. 

Ms. BROWNLEY. Okay. And the same for the Staab ruling and the 

emergency care nonservice-connected conditions. There is another, 

you know, sort of a blank there for how we are going to backfill 

a $1.5 billion without taking away items like the Choice Act. So I 

hear you are going to be working on it, and I think—you know, I 

am not sure when we will—but it seems like we will have to reconvene another hearing similar to this one to get some of those responses back, Mr. Chairman. 

And, you know, the transferring authority, too, is that still something that you believe is on the table to solve all or part of this 

problem? And if you could talk a little bit about that. 

Dr. ALAIGH. Thank you, Ranking Member. At this point, there 

are three options that we are exploring. The first option is something that we have already done, which is ensure that the Choice 

Fund continues until the end of this fiscal year. And to do that, 

what we have done is made sure that the accounts, the Choice accounts, are being used for the 30-day/ 40-mile rule, and then for everything else that our veterans need outside of the VA, we are 

using the community care funds for that. 

That will take us—and we are managing that on a daily basis. 

That should take us along with the community care funds to the 

end of the fiscal year. However, it will be at the expense of Choice 

being trimmed down significantly. 

The other options are the transfer authority or infusing new 

funds into the mandatory funding stream in order to make sure 

Choice continues at the same pace. 

Ms. BROWNLEY. Okay. Seems like we still have a lot of work cut 

out in order to figure out how we are going to, truly support these 

very, very important programs for veterans. 

On the IVF and adoption regulation that has gone through, I 

know that we have—the rulemaking has been done, the IVF, and 

that program is, I think, under way as we speak. And that is good 

news. I still do not believe we have a rule, regulations for the adoption piece of that. 

So I was wondering how we are progressing on that. 

Dr. ALAIGH. So the IVF program, you are absolutely right. We 

have about 37 families who have already contacted us to be part 

of that program, and we are supportive of continuing the program 

to the next year. I will get back to you on the adoption rules and 

where they are at this point, but we are definitely—I mean, that 

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16 

is part of supporting the whole women’s health and overall programs. 

Ms. BROWNLEY. Thank you very much. 

My time is up. I yield back. 

Mr. WENSTRUP. Mr. Bilirakis, you are now recognized for 5 minutes. 

Mr. BILIRAKIS. Thank you, Mr. Chairman. 

I thank the panel for their testimony today. 

And I thank our veterans for their service. 

Dr. Alaigh, I am hearing an uptick in the complaints and concerns about community providers about the VA’s ability to comply 

with the VA prompt pay rules. Particularly providing the expected 

community care funding shortfall announced just last week, how 

does this budget support improvements to VA’s claims process system, and what, if any, changes are needed in order for VA to fully 

comply with the prompt payment rule? And then can you say anything to assure providers and encourage them to keep accepting VA 

patients? 

I will tell you that the providers I speak to, the physicians I 

speak to, want to see veterans. They feel like it is their duty and 

obligation to see veterans in the community. But they are having 

a hard time getting paid. And you probably hear it. I think, probably some of my colleagues do too. How could we solve this quickly, 

because it is a great alternative to the VA, not to—you know, I love 

the VA. I think that the care is very good in most cases, but as 

an alternative, some of our veterans want to see private physicians. 

So please answer that question for me. I appreciate it. 

Dr. ALAIGH. Thank you, Congressman. I have to tell you, as a 

physician, it is just an honor to serve veterans, and there isn’t a 

single physician who—who doesn’t get touched by serving a veteran 

and taking care of a veteran. And I hear the same complaints that 

you do in terms of prompt payment but also of your process where 

there is a lot of administrative hassle. And so what we have done 

is simplified the process at least for the time being where we are 

requiring less of administrative back and forth and paperwork that 

they have to submit to streamline the process. 

We still have 20 percent of clean claims that are not paid within 

30 days, and that is a problem. And so we are working with our 

TPAs. Our payment to the TPA is within 30 days. The TPAs then 

have to pay their provider. And so this is one of the areas of focus. 

The TPAs are willing to work with us, and we are looking at ensuring streamlining and automating of processes to ensure that our 

providers are getting paid. 

In the new RFP that is out, we are going to have much more rigorous and stringent rules and expectations on the prompt pay piece 

of it. Whatever we are hearing about issues are things that we are 

incorporating into our new RFP process that is going to be awarded 

the first part of the next fiscal year. 

Mr. BILIRAKIS. How are you utilizing the Federal qualified community health centers? Is there a path there? I mean, would they 

be an alternative? I know you are utilizing them to a certain extent. If you can elaborate on that, I appreciate it. 

Dr. ALAIGH. Yes. They play a critical role in terms of access, especially in those critical access areas where we need to meet the 

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17 

needs of our veterans. So we are in discussions. We have an MOA 

with HRSA to ensure that the FQHCs are part of our network as 

we send our veterans out into the community. 

Mr. BILIRAKIS. Okay. Next question: In your budget, what steps 

have you taken to ensure that complementary and alternative therapy services are available to our veterans? That is very important, 

and I know that the Committee really cares about that. I sponsored 

the COVER Act, it passed last year. I want to know the status, the 

President is going to nominate two veterans, hopefully, two veterans on the Committee soon. You know, based on the budget, in 

the budget, tell me how we are utilizing—has it increased? Do you 

plan an increase so that veterans have access to complementary 

and alternative therapies that are, obviously, certified, but I know 

they work, and I think the veterans should have the choice to seek 

what type of therapy works for him or her. 

Can you give me an update on that, please? 

Dr. ALAIGH. Yes, sir. The complementary and critical medicine is 

a core piece of how we provide whole health for our veterans, and 

what we have is 18 flagship sites that are going to be launched in 

October of this year, one in each VISN, that actually delivers a 

whole health model. And in that whole health model, you have 

three prongs. One is to make sure that our veterans are empowered and they come up with their own life plan. The second piece 

is to equip them, and equip them means to have access to complementary and integrated medicine. And the third piece is treating them. But complementary and integrated medicine is an important part of taking care of our veterans who are dealing with severe pain conditions and opioid addiction and some of the other 

very difficult-to-treat conditions. 

Mr. BILIRAKIS. Thank you. So, if you can give me an update, follow up on this with regard to the COVER Act. I know that the Secretary—I have talked to the Secretary, and he just submitted 

names to the President. I wanted to see where we are on that. If 

you could get back to my office, I would really appreciate it very 

much. 

Dr. ALAIGH. Yes, I will. 

Mr. BILIRAKIS. Thank you. 

And I yield back, Mr. Chairman. 

Mr. WENSTRUP. Mr. Takano, you are now recognized. 

Mr. TAKANO. Thank you, Mr. Chairman. 

Mr. Blake, how important is it to VSOs or to your VA—how high 

a priority is it that the 38,000 unfilled positions at the VHA get 

filled? 

Mr. BLAKE. I would say it is critically important, even from the— 

taking it down to the more narrowly focused SCI level, we have 

been working closely with the VA to fill approximately 1,000 nurse 

staffing positions alone in the SCI system of care. It ranges somewhere between 900 and 1,100, but that is just a small snapshot. 

And that is just in the SCI service alone. If you take that out to 

a much wider net, I am sure that it is critical to ensuring the VA 

can function at its maximum capacity. 

Mr. TAKANO. Mr. Fuentes, how high a priority is it for you, for 

your position? 

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Mr. FUENTES. In the past 3 years in serving our members on VA 

health care six times and every single time we ask them, how 

would you improve the VA health care system, the number one answer is hire more doctors. So it is very important to our members. 

That is what they want to see. 

Mr. TAKANO. Mr. Shuman? 

Mr. SHUMAN. Thank you, sir. It is absolutely critical. I mean, 

staffing bleeds into every single—beyond VHA, every single element of the VA, so it is absolutely critical. 

Mr. TAKANO. I passed you last time. I am sorry. My eyes are— 

Ms.— 

Ms. ILEM. Ilem. 

Mr. TAKANO [continued]. Ms. Ilem. Sorry. 

Ms. ILEM. Thank you. Yes, absolutely critical to DAV members 

as well. Hiring at the VA health care system and having access to 

those providers, you know, plays into having timely access to care. 

Mr. TAKANO. So, Dr. Alaigh, did I hear you correctly answer the 

Chairman that all of the 38,000 positions that are unfilled are 

funded? 

Dr. ALAIGH. So, Congressman, we have a steady state of attrition 

and hiring, and that steady state for an organization— 

Mr. TAKANO. I don’t have much time. Can you just answer the 

question? Are they funded? 

Dr. ALAIGH [continued]. There are 7,000 positions that are funded. 

Mr. TAKANO. So 7,000 of the 38—so not all of the 38,000 are 

funded? 

Dr. ALAIGH. There is a 30,000 steady state of positions, positions 

that come and go at any given different time. So our steady state 

is 30,000. 

Mr. TAKANO. I am confused by your answer, because I am hearing 38—the Chairman himself used a figure of 38,000 unfilled positions, and you answered affirmatively that they were funded. 

Dr. ALAIGH. We have funded for 37,000 positions, 30 being the 

steady state and 7,000— 

Mr. TAKANO. Okay. So 37,000 are funded. Okay. 

Dr. ALAIGH [continued]. Yes. 

Mr. TAKANO. So out of the 37. That is quite—that is quite a lot 

of money that is not being spent. You said that money does get 

spent, though. It gets spent on community care. Is that what I hear 

you are saying? 

Dr. ALAIGH. We can hire. But it is the goal to make sure that 

our veterans are receiving care. 

Mr. TAKANO. How big of a commitment is it for—how high a priority is it for the VA to fill those positions? 

Dr. ALAIGH. This is a very big priority, one of our top priorities 

for the VA. 

Mr. TAKANO. It seems to be a persistent issue, though. Every 

year, we see the positions unfilled. I kind of see that you are trying 

to fill up community care funding, that there is this perverse incentive for the VA to not fill those positions and use those savings to 

fund community care. Have you—there is lot of money being spent 

on community care. Do they all spend money? 

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Dr. ALAIGH. No. The money is being spent to hire our staff, our 

employees, and if the—all the money is not spent, it goes into direct patient care services. 

Mr. TAKANO. Well, does that—has all that money been spent? 

Has all the money been spent? 

Dr. ALAIGH. I will have Mark— 

Mr. TAKANO. I realize it gets spent on patient care, but it gets 

spent, looks likes, on other programs. 

Mr. YOW. Yes, sir. I think what Dr. Alaigh was trying to explain: 

Typically, we have a large number of vacancies that are open with 

the turnover that we experience. We have more than 300,000 employees across the VA. No position gets advertised unless the VA 

medical center believes they have funds to support it. We have 

7,025 FTEs—that is a full-year, full-salary, full-time equivalent position—funded in this budget for growth to—with that steady turnover. So, if you are looking at some number above 30,000 vacancies, 

remember, a lot of that is turnover. It doesn’t mean there is extra 

money sitting anywhere that would be used otherwise. 

We have talked about the fact that creation of the medical community care account has eliminated the opportunity at the medical 

center level to move money from in-house care inside the VA medical center to community care and back when those positions are 

vacant. 

If you are missing a surgeon for some period of time, you will 

have to send that care out in order to continue to provide care to 

veterans. If we are able to hire that surgeon back, you would like 

to be able to bring those moneys back from community care and 

put it into our direct care system. So that is what she is trying to 

describe. 

Mr. TAKANO. All right. I am still—I feel like I need to spend— 

my time is out, but I would like to understand more about how this 

works, because I am very frustrated, and I think the VSO is very 

frustrated that we have all those positions vacant. I am trying to 

understand what—it is more than just the money issue. But I don’t 

want to be—I want to be courteous to the Committee. 

Dr. ALAIGH. I think just the one thing that we have lost as a result of this is our three Rs—so recruitment, retention, relocation— 

incentives to make this competitive with the community and the 

marketplace. You know, we have lost, and that has made it a little 

more challenging to bring in employees into the system. 

Mr. TAKANO. Well, thank you, Dr. Alaigh. 

Mr. WENSTRUP. Mrs. Radewagen, you are now recognized for 5 

minutes. 

Mrs. RADEWAGEN. Thank you, Chairman Wenstrup and Ranking 

Member Brownley, for holding this hearing today. 

Thank you, Under Secretary Alaigh and the VSO representatives 

on the panel, for taking the time to testify, and we appreciate you 

being here. 

As you know, this budget request calls for increases to veteran 

services across the board. And in that regard, I would like to praise 

the Department for their commitment to caring for our Nation’s heroes. I hope to continue to work with VA to bring further improvements to veterans’ health care and accessibility services, especially 

Leonard.horne on VACREP0180 with DISTILLER

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for veterans out in rural and remote areas like my own home district, American Samoa. 

However, as is usually the case, there is still much work to be 

done. For example, I would like the VA to work in conjunction with 

DOT and other related departments to make improvements to LBJ 

hospital, the only hospital in the territory, which currently cannot 

treat our veterans due to lack of adequate resources. 

As it stands, our veterans must be flown to Hawaii and put up 

in a hotel for several days on the taxpayers’ dime to receive even 

the most basic care. Last year alone, $3.2 million was spent on that 

exercise alone. That is a lot of money. 

This budget is a good first step, I think, and I look forward to 

more improvements to veteran services to come, especially for our 

veterans in the remote U.S. territories. 

Mrs. RADEWAGEN. My question for you, Dr. Alaigh. The budget 

cites that the Supportive Services for Veteran Families Program 

has a presence in all 50 States, including Puerto Rico, the District 

of Columbia, Guam, and the Virgin Islands, but does not include 

American Samoa. Does this mean that SSVF services are unavailable in my territory? 

And to follow up, how do the needs of homeless veterans and 

their families vary by geographic region? Specifically, how does the 

VA work to address the needs of homeless veterans in rural communities that may be particularly isolated from services? 

Dr. ALAIGH. Thank you, Congresswoman. 

We are committed to serving veterans regardless of where they 

are. And so if this is a specific issue in the Samoa Islands, we really do want to look into it further. 

Since we contacted your office, we are already starting to work 

with the local hospital there, which is a government hospital. We 

are looking for ways to collaborate with them, because we are two 

governmental agencies, and we are going to continue making sure 

that we synergize our efforts. And if there are still gaps in services, 

then we will work together on those. 

Mrs. RADEWAGEN. Thank you, Mr. Chairman. I yield back. 

Mr. WENSTRUP. Thank you. 

Ms. Kuster, you are now recognized. 

Ms. KUSTER. Thank you, Mr. Chairman. 

And thank you to the Committee, to the panel, for being with us 

today. We appreciate it. 

I wanted to ask about the issue about consolidated community 

care network that was outlined in the VA report, this was late 

2015, and get back to the question that Mr. Bilirakis had started 

about the Federally Qualified Health Centers. 

My question is, has the VA developed this plan any further to 

integrate these facilities, especially with regard to this moving to 

an off-the-shelf health record? And is that a barrier or will that be 

helpful to integrate the Federally Qualified Health Centers? 

Dr. ALAIGH. Thank you, Congresswoman. 

Our goal is that veterans get seamless care regardless of where 

they are getting care. Going down the path of adopting the DoD 

EHR platform is only our first step. And it is very clear as we are 

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ness of connectivity has to happen with all of our community providers, like FQHCs, and our private physicians at the same time. 

Ms. KUSTER. Okay. And then continuing that train of thought 

about the adequate funding, whether there is sufficient funding to 

successfully implement the evolution of the electronic health 

record, how much money will the VA require in the fiscal year 2018 

budget to implement the evolution? Because I recall Mr. Shulkin 

saying the moneys are not included in this budget request. 

Dr. ALAIGH. Yes, that is an important question to ask, because 

this is a huge implementation that is going to take years. But the 

most important thing, and having learned from the DoD experience, the first 2 years is really about change management, going 

through the specifications and making sure the standards align. 

And so for the first 2 years we have enough in the budget to be 

able to support the field assessments, going through the specifications, and doing change management. It is going to be in year 3 

that we are going to be asking for additional and significantly additional funding to be able to implement it. 

Ms. KUSTER. So we shouldn’t expect a supplemental budget request for fiscal year 2018? 

Dr. ALAIGH. No. 

Ms. KUSTER. You are saying it would be 2020. 

Dr. ALAIGH. It won’t be in 2018. 

Ms. KUSTER. Okay. Okay. 

The other reason that I am concerned about the requested funding for the IT system, it seems too low to accommodate simultaneous transformations of the electronic health record as well as financial management system, antiquated benefits management system, and one that I continue to try to pursue is a more efficient 

and effective scheduling system. 

So regarding the scheduling, will VA continue to pursue the 

MASS scheduling pilot, and if not, what does the VA plan to do to 

improve its scheduling software? 

Dr. ALAIGH. Again, a very important point. You know, one of the 

things that has been responsible for some of our access issues, including discrepancies in wait times, is our complex scheduling system. So we are rolling out the VSE, which is an interim solution, 

while we are still doing the MASS pilot, because all we are doing 

right now is contractual negotiations with the DoD product. 

So in the meantime, we still are moving ahead with rolling out 

VSE, which is going to be our interim bridge, and then also seeing 

what the MASS pilot demonstrates, because we will have lots of 

learnings just doing that pilot. And we still want to have options 

of the best software modules to be able to deliver the best care for 

our veterans. 

Ms. KUSTER. Well, many of the Members of this Committee were 

on the Committee when the Phoenix scandal was all over the news, 

and we certainly want you to resolve the scheduling issues, use the 

resources and the personnel that we have efficiently, and not end 

up back here daja vu all over again. So I will wish you well with 

that. 

One last, very quick question. I just have 30 seconds. I am concerned that the VA is not requesting adequate funding for medical 

research programs, and in particular the research around pain 

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22 

management and use of opioids to bring down the use of opioids 

in the system so that we don’t continue to create more and more 

and more people with substance use disorder, veterans that are addicted to opioids, heroin, now fentanyl. 

Is there anything that you could say to comment on that? 

Dr. ALAIGH. A third of our research funds do go into mental 

health and substance abuse, including PTSD, suicide, depression. 

We are going to continue down that route. We will have to look for 

additional partnerships and other sources of funding, because we 

are a leader in research. We come up with breakthrough research. 

The rest of the country follows us. And so we are going to continue 

that momentum, you know, in that current environment. 

Ms. KUSTER. Thank you very much. I yield back. 

Mr. WENSTRUP. Dr. Dunn, you are now recognized. 

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

Dr. Alaigh, what will be the impact on veterans care if Congress 

does not act to replenish the Choice Fund, and when will those consequences be felt? 

Dr. ALAIGH. This is a serious concern. And we have a plan that 

we have implemented right now, because under no situation can 

our veterans ever not have access to high-quality care. 

So what we are doing right now is managing the two accounts, 

the Choice account and the Community Care account, and making 

sure that both those accounts last until the end of this fiscal year. 

There will be unintended consequences if we continue down this 

path because the Choice accounts will start to be used very judiciously. And so I do know that the TPAs have put in a lot in 

terms— 

Mr. DUNN. Let me interrupt you, if I can right there. The TPAs, 

you made mention of those earlier, and it sounded like you were 

saying they were the problem paying on time. I was surprised that 

you farmed out the third party—the administration of the Choice 

funds to some external consultant. 

Dr. ALAIGH. So this was a program that was stood up in 3 

months. And if you look at any other managed care organization, 

it takes decades to stand up a program like this. And so we are 

still dealing with bumps along the way, and this is one of the 

things that we are going to have to work on. 

Mr. DUNN. Are there other, less mission-critical areas that you 

could tap the money from in the VA for the Choice Program? 

Dr. ALAIGH. We cannot transfer funds from the discretionary accounts into the mandatory accounts. So we cannot transfer funds— 

Mr. DUNN. So maybe from the mandatory—other places mandatory cannot. 

Let me change tacks here just for a minute. The vision statement 

attached to the budget said that the VA will focus on its 

foundational services, the ones that they can excel in. What are 

those foundational services? 

Dr. ALAIGH. So right now we know the foundational services are 

primary care, mental health, SCI, polytrauma, prosthetics, mental 

health. All those are our foundational services, but depending on 

the marketplace, we will add additional foundational services, for 

example, high-volume medical specialties, some surgical specialties. 

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Mr. DUNN. So let me take a dive at the surgical specialties really 

quickly, one that is near and dear to my heart as I was a former 

transplant surgeon. 

It is my understanding that the veterans who often need transplant care have to travel hundreds or thousands of miles to receive 

their transplant care, and then it may not even be done at the VA 

transplant center. It might be in an academic affiliate. 

Why is the VA hesitant to let veterans pursue transplants in the 

transplant centers, certified transplant centers, near their home 

where we know the transplants are more successful and they are 

much more likely to get the transplant? 

Dr. ALAIGH. Yeah, you are absolutely right, Congressman Dunn. 

This is an area that we have to redesign and change, because as 

long as the transplant centers have the best possible outcome after 

the surgery and have the team that can best manage it, we should 

be opening up the networks, and we are already doing that in certain cases. 

Mr. DUNN. So I can interpret that as that policy is going to go 

away. We are now going to be able to use the transplant—my veterans in Florida are going to be able to use the transplant centers 

in Florida and they will not have to go to Pittsburgh or— 

Dr. ALAIGH. We are doing a market analysis, and we are going 

to finish that market analysis in a year, and after that we will 

show you. But in the meantime, case by case, we are making exceptions and making sure that our veterans are going to the best possible places. 

Mr. DUNN. All right. In the little time left let’s take a look at the 

$226 million line item for modernization and interoperability of the 

VistA health record system, which I gather we are abandoning, 

right? We are walking away from that, going onto the DoD system. 

$226 million for a system we are leaving? Help me. 

Dr. ALAIGH. This includes the change management that we are 

going to be doing as we are rolling out the new EMR. 

Mr. DUNN. You are saying that is the cost of adoption upfront? 

Dr. ALAIGH. Yes. 

Mr. DUNN. $226 million? 

Dr. ALAIGH. And also maintaining our legacy VistA systems 

along the way. 

Mr. DUNN. Thank you. 

I yield back, Mr. Chairman. 

Mr. WENSTRUP. Mr. Higgins, you are now recognized for 5 minutes. 

Mr. HIGGINS. Thank you, Mr. Chairman. 

Dr. Alaigh, thank you for your service. 

I would like to follow up on what my colleague asked. Why does 

it take a year to figure out what everyone in this room knows is 

already an accurate conclusion? A veteran should be able to get a 

transplant in his own home State. This is just common sense. 

This is the type of thing that we are tired of. This is the kind 

of thing that veterans from sea to shining sea come to a veteran 

like me, as a Representative, and they say, ‘‘Captain, why don’t 

they get it in D.C.?’’ 

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So please tell us, why does it take a year to figure out what this 

distinguished surgeon has come to the conclusion of already and, 

I imagine, the other doctors on this Subcommittee? Why a year? 

Dr. ALAIGH. Again, a very valid concern. As you know, the VA 

delivers some of the best outcomes in quality care, and in order to 

ensure that our veterans are getting the highest quality of care, we 

are going to be doing an analysis of all the services that should be 

provided inside the VA versus— 

Mr. HIGGINS. And what does that cost? Because we have just arrived at that conclusion, it costs nothing. 

Dr. ALAIGH. And, Congressman, it is not just for transplant services that we are looking at. We are looking at hundreds of different 

types of specialties and services, and at the same time looking at 

veteran demand. We are looking at reliance. We are looking at 

what the highest performing providers are in the network. 

Depending on where our veterans get care is directly correlated 

with the outcomes for our veterans. And we want to make sure our 

veterans are getting the best possible care. 

Mr. HIGGINS. Thank you for your patient response, ma’am. 

Please understand my passion is strictly reflective of my love for 

our veterans. 

Dr. ALAIGH. We are on the same side. 

Mr. HIGGINS. All of us, in one way or another, continue to serve 

our country. I thank the veteran service organizations present. You 

have been very helpful to my office. In particular, Matthew 

Shuman, the director, has been very interactive with my office in 

helping us as we move forward. 

In talking about the budget, as soldiers, sailors, airmen, and marines, we recognize sacrifice for our country. And please let us note 

that the VA and the VHA has received a significant increase in 

funding despite the fact that our Nation faces a $20 trillion debt. 

That is the people’s treasure that we must protect. 

And despite that we exist in an era where we face such a danger 

to the future of our country, the VA and VHA have received a significant increase in budget, which I believe is reflective of the spirit 

of this Subcommittee and the VA Committee as a whole and of our 

President and of this body from both sides of the aisle. 

So my question, ma’am, if I may jump into veterans homelessness, the VA and many local and State governments have made 

tremendous strides in reducing the rate of veteran homelessness. 

However, nearly 40,000 veterans and their families still face homelessness. 

The 2018 budget requests 1.7 billion to assist homeless veterans 

and prevent at-risk veterans from becoming homeless, in part by 

building a capacity of available residential, rehabilitative, transition, and permanent housing supply. And the VA has a program 

called a VA Enhanced-Use Lease Program. It occurs to me to be 

a very wise investment of the people’s treasure. 

Can you please provide information to the Subcommittee regarding appropriate properties that the VA could utilize for job training, medical services, transitional services, transitional housing for 

our homeless veterans and their families, please? 

Dr. ALAIGH. Yes, we will. 

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Mr. HIGGINS. And we would like those properties identified. If 

you could provide that to the Subcommittee, I would appreciate it. 

In my remaining 40 seconds, regarding caregivers, under the 

Program for Comprehensive Assistance for Family Caregivers, 

24,555 primary family caregivers were approved in 2016; 33,345 in 

2017; and expected 37,100 caregivers for 2018. This is significantly 

higher numbers than were expected when the program was initially established. 

Has the VA begun working to ensure that the Caregivers Program can continue to provide services and stipends to the veterans 

and caregivers most in need? And can you lay out how the program 

has and will change to ensure its longevity? This is a crucial program for our veterans. 

Dr. ALAIGH. Yes. I mean, the Caregiver Program is a very important fabric of how we keep our veterans at home, independent, and 

autonomous. So we support the program. We are working on redesigning the program so that we can also offer it to the pre-9/11, the 

most vulnerable veterans who need it. 

But in the meantime, we have a whole compendium of services 

that we can use to help support our veterans so that they stay at 

home, our Home-Based Primary Care and Respite Program, lots of 

different other entities. 

Mr. HIGGINS. I applaud your answer, ma’am. And I thank you 

particularly for mentioning pre-9/11 veterans. 

Mr. Chairman, I apologize for going over time. I yield back. 

Mr. WENSTRUP. Mr. Chairman, Dr. Roe, you are now recognized. 

Mr. ROE. Thank you, Mr. Chairman. 

And just an opening round, I know one of the things we hear 

every year is about how the VSOs are worried about being 

privatized. And while the Subcommittee was asking questions, I 

looked up some data. In 2009, the entire VA budget was $93.7 billion. There were about 240,000 employees, I think, at that time. This budget request is for $186 billion. That is for fiscal year 

2018. That is in 9 years. That is a doubling in 9 years of the VA 

budget. And the VA currently has 364,000 employees. It is over 

100,000 more people working than 8 years ago or when I came to 

the U.S. Congress. So I don’t see how in the world anybody can 

make an argument that it has been privatized. 

I think what the VA is trying to do is provide the very best care 

it can for veterans. And if they can’t provide it in-house, they wanted a way to provide it outside, just as has been mentioned on the 

transplants and other things, and I applaud them for that. 

And I am sorry that Mr. Higgins just left, but I was in Los Angeles a couple months ago and they are using property there. Ten 

percent of the homeless veterans in America are in Los Angeles 

County. And they are using a 387-acre campus, and many buildings that have been abandoned are not used. They are refurbishing 

those buildings for homeless veterans and creating a village there. 

And with all the other support services, with the HUD-VASH and 

so forth, it is a tremendous program. 

I was in Fayetteville, Arkansas, Monday, with the Secretary, and 

they have taken a building on the campus and have rehabbed it 

for inpatient mental health treatment up to 90 days for alcohol and 

drug abuse. And we know that Medicare now stops paying after 15 

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days. You can’t do the care in 15 days for drug abuse, and VA has 

recognized that. 

And so they need a shout-out for those programs that they are 

doing. There are some really good ones around the country. I think 

we hear all the bad. We don’t hear a lot of times the good. 

We have a tremendous problem in the Budget Control Act—Mr. 

Fuentes mentioned this—with budget caps. He is correct. Our discretionary part of the U.S. budget has been almost the same, which 

means that we have taken away from Education and Department 

of Defense and other things to provide services for the VA. 

And I get a little frustrated sometimes because I know we have 

done that, and have had other requests that come on from educators, from people in other parts that are very needy parts of our 

society too. 

So I think this Committee has done what it can do in certainly 

listening to everybody and trying to provide every benefit we can 

for the VA. 

A question that Mr. Takano was talking about that I want to get 

a little bit clearer myself was that when that money is appropriated and it takes months because of the VA’s convoluted way 

they fill that position, what happens to that money if you hired 

that physician on day 1, or that nurse, it doesn’t matter, that 

health care provider? That money has been there for 6 months. 

What happens to that money and where is it? Because it is not 

spent, because the position isn’t filled. 

I think that was your question, wasn’t it? Yeah. 

So—I think I heard Mr. Yow say, and he can, Mr. Yow can answer if he wants to. But if a veteran like myself would come in and 

need a hernia fixed and there is no surgeon there, would you use 

that surgeon’s salary that you would have been paying to pay for 

my community care? I think that is what he was asking. Or where 

is the money? Is it still there? 

Mr. YOW. Yes, sir. Remember, what we have in the budget is an 

FTE, a full-time equivalent salary for 7,000 FTE. 

Mr. ROE. That is a person. 

Mr. YOW. Over the course of the year— 

Mr. ROE. An FTE is a human being, that if you hired him that 

day would go to work and get a salary. 

Mr. YOW. It is a full-year salary for a human being, yes, sir. And 

when we are hiring new people, those 7,000 FTE may represent 

20,000 new hires, depending on when they were hired during the 

course of the year. So it is new money that goes towards hiring. 

In the event that you can’t hire someone, say in a remote location, that is what we are talking about, we used to have the ability 

when it was all within the medical services account to move those 

funds back and forth between purchasing the care, if we had a vacancy, or if we were able to bring somebody in, bring it back to provide in-house care. It still goes to care for veterans regardless— 

Mr. ROE. So it is. We are just not spending it on salary, but it 

would be spent on paying a physician outside. That is what I am 

trying to get to. Is that correct? 

Mr. YOW. It may well be, or it may be paid—we do something 

called fee-basis physicians where we hire a contract physician and 

bring them in-house to provide care. 

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Mr. ROE. Sure, I mean, but it is paid for care. That money is not 

just sitting in an account somewhere accumulating? 

Mr. YOW. No, sir. It is used. It is all going to care for veterans. 

Mr. ROE. Okay. I think that wasn’t clear to me either. I agree 

with that. 

I see my time has expired, Mr. Chairman. 

Mr. RUTHERFORD. [Presiding.] Thank you, Mr. Chairman. I appreciate that. 

I actually have 5 minutes myself now that I have moved into the 

chair. 

Dr. Alaigh, let me ask you this. In your written testimony it 

says, ‘‘In addition to increasing the number of veterans accessing 

care through the Choice Program, VA is working to increase the 

number of community providers available through the program.’’ 

And I can tell you, as a result of the way some of these providers 

are being paid, I just passed a letter to Chairman Roe earlier, a 

provider in Jacksonville, Florida, who is no longer going to see veterans because they are hundreds of thousands of dollars behind in 

payment. And there is a hospital who has the letter on the way 

that is also going to no longer see veterans. 

And so I am very concerned because one of the purposes for the 

Choice Program, when Congress enacted that, was because veterans were not receiving access to care that they needed and deserved. And so we now see you are trying to add facilities and we 

are losing facilities as well. So I am concerned about that. Can you 

tell me how the VA plans to address this problem? 

Dr. ALAIGH. Congressman, this is an important problem and one 

of the reasons of dissatisfaction in our community providers. And 

we are working, again, very hard with the TPAs. 

But at the same time, all the learnings that we have had from 

the input that you have been giving us and we have been working 

together on with our partners here around the table, we are incorporating that into our new RFP process where we will be able to 

award new TPA agreements where there is more accountability 

and they are held responsible for prompt payments and making 

sure that our providers, the providers are satisfied as part of— 

being part of this network. 

Mr. RUTHERFORD. Okay. You know, another concern that I have, 

when I hear that it is going to take a year to assess transplant facilities that are already certified, and VA is now going to do some, 

I guess this is like an internal certification that you do of your 

own? Is that what is going on here? 

Dr. ALAIGH. No. This is not a certification process. What we are 

doing is, as we are looking at how we identify a high-performing 

network and also identify what services we develop inside the VA 

based on region and marketplace, we are doing a detailed market 

analysis. 

Mr. RUTHERFORD. If I can interrupt, though, these facilities are 

already certified. They are out there. Folks are using them every 

day. And so I am concerned that that is going to take a year. 

I am also concerned, I heard you mention that it is going to take 

2 years to do an assessment and an alignment to figure out the her 

and the integration with DoD. 

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Now, Secretary Shulkin sat at that table and said: We are not 

in the IT business anymore. We are going to go out and we are 

going to find product that meets our need. And now I hear you saying that we are going back to the old 2-year process of studying 

something, looking at something, figuring out what the elements 

need to be to create this integration. 

Tell me what this program needs to look like that is so different 

that it is going to take 2 years to get alignment. 

Dr. ALAIGH. Congressman, any big project like an EMR implementation requires a lot of change management. We have providers, we have nurses, we have clinical teams that have been used 

to using a certain electronic health record. It is sort of part of the 

core of how we deliver care today. 

In order to make sure that the off-the-shelf product is customized 

to all the different elements of care that we have incorporated into 

the VA, because the VA does such amazing things with team-based 

care and PACT teams, we are going to have to customize a lot of 

those standards and specifications. 

That is what is going to take time. We are going to have the 

frontline physicians, nurses, all involved with this. There are different, like there is an OR piece. There is a behavioral health piece. 

All those things are going to happen because it is going to be a bottom-up approach. EMR implementation cannot be a top-down approach. It has to be a bottoms-up approach. 

Mr. RUTHERFORD. Seems like you just go pick it off the shelf. I 

mean, that is what Secretary Shulkin was talking about. 

My time is up. Thank you very much. 

Mr. Sablan, 5 minutes. 

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

And I appreciate very much you allowing me to join you this afternoon. 

Dr. Alaigh or Mr. Yow, what efforts are being made to recruit 

and retain—well, let me go back. Let me try to understand, I think, 

Mr. Takano brought it up, you have 7,000 vacancies or was that 

37,000 vacancies? 

Dr. ALAIGH. We have the budget to support a 7,000 increase in 

FTEs. 

Mr. SABLAN. FTEs. And that is medical professionals or that includes clerical— 

Dr. ALAIGH. It could be everything. 

Mr. SABLAN. Everything, okay. And you already have—right now 

you have over—some 180,000 employees? 

Dr. ALAIGH. Over 300,000. 

Mr. SABLAN. Okay. Right. Thank you. 

So let me go parochial here. What efforts are being made to recruit and retain health care professionals for remote and underserved areas, and have they been successful? 

Let me say this. I understand that staff from the Pacific Island 

Healthcare System, from staff, that a licensed clinical social worker 

position was approved for my district in Northern Marianas. What 

is the status of that recruitment? 

Dr. ALAIGH. I am sorry, for your social worker? 

Mr. SABLAN. Yes. 

Dr. ALAIGH. I would have to get back to you on that. 

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Mr. SABLAN. Okay. And if you do have that information, we have 

a way of getting out Federal job announcements on a weekly basis. 

And if you would share with us, then we could help you promote, 

provide that information in our newsletter. It goes out to, you 

know— 

Dr. ALAIGH. Yes, absolutely. In fact, there are two programs— 

Mr. SABLAN [continued].—thousands of people. Because right 

now you only have a clerk who handles appointments and a fee or 

a contracted physician. Thank you. 

You also mentioned earlier that the VA is trying to manage 

Choice so that funds last through the end of the fiscal year. Could 

you explain how the VA will do that? When I thought you mentioned prioritizing those veterans, I thought you also mentioned 

prioritizing those veterans living 40 miles from the VA facilities. Is 

that correct? 

Dr. ALAIGH. Correct. 

Mr. SABLAN. So those veterans who live 40 miles away from a 

facility will be prioritized or if they travel by sea or by air. 

Dr. ALAIGH. Yeah. They will still be prioritized as part of the 

Choice Program, and then we still have Community Care funds for 

the other veterans. 

Mr. SABLAN. Okay. Right. 

So, Mr. Yow, what is the FTE formula for determining the number of health care professionals needed in remote and underserved 

areas, particularly, again, areas like the Northern Mariana Islands? 

Mr. YOW. Yes, sir. I don’t believe that VA currently has any sort 

of a standardized staffing methodology to determine that. It has 

been determined at a local level based on resource availability. 

I believe we are in the process of looking at several different 

types of models to use. One of which we are looking at is the DoD 

model for their fixed facility hospitals to see if we might be able 

to standardize staffing across the VA. But it has been very much 

a decentralized process. 

Mr. SABLAN. But neither VA or DoD has a facility in the Northern Mariana Islands. So how do you use that model to—how do you 

use it to get information on the number of people you need? 

Mr. YOW. Yes, sir. It would be driven by the patient demand that 

you would have in that area and the scale of the size of the local 

facility. But like I say, we are very much in the beginning stages 

of that process. 

Mr. SABLAN. And my next question is moot, I guess. 

Thank you very much. Thank you. I yield back my time. 

Mr. RUTHERFORD. The gentleman yields back. Thank you, Mr. 

Sablan. 

I believe Chairman Roe has a follow-up question. 

Mr. ROE. I do, just very briefly. And thank you, Mr. Chairman 

for yielding. 

A follow-up from what Dr. Dunn was talking about just a minute 

ago. If Congress does not replenish the Choice Fund, will wait 

times lengthen like they were before Phoenix? 

Dr. ALAIGH. Yes. 

Mr. ROE. Okay. That is one thing I wanted to know. 

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Will veterans be able to seek appointments in the community 

like they have before if the Choice is not replenished? 

Dr. ALAIGH. No. 

Mr. ROE. And will the TPAs have to let staff across the country 

go if it is not replenished? 

Dr. ALAIGH. Yes. 

Mr. ROE. They will, okay. 

Those were the three things I would have liked to have placed 

on the record. And I yield back. 

Mr. RUTHERFORD. Thank you, Mr. Chairman. 

I believe Mr. Takano has a follow-up as well. Oh, I am sorry, Ms. 

Brownley. 

Ms. BROWNLEY. No, that is fine. Go ahead. 

Mr. TAKANO. So I just want to get clear about, Dr. Alaigh—or is 

it Dr. Young is next door? Mr. Yow, okay. I just can’t read the 

names. My eyes can’t see. These are reading glasses. These are not 

binoculars. 

So let me get this straight. So you have 7,000 funded FTEs for 

personnel in VHA, but how many vacancies are there? 

Mr. YOW. I have heard the Secretary use numbers between 

35,000 and 45,000, but I think our personnel staff are trying to go 

back and verify those. We have a number that are open for any period of time for repeated vacancies for things like nurses and so 

forth. So I believe they are trying to go through right now and 

scrub that and come back with a better estimate. 

But like I say, typically we have about 10 percent of our total 

workforce that will turn over within a year, so that would be about 

30,000 at any given time that we would be recruiting. 

Mr. TAKANO. So there is a 10 percent turnover, but there are also 

positions that are unfilled in addition, right? 

Mr. YOW. Yes, sir. 

Mr. TAKANO. So the total workforce represents a shortfall in 

what is needed, and so I am trying to get a sense of that. 

Mr. Fuentes, you mentioned earlier, I want you to kind of explain more what you meant about that you feel that the VA’s budget was shorted or constrained by sequester. Can you elaborate just 

a little further on that? 

Mr. FUENTES. Yes. Thank you, Congressman. 

So sequestration occurred because, you know, this was a super 

committee that was created in 2010, so essentially reduced the 

budget over 10 years for a certain amount of—I forgot the exact billions amount of money. They failed, so then it was an arbitrary 

every year 10 percent cut of the budget. 

There were negotiations the past 4 years. In 2018 the fiscal—the 

budget for fiscal year 2018 reverts back to those budget caps that 

were set 7 years ago. So what really happens is when you have, 

you know, the overall cap, then you have to decide how you are 

going to split that money. 

And really, because of that, VA is impacted in how much they 

can request because OMB tells them you need this much money 

but this is only how much you can get. And then it also limits Congress’ ability to fully fund what VA has requested because of the 

needs of other departments, other committees, and other programs. 

Mr. TAKANO. Well, thank you. 

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31 

And I just have one more— 

Mr. ROE. Would the gentleman yield? 

Mr. TAKANO [continued]. I do want to ask one more question, if 

I can just ask the last question. But I will yield. 

Mr. ROE. Just very briefly, just to put that in context. Like I said 

a moment ago, I was here for the BCA. We had a number in the 

discretionary part of the budget that we funded. We have taken 

money away from other departments and almost doubled, as a matter of fact over doubled the VA’s budget, just for clarification. I 

yield back. 

Mr. TAKANO. Thank you, Mr. Chairman. 

If I could, I just want to ask a question on homelessness. It was 

mentioned before. 

In 2015, the Supportive Services for Veteran Families, SSVF programs, received a nationwide surge in funding. That surge consisted of about $300 million to 56 communities, including my own, 

over 3 years. Those funds dry up at the end of this fiscal year. 

In order to maintain the same levels of services and prevent the 

expiration of these surge grants, the SSVF program would need up 

to $80 million more in fiscal year 2018 than the Department requested. 

Now, many communities that receive that money say it is still 

necessary to end veterans’ homelessness in their areas, and some 

communities have reached the goal of ending veterans’ homelessness with that money, say that it is also necessary to rapidly rehouse newly homeless veterans in their areas. These areas will 

need funding for the SSVF program. 

Now, please explain why the Department’s budget did not reflect 

the cost of maintaining these surge grants. 

Dr. ALAIGH. I can tell you that homelessness is one of our most 

important priorities. We have made huge strides in fighting homelessness. We have a 4 percent increase in our homelessness budget 

for fiscal year 2018. 

And we will continue to make sure that we are working on appropriate case management programs, appropriate housing programs, and also the grant programs that all of your communities 

get in terms of the ability to fight it. About 50 percent of our funding actually goes to those grant programs in each of your communities. 

Mr. TAKANO. I am going to take this to follow up for the record, 

in written, but as I understand it, HUD has cut from $60 million 

to $7 million funding for the HUD portion. I would like to be able 

to—if you—if the VA considered that as they are making their requests. But I will take that for the record later. 

Dr. ALAIGH. Thank you. 

Mr. RUTHERFORD. Thank you. The gentleman’s time has expired. 

Ranking Member Ms. Brownley. 

Ms. BROWNLEY. Thank you, Mr. Chairman. 

Since we have been talking so much about the vacancies within 

the VA, which is a very, very important topic, I just wanted to ask 

a question, because I know that we have had many hearings about 

HR services and the vacancies that needed to be if I would within 

HR. 

Leonard.horne on VACREP0180 with DISTILLER

32 

Can you tell me, within HR across the board in the VA, how 

many vacancies there are within Human Resources? These are the 

people that actually hire the people. 

Dr. ALAIGH. Ranking Member, this is one of the weak links for 

us right now, and we don’t have enough HR staff to support the 

hiring process. And we are looking at different ways of improving 

that hiring process. 

One of those programs that I know I was talking to Chairman 

Wenstrup about is the WARTAC program where servicemembers in 

the last 6 months before separation can be trained while they are 

still in their military facilities and be brought into the VA system. 

And so that is one of the things that we are going to be focusing 

on as we are trying to hire HR staff, scheduling staff, and logistics 

staff. Those are going to be our three focus areas. 

Ms. BROWNLEY. Just it is hard for me to imagine that an HR 

staff—I mean, I can understand doctors. I can understand nurses. 

I can understand a lot of reasons and barriers for filling those pipelines and hiring those people. It is hard for me to understand that 

we can’t fill positions in Human Resources. It is just hard for me 

to understand. And I would like to know a little bit more about 

that, and I would like to know with accuracy what are the vacancies within Human Resources. 

My colleague here is also saying that I know we had a hiring 

freeze. I don’t know if that freeze is still on or off. 

Mr. TAKANO. Does it affect HR in particular? 

Ms. BROWNLEY. There is a freeze on human resources? 

Dr. ALAIGH. No, there is no freeze on any of the field positions 

at all. The field can hire, including HR, IT staff, and all the staff. 

Ms. BROWNLEY. Okay. And then the last thing that I just wanted 

to get back to for a minute, which we talked a little bit about in 

my office yesterday, is Cerner and the electronic health records. 

So I was wondering if you could give the Committee a basic 

timeline. I think Mr. Rutherford is surprised that he is hearing 

that it is going to take kind of 2 years to gear up with the Cerner 

system to have compatibility with the DoD. 

And you have given all the reasons why that is. And I think I 

understand it a little bit more because we had deeper conversation 

in my office yesterday. But, you know, as I said to you in my office, 

I am like, I am surprised, because I was as surprised like you were. 

But if you could provide us—or if you could tell us right now, which 

would be great—what you believe the timeline is. 

I know you said in the office it is going to take 6 or 8 months 

to negotiate a contract, and then it is going to be kind of a 2-year 

period to get up and going, and that is the interoperability between 

the VA and the DoD. And then we have got to figure out—the 

Cerner system doesn’t come with automatic interoperability with 

community partners. 

Dr. ALAIGH. Right. 

Ms. BROWNLEY. And so that all has to be figured out too. 

So I started to think yesterday, well, this is going to be a pretty 

extensive timeline before we actually get to the place that we all 

want to be. So do you have a specific timeline that you could share 

with us so that we can monitor it? 

Leonard.horne on VACREP0180 with DISTILLER

33 

Dr. ALAIGH. Yeah, absolutely. And what we are committed to do 

is once we have developed the high-level implementation plan we 

will share it with you. You know, you have been, the Committee 

has been amazing when it comes to every step of the way, as we 

have developed new programs, including the new care programs. 

So we will be sharing this with you along the way, but, yes, 3 

to 6 months for negotiation and executing on the contract and then 

preparing the field for it. And we are talking—this is what happens 

in EMR implementation at this scale. This is not different than the 

VA. The DoD is going through this, and this is one of the largest 

implementations ever for any health care system. 

And you want to do it right. It is patient safety. You don’t want 

to lose data. You want to make sure all the users know exactly 

what to do and have all the key elements of care that are going 

to ensure that the patient is getting the best possible care. 

So this is not something that you just do with the turn of a 

switch. This is something that has to be done very carefully. And, 

again, as I said, it has to be a grassroots effort. It is not something 

that we just say this is what the product is and you just go ahead 

and implement it. 

But I can understand how you are feeling about this. It is going 

to be a multiyear, you know, 5- to 10-year project at this point. 

Ms. BROWNLEY. Well, what I am interested in, and I hear it and 

I am understanding it much better, but what I would really like 

is a very specific timeline in terms of what the implementation 

looks like. 

Dr. ALAIGH. Yeah, and we will share it with you. The Secretary 

is so committed to making sure that we are walking with you every 

step of the way. So we will be transparent. 

Ms. BROWNLEY. Okay. And I understand that there is, you know, 

the VA would have to issue a solicitation to Cerner. I am not quite 

sure I fully understand what all of this means. But if you have to 

offer a solicitation in the negotiations of the contract, does that 

make sense to you at all? 

My understanding is a solicitation to support the fact that you 

are awarding the sole source contract. But I guess my question is, 

have you looked into that, and if you have, are you going to need 

any kind of legislation to move forward with that? 

Dr. ALAIGH. My understanding is no, but if we do, we will get 

back to you on that. 

Ms. BROWNLEY. Okay. Very good. Thank you. 

I yield back. 

Mr. RUTHERFORD. The gentlelady yields back. 

Before we close, I would like to have a follow-up myself with Mr. 

Yow. 

I presume that hospitals run a lot like other facilities that require fixed-post positions. I want to go back to this vacancy situation a moment. Fixed-post positions often require overtime. Do you 

have an overtime budget at VA? 

Mr. YOW. We will have to get that for you. I don’t have that with 

me, but we do track it. 

Mr. RUTHERFORD. Okay. And if you could at the same time, what 

I would like to know is, number one, what is the overtime budget; 

and number two, how much of that budget overtime is directly reLeonard.horne on VACREP0180 with DISTILLER

34 

lated to the vacancies that you are being forced to carry? Can you 

get that for me as well? 

Mr. YOW. I am not as confident in the second half of your question, to be able to differentiate the vacancies versus the overtime 

compared to anything else, but we will give it our best effort. 

Mr. RUTHERFORD. Okay. 

Dr. Alaigh, you don’t track it that way? 

Dr. ALAIGH. Like I said, we are going to go back and look into 

it. 

Mr. RUTHERFORD. Okay. All right. Thank you very much. 

I thank all of you once again. I really appreciate your testimony 

here today. If there are no further questions, the panel is now excused. 

I ask unanimous consent that all Members have 5 legislative 

days to revise and extend their remarks and include extemporaneous material. Without objection, so ordered. 

This hearing is now adjourned. 

[Whereupon, at 3:50 p.m., the Subcommittee was adjourned.] 

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(35) 

A P P E N D I X 

Prepared Statement of Joy Ilem 

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

On behalf of DAV (Disabled American Veterans) and as one of the co-authors of 

the Independent Budget, along with Paralyzed Veterans of America and Veterans 

of Foreign Wars of the United States, I am pleased to present our views on the resource needs of the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) for fiscal year (FY) 2018 and advance appropriations for FY 2019. I 

associate my remarks with the statements and recommendations provided by our 

Independent Budget partners for VHA medical care accounts, construction accounts 

and the National Cemetery Administration. I will concentrate my remarks on the 

budgetary needs of a few of VA’s most critical programs for ill and injured veteransmental health care, suicide prevention, homelessness, women veterans and caregivers. 

While we appreciate the increases recommended in the President’s budget for veterans health care in FY 2018, we are concerned the budget will not meet increasing 

demand for care and allow VA to meet its goals of providing timely, high quality 

care to veterans both in VA and the community. We applaud Secretary Shulkin for 

his leadership and efforts over the past few years to improve veterans’ access to care 

and timeliness of services with a focus on creating a strong management team, increasing operational efficiency, streamlining and replacing outdated business processes, modernizing the veterans benefits system, health infrastructure and information technology (IT) system to include a new scheduling package and electronic 

health records system. The Secretary has also set a number of priorities to include: 

greater choice for veterans; building a high performing network of care to enhance 

VA services while optimizing community care options, expanding mental health 

services to veterans in crisis with less than honorable discharges, and an increased 

focus on suicide prevention efforts to eliminate veteran suicide. While we welcome 

increased funding to improve care and services for ill and injured veterans we want 

there to be an honest assessment and discussion about what the real costs are for 

accomplishing all of these important goals. 

DAV, along with our Independent Budget partners note two proposals contained 

in the Administration’s budget that we strongly oppose. One, a provision that would 

scale back VA’s Individual Employability (IU) benefit for thousands of veterans that 

are unable to maintain gainful employment as a result of their service-connected 

disability. Specifically, this proposal would terminate existing IU ratings for veterans, along with associated ancillary benefits, when they reach the minimum retirement age for Social Security purposes, currently 62, as well as cut off IU benefits 

for any veteran already in receipt of Social Security retirement benefits. This proposal is simply an unjust penalty and would place an undue financial hardship on 

all service-disabled veterans in receipt of IU and their families. 

The second proposal would round down cost-of-living adjustments (COLAs) for disability compensation, Dependency and Indemnity Compensation (DIC) and some 

other benefits for the next 10 years. Veterans and their survivors rely on their disability compensation for essential purchases such as food, transportation, rent and 

utilities. This provision would unfairly target disabled veterans, their dependents 

and survivors to save the government money and offset the cost of other federal programs. All totaled, VA estimates this proposed COLA round down would cost beneficiaries close to $2.7 billion over the next 10 years. We are pleased that the Secretary acknowledged the negative impact the IU proposal would have on service-disabled veterans and indicated he was interested in finding another funding source 

to pay for Choice. We ask the Subcommittee to reject these proposals and reconsider 

the resources necessary for VA to meet the needs of our nation’s veterans. 

Leonard.horne on VACREP0180 with DISTILLER

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Mental Health Care 

An independent study found that most of VA’s mental health providers were 

working at peak capacity and despite VA’s concerted effort to hire more mental 

health clinicians, shortages still exist at some locations. Without sufficient resources, the Independent Budget veterans service organizations (IBVSOs) are concerned that this could potentially affect veterans’ access to timely and appropriate 

care, particularly for specialized mental health services. 

Demand for VA mental health care services has grown significantly as Vietnam 

veterans age and our more recent war fighters return from combat deployments 

(often multiple deployments) and leave military service. Experts estimate that about 

20 percent of our newest generation of war veterans are affected by post-traumatic 

stress disorder (PTSD). Researchers note that veterans using VA care from Operations Iraqi Freedom, Enduring Freedom and New Dawn (OIF/OEF/OND) have a 

high burden of post-deployment mental health challenges (56 percent have a mental 

health diagnosis). Subgroups within this population, such as service-connected 

women veterans, also have an even higher prevalence of mental health needs. While 

VA has made progress and focused its efforts on outreach, decreasing stigma and 

improving access to a wide variety of mental health services, there continue to be 

unmet needs. Many of our most vulnerable veterans have risk factors associated 

with or exacerbated by their military service that lead to family disintegration, legal 

issues, unemployment, homelessness and unfortunately, in some cases, suicide. 

Despite the challenges, research indicates that veterans who are engaged in VA 

care and treatment programs are less likely to take their lives. Likewise, veterans 

with serious mental illnesses using VA health care have longer life expectancies 

than other Americans with such conditions. Integration of mental health services 

into VA primary care settings and the development and use of evidence-based practices to treat disorders such as PTSD linked to combat and sexual trauma have 

proven effective. We are pleased that VA, as part of its suicide prevention efforts, 

is also beginning to use analytic predictive models (VA REACH VET initiative) to 

better identify at-risk veterans. While problems, including the timeliness of care and 

sufficient staffing levels remain at certain locations, we believe veterans with serious mental illness, PTSD (associated with combat or sexual trauma), or post-deployment mental health challenges are best served by VA’s highly specialized and comprehensive mental health care model. 

VA’s primary care teams with integrated behavioral health services routinely 

identify and refer veterans for advanced screening for such commonly diagnosed 

conditions as depression, anxiety, and substance use disorders. We commend VA for 

ensuring mental health is considered an important part of a veteran’s overall 

health-but this new model of care has increased the need for mental health services 

among thousands of VA patients who have not previously used these services. VA 

will need to continue to attract, hire and train a sufficient number of mental health 

professionals, including family and marital counselors and community partners in 

some locations to meet rising demand and provide timely and individualized care. 

VA must also continue its efforts to help family members coach struggling veterans 

into care and keep them engaged in treatment. VA must also focus on meeting the 

diverse needs of its veteran population to include elderly veterans, Vietnam veterans, and women veterans. 

PTSD often co-occurs with other mental health issues including substance use disorders, depression, and traumatic brain injury. Veterans with ‘‘dual diagnoses’’ are 

often among the most difficult to treat and require intensive care and case-management. VA must continue to research more effective treatments to address these complex patients with comorbid conditions. Likewise, clinicians must have the ability 

to schedule and carry out more resource intensive, evidence-based treatments for 

veterans who need it. VA clinicians are beginning to understand the value of peer 

specialists as these professionals are often able to engage isolated veterans because 

of their shared military experience, and better assist veterans with patient education and navigating VA’s complex health care system. 

VA must have sufficient resources to treat case-intensive veterans with serious 

mental illness, employ more peer specialists, properly staff the veterans crisis line, 

increase outreach and focus on shared prevention efforts, and develop programs that 

meet the unique needs of women veterans who are at high risk for homelessness 

and suicide. 

There must be continued oversight by the Subcommittee to ensure that VA has 

the resources necessary to provide timely and individualized mental health care to 

a diverse veteran population. Sufficient resources are necessary to meet increased 

demand for specialized mental health care services for PTSD, substance use disorder, serious mental illness or for veterans who have experienced military sexual 

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trauma. VA must also have sufficient resources to properly staff the veterans crisis 

line, improve suicide prevention efforts and develop programs that meet the unique 

needs of women veterans who are at high risk for homelessness and suicide. 

We urge the Subcommittee to ensure VA mental health programs continue to receive adjustments commensurate with increased workloads and continue to monitor 

VA’s ability to fully implement newly authorized services and programs, such as 

those contained in Public Law 114–2, the Clay Hunt Suicide Prevention for American Veterans (SAV) Act. 

Another issue that will require the Subcommittee’s oversight is the proposal to 

provide veterans with other than honorable discharges access to urgent health and 

mental health services. We commend Secretary Shulkin for taking steps to address 

the needs of this population (an estimated 500,000 veterans). We know that many 

of these individuals have PTSD, experienced military sexual trauma or have 

undiagnosed mental health issues or a mild traumatic brain injury that may have 

contributed to behavior that led to their less favorably characterized administrative 

discharges. 

While we acknowledge the Secretary’s assertion that he does not require increased 

funding to address the potential increase in workload, we believe the impact on access to mental health care could be significant and may require hiring of additional 

providers as well as clinical and Vet Center space to accommodate increased demand. We recommend that VA identify the full estimated cost of implementing this 

decision and request that Congress provide additional funds if necessary. The 

IBVSOs believe these veterans need and should receive this critical care, especially 

veterans who may have sustained a brain injury during military service or suffering 

from a mental health condition that went undiagnosed or untreated. 

Veterans’ Homelessness 

Unemployment, homelessness and suicide are often the consequences of a failed 

mental health safety net. Since 2010, based on intensely focused resources and efforts, VA and its partner agencies have decreased the numbers of veterans who are 

homeless by nearly 50 percent. 

In the FY 2018 budget plan, the Administration requested less funding for VA’s 

psychiatric rehabilitation and homeless veteran domiciliary beds and a significant 

cut to funding for these beds in FY 2019. These cuts will undermine veterans’ recovery. It is unrealistic to expect veterans who are homeless or in unstable housing to 

achieve difficult treatment goals such as achieving sobriety (or even reducing dependency upon substances) or attending to basic hygiene, independent living and vocational skills in order to successfully reintegrate into their communities. Psychiatric rehabilitation and domiciliary beds were designed as a less intensive and 

more cost-effective alternative which still give veterans a stable environment from 

which to launch recovery. Many of the veterans using such programs also have significant medical and mental health issues to address after living on the street. 

Without access to stable, supervised lodging and adequate nutrition and rest, these 

vulnerable veterans’ chances to recover from years of addiction and/or significant 

chronic mental illness including psychoses and severe PTSD are severely jeopardized. 

Unfortunately, the progress made through collaborations between VA, other federal agencies, states and community partners appear imperiled by the current budget proposal. Proposed cuts in programs will impact the ability for homeless veterans 

to receive comprehensive services. While these proposals are outside of the House 

Veterans’ Affairs Committee’s jurisdiction in agencies such as HUD, the Interagency 

Council on Homelessness, the Legal Services Corporation, the Small Business Administration and Medicaid-they will impact this population. VA has invested a significant amount of resources to reduce the number of homeless veterans and we are 

very concerned the potential cuts to these important programs could undermine 

VA’s progress to end homelessness among this population. VA’s ability to work with 

other federal, state, and local agencies is critical to providing a comprehensive set 

of services to veterans who are homeless-from rehabilitation to reintegration into society with a goal of good health, recovery from mental illness or addiction and longterm stable employment and housing. 

Women Veterans 

The delivery of care for women veterans has been a special challenge for VHA. 

While the number of women serving in the military continues to grow as does the 

number of women coming to VA for care, women still comprise a relatively small 

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38 

portion (about 11 percent) of VA’s patient population. For these reasons, it has often 

been difficult for VA, especially outside of urban population centers, to provide highquality comprehensive services in-house to women. Today, women serving in combat 

theaters are exposed to serious injury or death like their male counterparts. This 

new reality requires a focus on meeting the unique needs of an increasing number 

of women veterans in a health care system historically devoted to the treatment of 

men. 

Learning how to care for wounded women veterans, half of whom are of childbearing age, and their particular health issues and transition and rehabilitation 

needs includes learning how to best meet their needs for prosthetic and assistive 

devices. The IBVSOs recognize and commend the VA’s efforts to enhance the care 

of female veterans in regard to technology, research, training, repair, and replacement of prosthetic appliances through the establishment of a women’s prosthetic 

working group. The working group’s mission was to eliminate barriers to prosthetic 

care experienced by women veterans and change the culture and perception of 

women veterans through education and information dissemination. 

The IBVSOs recommend the Medical Services appropriation for FY 2018 be supplemented with $110 million designated for women’s health care programs. These 

funds would be used to help the VHA deal with the continuing growth in women 

veterans coming to VA for care, including coverage for gynecological, prenatal, and 

obstetrical care, other gender-specific services, and for expansion and repair of facilities to improve privacy and safety for women receiving care. VA must also be able 

to continue its important research on the health impacts of wartime service on 

women veterans to better address the high rates of homelessness, suicide and 

unique transition challenges among this population. 

Additional funds would also aid the Department in its efforts to transform the culture of the system to ensure women veterans are provided equal benefits and health 

care services, have access to comprehensive care in a safe, private and comfortable 

setting and are recognized for their service and made to feel welcome at VA. Funds 

are necessary to address identified gaps in current programs and services, particularly post-deployment readjustment services for women veterans. 

Like all veterans, women veterans deserve the opportunity to receive care in VA 

with access to its highly specialized transition and rehabilitation services, veteranfocused research and care and psycho-social wrap-around supportive services. This 

is especially critical for service-connected women veterans, women veterans with 

wartime service and veterans who have experienced sexual trauma. 

Caregiver Support 

A final issue we ask the Subcommittee to consider championing is fixing the inequity of the current law supporting seriously disabled veterans’ caregivers. The 

IBVSOs have worked diligently for many years as a part of a larger coalition of veterans organizations that promoted the advent of family caregiver support services 

for severely injured and ill veterans. Congress enacted Public Law 111–163, the 

Caregivers and Veterans Omnibus Health Services Act of 2010. However, that law 

limited services and supports to family caregivers of veterans who were injured or 

became severely ill in military service only on or after September 11, 2001. That 

omission left thousands of veterans’ families without the level of caregiver support 

and services they needed because those veterans’ health challenges or war injuries 

occurred before that effective date. 

Legislation has been introduced in both Chambers that would address this inequity and improve the lives of tens of thousands of veteran families. Not only is 

it the right thing to do for seriously ill and injured veterans, it will save the federal 

government a significant amount of resources that otherwise would need to be spent 

to provide more costly institutional care solutions for these veterans. We ask that 

resources be included in the budget to resolve this issue. 

In closing, we ask the Subcommittee to consider, as the budget process moves forward, that this is very critical time for VA. The new Administration has pledged 

support for our nation’s veterans and Secretary Shulkin has committed to carry out 

that promise by creating a system that is worthy of their service and sacrifices. As 

VA moves forward to rebuild trust with veterans, make needed reforms and carry 

out modernization plans to strengthen and improve the VA, for the benefit of those 

who served, it is critical it has the resources and support it needs to be successful. 

Mr. Chairman, thank you for the opportunity to share the Independent Budget 

recommendations at this hearing today. I am prepared to answer any questions you 

or other members of the Subcommittee may have. 

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39 

Prepared Statement of Carl Blake 

Chairman Wenstrup, Ranking Member Brownley, and members of the Subcommittee, as one of the co-authors of The Independent Budget (IB), along with 

DAV and Veterans of Foreign Wars, Paralyzed Veterans of America (PVA) is 

pleased to present our views regarding the funding requirements for the delivery 

of health care for the Department of Veterans Affairs (VA) for FY 2018 and advance 

appropriations for FY 2019. On the following page, we have included a side-by-side 

comparison of funding recommendations previously appropriated for FY 2017 recommended by the Administration by the IB for FY 2018, as well as the advance appropriations for FY 2019. 

**Choice Program funding for FY 2018 includes the expected carryover of $600 

million from the previous fiscal year as well as $2.9 billion in new funding for the 

program. All Choice program funding is currently scored as a mandatory cost for VA. 

The IB’s recommendations include funding for all discretionary programs for FY 

2018 as well as advance appropriations recommendations for medical care accounts 

for FY 2019. The full budget report, released by The Independent Budget in March, 

addressing all aspects of discretionary funding for the VA can be downloaded at 

www.independentbudget.org. The FY 2018 projections are particularly important because previous VA Secretary Robert McDonald admitted last year that the VA’s FY 

2018 advance appropriation request was not truly sufficient and would need significant additional resources provided this year. We hope that Congress will take this 

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defined shortfall very seriously and appropriately address this need. Our own FY 

2018 estimates affirm this need. 

We appreciate the fact that the Administration’s recently released budget request 

for FY 2018 includes some increases in discretionary dollars for the Medical Care 

accounts above what had been previously provided through advance appropriations. 

Before addressing our specific budget recommendations, it is important for us to address the notion that VA does not need any additional resources, based on the expansive growth of overall VA expenses in the last 10 years. These ideas are not 

grounded in thorough analysis of demand and utilization of VA health care. Perhaps 

Congress can explain how the VA can take on significantly more demand for services both inside VA and in the community, and yet meet that demand and utilization with less resources-an assertion peddled by some organizations. While VA has 

seen substantial growth in its funding needs over the last decade, much of that is 

reflected in mandatory benefits to include the implementation of the Post-9/11 GI 

Bill. The fact is demand for health care services and actual utilization continue to 

rise at a significant rate. It may be possible to wring some efficiency savings out 

of VA to free up additional resources to address growing demand, but history has 

proven that process will not be sufficient to provide all of the resources VA needs 

to deliver on its promise to the men and women seeking health care and benefits. 

We also believe it is necessary to consider the projected expenditures under the 

Choice program authority that the previous Administration planned in FY 2017 and 

how that impacts the baseline that will dictate the funding needs for FY 2018. The 

previous Administration assumed as much as $5.7 billion in spending through the 

Choice program in FY 2017, on top of the Medical Services discretionary funding 

and the newly created Medical Community Care account. That amount was revised 

to approximately $2.9 billion. This means that the VA projected to spend more than 

$59.0 billion in Medical Services and more than $71.0 billion in overall Medical Care 

funding in FY 2017. These considerations inform the decisions of The Independent 

Budget to establish our baseline for our funding recommendations for both FY 2018 

and FY 2019. 

Earlier this year, the Administration also indicated that it intends to request as much as $3.5 billion in additional funding for the Choice program to keep it operating at least through the end of FY 2018. That amount has since been revised to 

$2.9 billion for FY 2018 (actually $3.5 billion when considering the already available 

$600 million left over from the original authorization), as well as $3.5 billion for FY 

2019 and beyond. However, this recommendation begs the question: does this recommendation suggest that the Choice program as currently designed should continue in perpetuity? Certainly no reasonable person supports that idea. We believe 

that Congress must reject continued funding of this program through a mandatory 

account and place it in line with all other community care funded through the discretionary Community Care account established previously. This will eliminate competing sources of funding for delivery of health care services in the community, 

while maintaining visibility on spending through the Choice program. 

Moreover, we strongly oppose the decision to curtail Individual Unemployability 

(IU) benefits for veterans with significant service-connected disabilities simply as a 

means to fund the continuation of the Choice program. It is beyond comprehension 

that the Administration would propose such a benefit reduction in order to pay for 

a flawed funding mechanism for a program (Choice) that sometimes provides health 

care access to non-service connected disabled veterans. Does this Committee really 

believe that veterans with disabilities rated between 60 percent and 90 percent 

should be the source of funding for the Choice program? Eliminating IU benefits for 

veterans over the age of 62 provokes numerous questions for us. Will veterans who 

have statutorily protected evaluations (the 20-year rule) also be subject to reduction? Will those dependents using Chapter 35 education benefits based on their 

sponsor’s IU rating be forced to drop out of school? Will those veterans on IU who 

are covered by Service-Disabled Life Insurance at no premium be forced to now pay 

premiums in order to keep coverage? What about state benefits, such as property 

tax exemptions or state education benefits that are based on 100 percent VA disability ratings? How will this proposal affect efforts to combat veteran suicide and 

homelessness? We hope that you will reject this proposal in the strongest terms. 

For FY 2018, the IB recommends approximately $77.0 billion in total medical care 

funding. Congress previously approved only $70.0 billion in total medical care funding for FY 2018 (which includes an assumption of approximately $3.6 billion in medical care collections). The Administration’s budget request includes a not-insignificant overall medical care funding recommendation of approximately $75.2 billion. 

However, we remain concerned that this level of funding will not keep pace with 

the continually increasing demand and utilization. The IB’s recommendation also 

considers the approximately $1 billion VA is expected to have remaining in the VetLeonard.horne on VACREP0180 with DISTILLER

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erans Choice Fund and expected demand for care, including community care, that 

will not diminish or go away if the Choice Program expires. The Independent Budget recommends approximately $82.8 billion in advance appropriations for total Medical Care for FY 2019. 

Medical Services 

For FY 2018, The Independent Budget recommends $64.5 billion for Medical Services. This recommendation includes: 

Current Services Estimate $60,897,313,000 

Increase in Patient Workload $1,595,242,000 

Additional Medical Care Program Cost $2,001,000,000 

Total FY 2018 Medical Services $64,493,555,000 

The current services estimate reflects the impact of projected uncontrollable inflation on the cost to provide services to veterans currently using the system. This estimate also assumes a 1.5 percent increase for pay and benefits across the board for 

all VA employees in FY 2018. It was previously reported that the new Administration would like to consider a 1.9 percent federal pay raise. 

Our estimate of growth in patient workload is based on a projected increase of 

approximately 90,000 new unique patients. These patients include priority group 1≥- 8 veterans and covered non-veterans. We estimate the cost of these new unique patients to be approximately $1.4 billion. The increase in patient workload also includes a projected increase of 58,000 new Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) enrollees, as well as Operation New Dawn (OND) 

veterans at a cost of approximately $242 million. The increase in utilization among 

OEF/OIF/OND veterans is supported by the average annual increase in new users 

through the third quarter of FY 2016. 

Additionally, The Independent Budget believes that there are medical program 

funding needs for VA that must be considered. Those costs total approximately $2.0 

billion. 

Long-Term Services and Supports 

The Independent Budget recommends $535 million for FY 2018. This recommendation reflects the fact that there was a significant increase in the number 

of veterans receiving Long Term Services and Supports (LTSS) in 2016. Unfortunately, due to loss of authorities-specifically fee-care no longer being authorized, provider agreement authority not yet enacted, and the inability to use Choice funds for 

all but skilled nursing care-to purchase appropriate LTSS care particularly for home 

and community-based care, we estimate an increase in the number of veterans 

using the more costly long-stay and short-stay nursing home care. 

Prosthetics and Sensory Aids 

In order to meet the increase in demand for prosthetics, the IB recommends an 

additional $320 million. This increase in prosthetics funding reflects a similar increase in expenditures from FY 2016 to FY 2017 and the expected continued growth 

in expenditures for FY 2018. 

Women Veterans 

The Medical Services appropriation should be supplemented with $110 million 

designated for women’s health care programs in FY 2018. These funds will be used 

to help the VA deal with the continuing growth in women veterans coming to VA 

for care, including coverage for gynecological, prenatal, and obstetric care, other gender-specific services, and for expansion and repair of facilities hosting women’s care 

to improve privacy and safety of these facilities. The new funds would also aid VHA 

in making its cultural transformation to ensure women veterans are made to feel 

welcome at VA, and provide means for VA to improve specialized services for preventing suicide and homelessness and improvements for mental health and readjustment services for women veterans. 

Reproductive Services (to Include IVF) 

Last year, Congress authorized appropriations for the remainder of FY 2017 and 

FY 2018 to provide reproductive services, to include in vitro fertilization (IVF), to 

service-connected catastrophically disabled veterans whose injuries preclude their 

ability to conceive children. The VA projects that this service will impact less than 

500 veterans and their spouses in FY 2018. The VA also anticipates an expenditure 

of no more than $20 million during that period. However, these services are not directly funded; therefore, the IB recommends approximately $20 million to cover the 

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cost of reproductive services in FY 2018. We are pleased to see that the Administration does retain the authority to provide reproductive services in its budget proposal. 

Emergency Care 

Recently, the VA has received serious scrutiny for its interpretation of legislation 

dating back to 2009, which required it to pay for veterans who sought emergency 

care outside of the VA health care system. The Richard W. Staab v. Robert A. 

McDonald ruling handed down by the US Court of Appeals for Veterans Claims last 

year, places the financial responsibility of these emergency care claims squarely on 

the VA. Although VA continues to appeal this decision, it is not expected to prevail 

in this case leaving itself with a more than $10 billion dollar obligation over the 

next 10 years. The Staab ruling is estimated to cost VA approximately $1.0 billion 

in FY 2018 and about $1.1 billion in FY 2019, which the IB has included in our 

recommendations. 

We are disappointed to see that the Administration’s proposal continues to ignore 

its growing obligation to cover the cost of emergency care as dictated by the Staab 

decision. In fact, the Secretary suggested during a recent testimony before the Senate Committee on Veterans’ Affairs that unfortunately the VA will have to take the 

money away from other places in its budget to pay these obligations. This is wholly 

unacceptable. Veterans should not have their benefits and services curtailed to pay 

for an utter failure of VA to accept this requirement. The VA should have requested 

the necessary funds in its Budget Request for FY 2018 to address this need. As it 

did not, it is incumbent upon Congress to provide the additional necessary resources. If Congress, fails to do so, it and the VA will both bear the blame for the 

negative impact that will be experienced in other areas of the VA. 

FY 2019 Medical Services Advance Appropriations 

The Independent Budget once again offers baseline projections for funding 

through advance appropriations for the Medical Care accounts for FY 2019. While 

the enactment of advance appropriations for VA medical care in 2009 helped to improve the predictability of funding requested by the Administration and approved 

by Congress, we have become increasingly concerned that sufficient corrections have 

not been made in recent years to adjust for new, unexpected demand for care. As 

indicated previously, we have serious concerns that the previous Administration significantly underestimated its FY 2018 advance appropriations request. This trend 

cannot be allowed to continue, particularly as Congress continues to look for ways 

to reduce discretionary spending, even when those reductions cannot be justified. 

For FY 2019, The Independent Budget recommends approximately $69.5 billion 

for Medical Services. Our Medical Services advance appropriations recommendation 

includes: 

Current Services Estimate $66,334,946,000 

Increase in Patient Workload $1,589,892,000 

Additional Medical Care Program Cost $1,526,000,000 

Total FY 2019 Medical Services $69,450,838,000 

Our estimate of growth in patient workload is based on a projected increase of 

approximately 78,000 new patients. These new unique patients include priority 

group 1≥-8 veterans and covered nonveterans. We estimate the cost of these new 

patients to be approximately $1.3 billion. This recommendation also reflects an assumption that more veterans will be accessing the system as VA expands its capacity and services and we believe that reliance rates will increase as veterans examine 

their health care options as a part of the Choice program. The increase in patient 

workload also assumes a projected increase of 62,500 new OEF/OIF and OND veterans, at a cost of approximately $272 million. 

As previously discussed, the IBVSOs believe that there are additional medical 

program funding needs for VA. In order to meet the increase in demand for prosthetics, the IB recommends an additional $330 million. We believe that VA should 

invest a minimum of $120 million as an advance appropriation in FY 2019 to expand and improve access to women veterans’ health care programs. Our additional 

program cost recommendation includes continued investment of $20 million to support extension of the authority to provide reproductive services to the most catastrophically disabled veterans. Finally, VA’s cost burden for paying emergency care 

claims dictated by the Staab ruling will require at least $1.1 billion in FY 2019 

alone. 

Medical Support and Compliance 

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For Medical Support and Compliance, The Independent Budget recommends $6.7 

billion for FY 2018. Our projected increase reflects growth in current services based 

on the impact of inflation on the FY 2017 appropriated level. Additionally, for FY 

2019 The Independent Budget recommends $6.8 billion for Medical Support and 

Compliance. We have concerns about the significant growth in these administrative 

account functions recommended by the Administration (nearly $300 million in FY 

2018 and an additional $300 million in FY 2019) as these areas have been shown 

to be bloated on numerous occasions in the past. These dollars could certainly be 

better spent providing direct care services to veterans. 

Medical Facilities 

For Medical Facilities, The Independent Budget recommends $5.8 billion for FY 

2018. Our Medical Facilities recommendation includes $1.35 billion for Non-Recurring Maintenance (NRM). Likewise, The Independent Budget recommends approximately $6.6 billion for Medical Facilities for FY 2019. Our FY 2019 advance appropriation recommendation also includes $1.35 billion for NRM. We are pleased to see 

the Administration recommending real funding for this account in FY 2018 (approximately $6.5 billion), but we are concerned that the Budget Request reflects the continued trend of reducing the recommendation in the advance appropriation year 

($5.9 billion in FY 2019) in order to seemingly hold down discretionary projections. 

Medical and Prosthetic Research 

We are very disappointed to see the major cut in funding for the Medical and 

Prosthetic Research program in the Administration’s Budget Request-from $675 million in FY 2017 to $640 million in FY 2018. Despite documented success of VA investigators across many fields, the amount of appropriated funding for VA research 

since FY 2010 has lagged far behind annual biomedical research inflation rates, resulting in a net loss over these years of nearly 10 percent of the program’s overall 

purchasing power. The VA Medical and Prosthetic Research program is widely acknowledged as a success on many levels, and contributes directly to improved care 

for veterans and an elevated standard of care for all Americans. We recommend that 

Congress appropriate $713 million for Medical and Prosthetic Research for FY 2018. 

Additionally, under the President’s Precision Medicine Initiative, the IBVSOs recommend $65 million to enable VA to process one quarter of the MVP samples collected, for a total research appropriation of $778 million. 

Thank you for the opportunity to submit our views on the FY 2018 VA Budget 

Request. We would be happy to answer any questions the Subcommittee may have. 

f 

Prepared Statement of Carlos Fuentes 

Chairman Wenstrup, Ranking Member Brownley and members of the Subcommittee, on behalf of the men and women of the Veterans of Foreign Wars of the 

United States (VFW) and its Auxiliary, thank you for the opportunity to present the 

VFW’s views on the Department of Veterans Affairs’ budget request. 

The VFW is glad to see President Trump has proposed a six percent increase in 

VA’s FY 2018 discretionary budget compared to FY 2017. However, we feel his proposal falls short of what VA needs to keep pace with demand for health care. The 

VFW thanks the administration for its commitment to community care, long-term 

care, mental health care, woman veterans and efforts to prevent and eliminate veteran homelessness. 

However, we are very concerned that the administration’s request to make the 

Veterans Choice Program a permanent mandatory program could lead to a gradual 

erosion of the VA health care system. What is more concerning is that the administration has chosen to make permanent a flawed program by ending Individual 

Unemployability benefits for severely disabled veterans who are unable to work due 

to their service-connected disabilities, and a round down of cost of living disability 

pay increases—a proposal which the VFW has opposed in the past and continues 

to strongly oppose. 

The continued failure of Congress to eliminate sequestration has forced the administration to propose cuts to veteran benefits and cap GI Bill expenditures in 

order to expand the Choice Program under mandatory spending, instead of including the program in its discretionary community care account. In testimony before 

the Senate and House Committees on Appropriations, Secretary of Veterans Affairs 

(VA) David J. Shulkin has indicated that VA would like all of its community care 

money to come from one account, instead of having two separate accounts for the 

same purpose and not having the flexibility to use both accounts in accordance with 

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veterans’ demand for community care. The VFW agrees with Secretary Shulkin and 

urges Congress to consolidate VA’s community care programs and to fund such programs through VA’s discretionary appropriations account. 

Sequestration and its draconian spending caps limit our nation’s ability to provide 

service members, veterans, and their families the care and benefits they have 

earned and deserve. The VFW calls on the Subcommittee to join our campaign to 

finally end sequestration and do away with a federal budget process based on the 

arbitrary budget caps, which significantly limit the government’s ability to carry out 

programs that experience spikes in demand, such as VA health care. To the VFW, 

sequestration is the most significant readiness and national security threat of the 

21st century, and despite almost universal congressional opposition to such haphazard budgeting, Congress has failed to end it. 

Caregivers 

The VFW has heard for many years that veterans who require the assistance of 

a caregiver to perform activities of daily living have been rejected from the VA Caregivers Program, have been downgraded in tier level or outright kicked out of the 

program. These issues have led to VA implementing a moratorium on involuntary 

revocations from the program until VA is able to analyze the thousands of recent 

revocations to determine if veterans are being erroneously removed from the program. The VFW commends Secretary Shulkin for halting revocations and improving 

processes to ensure the program is functioning properly and implemented consistently throughout the VA health care system. 

However the administration’s budget request assumes a $236 million decrease in 

funding for the program due to a projected decrease in the number of caregivers receiving stipend payments in fiscal year 2018. Given recent developments and the 

continued demand for this important program, the VFW believes funding for this 

important program should be increased, not decreased. 

While the VFW certainly agrees that veterans who have recovered from injuries 

and illnesses should be put on a path to achieve independent living and no longer 

require the assistance of a caregiver, such decisions must be made when the veteran 

and the caregiver agree and not by VA employees who lack the proper training and 

medical expertise to make such decisions. When a decision is made to graduate a 

veteran from the caregiver program, VA must ensure veterans and their caregivers 

are given the training and resources, such as employment training and independent 

living counseling, to ensure veterans can properly transition from needing a caregiver to performing activities of daily living without the assistance of others. 

The VFW has also said for years that the arbitrary delimitation of eligibility for 

the VA Caregiver Program unjustly ignores the selfless sacrifice of those who care 

for our pre-9/11 ill and injured veterans. Family caregivers who choose to provide 

in-home care to veterans who were severely disabled in the line of duty truly epitomize the concept of selfless service. They choose to put their lives and careers on 

hold, often accepting great emotional and financial burdens. They do so recognizing 

that their loved ones benefit greatly by receiving care in their homes, as opposed 

to institutional settings. 

The VFW strongly believes that the contributions of family caregivers cannot be 

overstated, and that our nation owes them the support they need and deserve. The 

VFW sees no justifiable reason to exclude otherwise deserving veterans from program eligibility simply based on the era in which they served. Accordingly, we 

strongly urge the Subcommittee to swiftly consider and pass a bill to expand the 

VA Caregiver Program to veterans of all eras who need the assistance of a caregiver 

due to service-connected illnesses and injuries. 

Major Construction 

For more than a decade, the Independent Budget Veterans Service Organizations 

(IBVSOs) have warned Congress and VA that perpetual underfunding has allowed 

VA’s infrastructure to erode, while its capacity has swelled from 81 percent in 2004 

to as high as 120 percent in 2010. We continue to believe that this need for space 

and chronic underfunding of medical services could lead VA to ration care. 

The IBVSOs are working with VA to reform its construction process so facilities 

can be delivered on time and on budget. Previous errors must be corrected to ensure 

the issues in Aurora, Colorado, never occur again. However, Congress and the administration must not ignore the growing capital infrastructure needs of the Department’s health care system. 

When VA asked its Veteran Integrated Service Networks (VISN) to evaluate what 

they need to improve its facilities to meet the increased outpatient demand, VA determined that ‘‘improving the condition of VA’s facilities through major construction 

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1Department of Veterans Affairs 2018 Budget and 2019 Advance Appropriations Requests, 

Volume IV: Construction, Long Range Capital Plan and Appendix. Long Range Capital Plan, 

page 8.3–8. 

projects (96) accounted for the largest resource need. 1’’ Yet, the administration’s 

major construction request for the Veterans Health Administration (VHA) is 36 percent less than FY 2017 and 85 percent less than actual expenditures in FY 2016. 

When asked why VA is taking a strategic pause on major construction for VHA 

when its capital infrastructure continues to age and demand continues to increase, 

VA informed the IBVSOs that it simply did not receive the request that it needed 

for major construction because of sequestration budget caps. Congress must not 

allow VA’s inability to invest in VHA’s major construction to limit veterans’ access 

to the health care they have earned and deserve by forcing veterans into VA’s community care programs and eliminating the choice to receive care at VA medical facilities. 

Currently, VA has 12 VHA construction projects that are partially funded that 

need a clear path to completion. Several projects have been removed from the priority list as candidates for public private partnership (P3) projects using recently 

enacted authority to combine private and public resources to fund VA construction 

projects. While the VFW supported Public Law 114–294, Communities Helping Invest through Property and Improvements Needed for Veterans Act of 2016, we do 

not believe the private sector can abrogate the federal government’s obligation to 

properly fund medical facility construction projects. 

At the top of VA’s Integrated Priority List for 2018 are several seismic correction 

projects, which must be fixed urgently or VA will continue to risk the lives of its 

patients and employees in the case of an earthquake. These projects cannot take a 

strategic pause while Congress and VA decide how to manage capital infrastructure 

long-term. VA will need to invest more than $3.5 billion to complete all 12 partially 

funded construction projects. What is more concerning to the VFW is that none of 

the nine VHA construction projects of the top 15 projects in VA’s Integrated Priority 

List for 2018 received funding in the administration’s fiscal year 2018 request. This 

mean that VHA is not only drastically behind in funding for its existing projects, 

its urgently needed projects are also being ignored, which can significantly impact 

its ability to provide care to veterans. 

The IBVSOs recommend that Congress appropriate at least $1.5 billion for major 

construction in FY 2018. This amount will fund either the ‘‘next phase’’ or fund 

‘‘through completion’’ all existing projects, and begin advance planning and design 

development on six major construction projects that are the highest ranked on VA’s 

priority list. 

Minor Construction 

In FY 2017, Congress appropriated $372.1 million for minor construction projects. 

Currently, approximately 600 minor construction projects need funding to close all 

current and future year gaps within ten years. To complete all of these current and 

projected projects, VA will need to invest between $6.7 and $8.2 billion in minor construction over the next decade. 

In August 2014, the president signed the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113–146). In this law, Congress provided $5 billion 

to increase health care access by increasing medical staffing levels and investing in 

infrastructure. VA has developed a spending plan that obligated $511 million for 64 

minor construction projects over a two-year period. 

While this infusion of funds has helped, there are still hundreds of minor construction projects that need funding for completion. It is important to remember 

that these funds are a supplement to, not a replacement of, annual appropriations 

for minor construction projects. The IBVSOs recommend that Congress fund VA’s 

minor construction account at $700 million in an effort to close all identified gaps 

within ten years. 

Leasing 

Historically, VA has submitted capital leasing requests that meet the growing and 

changing needs of veterans. VA has again requested an adequate amount—$270.1 

million for its FY 2018 major medical leasing needs. While VA has requested adequate resources, Congress must find a way to authorize and appropriate leasing 

projects in a way that does not require Congress to pass a law to authorize individual leases. The VFW urges the Subcommittee to explore options similar to the 

process used by the House Committee on Transportation and Infrastructure to review and approve U.S. General Service Administration leases. 

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There are now 27 major medical leases awaiting congressional authorization, 18 

of which have been waiting since FY 2016 and six from FY 2017. Delays in authorization of these leases will have a direct impact on VA’s ability to provide timely 

care to veterans in their communities. 

Legislative Proposals 

As part of the budget, VA submitted a list of legislative proposals which have a 

budgetary impact. The VFW supports VA’s proposals to amend pay caps for nurse 

executives; cover the cost of medical foster homes, so veterans can continue to live 

in the comfort of a home environment instead of being forced into institutional longterm care; convert perfusionists to title 38 employees; reimburse advance practice 

registered nurses for continuing professional education; make VA a participating 

provider by third party payers; and improve the hiring authorities for medical center and network directors. 

The VFW does not take a position on the proposal to require VA medical facilities 

to become smoke free campuses, but we urge the Subcommittee to consider an appropriate implementation timeline for the more than 120 VA community living centers which have onsite designated smoking areas. Veterans who live in such facilities must be given the opportunity to adjust to a smoke free environment, not forced 

to quit and adjust to a new way of live within 90 days. 

The VFW opposes the VA proposal to discontinue reducing the first party copayment obligations of veterans who have their copayments covered by their third-party 

health coverage. Under current law, VA is required to offset a veteran’s VA copayment obligation with funds it collects from the veteran’s third-party health care coverage. Doing so incentivizes veterans to report their third-party coverage to VA and 

ensure VA is able to offset the cost of providing non-service connected care. Discontinuing this practice would add cost burdens to veterans who, according to independent assessments, can least afford it. Such veterans could also choose to terminate their other health insurance—reducing the amount of funds it is able to collect—or forgo receiving all their care at VA, which results in fragmented care that 

endangers patient safety. 

Mr. Chairman, this concludes my testimony. I will be happy to answer any questions you or the Subcommittee members may have. 

f 

Prepared Statement of Matthew J. Shuman 

SHUMAN 8 footnotes 

Chairman Wenstrup, Ranking Member Brownley, and Members of the Subcommittee; On behalf of Charles E. Schmidt, the National Commander of the largest 

Veteran Service Organization in the United States of America representing more 

than 2.2 million members; we welcome this opportunity to comment on the federal 

budget and specific funding programs of the Department of Veterans Affairs (VA). 

Choice 

The American Legion has reviewed the President’s budget request and while we 

fully support the Administration’s proposal to increase the discretionary budget of 

the Department of Veterans Affairs by $4.3 billion, we would like to draw this committee’s attention to several components of this request that The American Legion 

calls on Congress to address. 

One of the highlights of the President’s budget request is a $2.9 billion request 

to continue the Veterans Choice Program. The American Legion remains steadfast 

in our position that a consolidated community care program replace the disparate 

contracting and procurement vehicles that have amassed over the years at VHA to 

supplement care for veterans when medically necessary care is not available organically at VA. 

In August 2014, President Obama signed into law the Veterans Access, Choice, 

and Accountability Act (VACAA). Included in that legislation was the Veterans 

Choice Program or the VCP. The Veterans Choice Program expands the availability 

of medical services for eligible veterans with community providers and was intended 

to be a temporary, emergency program in response to the revelation that VA medical centers were unable to serve the veterans in catchment areas who were requesting care, and subsequently created off-the-books wait lists to try and keep track of 

veterans who needed care but could not get an appointment in a timely manner. 

The American Legion supported this program as an emergency, temporary measure and insisted on a sunset date, as did the House Committee of Veterans Affairs 

and other major veteran service organizations. Through increased emphasis on 

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1http://www.rand.org/pubs/research—briefs/RB9336.html 

2http://www.modernhealthcare.com/article/20161231/TRANSFORMATION03/161229942 

3https://www.va.gov/HEALTH/docs/DR71—062017—Pending—and—EWL—Biweekly—Desired—Date—Division.pdf 4https://www.legion.org/legislative/236723/legion-testifies-dangers-va-staff-shortages 

5 American Legion Resolution No. 259 (2016): Extend Caregiver Benefits to Include Veterans 

Before September 11, 2001 

eradicating all hidden wait lists and ensuring that all veterans asking VA for medical appointments were seen in 30 days or less, VA quickly exhausted their community care accounts while Choice funding remained largely untouched. Because of the 

funding mechanism used to support the Choice program VA was unable to adjust 

funding between their traditional contracting accounts, creating an unbalanced community care program that required former VA Secretary Bob McDonald to mandate 

that all appointment requests be pushed into the Choice program because that was 

the only way VA was able to spend down the appropriated funds. This caused an 

artificial dependence on the Choice program while preserving resources in VA’s 

more established community care program accounts. 

The American Legion calls on the President and this Congress to rededicate the 

funding proposed in the 2018 Presidential budget request toward supporting VA’s 

medical infrastructure and existing community care programs, and allow Choice to 

terminate as originally planned. 

Mental Health 

According to RAND 1 about one-third of returning servicemembers report symptoms of mental health or cognitive condition which served in either Iraq or Afghanistan and suffer from either major depression or post-traumatic stress disorder. This 

has increased the demand for mental health services at VA. Unfortunately, there 

is a national shortage of mental healthcare providers, and the shortage is projected 

to grow acute over the next decade. According to a recent analysis by the U.S. 

Health Resources & Services Administration, the nation needs to add 10,000 providers to each of seven separate mental healthcare professions by 2025 to meet the 

expected growth in demand. 2 The widening gap between demand and the supply 

of available behavioral healthcare providers is being driven by a greater emphasis 

on addressing mental health issues within primary care settings. Yet the average 

wait time at VA is about four days for routine appointments and urgent care remains same day 3 despite staffing shortages 4. The American Legion calls on the 

President and this Congress to increase funding at VA to eradicate staffing shortages and support American veterans with the superior services they have earned 

at their VA medical facilities. 

Caregivers 

The struggle to care for veterans wounded in defense of this nation takes a terrible toll on families. In recognition of this, Congress passed, and President Barack 

Obama signed into law, the Caregivers and Veterans Omnibus Health Services Act 

of 2010. The unprecedented package of caregiver benefits authorized by this landmark legislation includes training to help to ensure patient safety, cash stipends to 

partially compensate for caregiver time and effort, caregiver health coverage if they 

have none, and guaranteed periods of respite to protect against burnout. 

The comprehensive package, however, is not available to most family members 

who are primary caregivers to severely ill and injured veterans. Congress opened 

the program only to caregivers of veterans severely ‘‘injured,’’ either physically or 

mentally, in the line of duty on or after Sept. 11, 2001. It is not open to families 

of severely disabled veterans injured before 9/11, nor is it open to post-9/11 veterans 

who have severe service-connected illnesses, rather than injuries, which is why we 

call on Congress to immediately pass the Military and Veteran Caregiver Services 

Improvement Act of 2017. 

The American Legion has long advocated for expanding eligibility and ending the 

obvious inequity that Caregivers and Veterans Omnibus Health Services Act of 2010 

created. Simply put, a veteran is a veteran! All veterans should receive the same 

level of benefits for equal service. As affirmed in American Legion Resolution No. 

259: Extend Caregiver Benefits to Include Veterans Before September 11, 2001, The 

American Legion supports legislation to remove the date September 11, 2001, from 

Public Law 111–163 and revise the law to include all veterans who otherwise meet 

the eligibility requirements. 5

The American Legion is optimistic that providing expanded support services and 

stipends to caregivers of veterans to all eras is not only possible but also budgetary 

feasible and the right thing to do. We urge this committee and the U.S. Congress 

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6https://www.va.gov/budget/docs/summary/fy2018VAsBudgetFastFacts.pdf 

7https://www.legion.org/commander/237583/legion-slams-white-house-va-budget 

8https://archive.legion.org/bitstream/handle/123456789/5504/ 

2016N164.pdf?sequence=1&isAllowed=y 

to allocate the required funding to expand the caregiver program to all eras of conflict and veterans who should be in this program. 

Though The American Legion is urging this Congress to expand the program, we 

are concerned that the FY18 budget reduces VA’s caregiver program budget by over 

200 million dollars. According to VA the ‘‘caregivers program cost estimate decreased by $235.9 million [which was] driven largely by a revision, based on actuals, 

in the projected number of Caregivers receiving stipend payments 6.’’ Based on the 

Secretary’s recent reversal on program reviews being conducted in several regions 

across the United States, The American Legion is concerned that this diminished 

request is premature and fails to properly budget for all eligible program participants. The American Legion is working with several caregiver families who have 

been notified that they are in jeopardy of losing, or have already lost their caregiver 

stipends, and will continue working with individuals at VA, and in the caregiver 

program, to ensure that no one who is eligible to enter into or remain in the program are unjustly denied. 

Proposed Funding Offsets 

The President’s budget proposes funding expanded VA needs by reducing existing 

VA funding needs in other areas. In general, The American Legion opposes 

cannibalizing existing benefits earned by some veterans to support benefits for other 

veterans. Further, the proposal to eliminate the individual unemployability benefit 

has got to be one of the worst proposals The American Legion has heard in years 

and adamantly opposes this request 7. 

The administration’s proposal would also round down to the nearest dollar the annual Cost-of-Living Adjustment (COLA) for service-connected disability compensation, dependency and indemnity compensation, along with certain education programs. The American Legion opposes any reduction what so ever in the annual cost 

of living increases entitled to veterans 8. 

The American Legion thanks this committee for the opportunity to elucidate the 

position of the over 2.2 million veteran members of this organization. For additional 

information regarding this testimony, please contact Mr. Matthew Shuman, Director 

of The American Legion Legislative Division at (202) 861–2700 or 

mshuman@legion.org. 

f 

Prepared Statement of Poonam Alaigh, M.D. 

Good afternoon Chairman Wenstrup, Ranking Member Brownley, and Members 

of the Subcommittee. Thank you for the opportunity to appear before you to discuss 

the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) fiscal year (FY) 2018 Budget and FY 2019 Medical Care Advance Appropriations budget requests. I am accompanied today by Mark Yow, VHA Chief Finance Officer. 

The 2018 budget request fulfills the Administration’s strong commitment to all of 

our Nation’s Veterans by providing the resources necessary for improving the care 

and support our Veterans have earned through sacrifice and service to our country. 

The President’s 2018 budget requests $75.2 billion for VHA—$72.3 billion in discretionary funding (including medical care collections), of which $70 billion was previously provided as the 2018 AA for Medical Care. The discretionary request is an 

increase of $4.6 billion, or 6.7 percent, over 2017. It will improve patient access and 

timeliness of medical care services for over 9 million enrolled Veterans. The President’s 2018 budget also requests additional mandatory funding to carry out the Veterans Choice Program (Choice Program). 

For the 2019 AA, the budget requests $74 billion in discretionary funding (including medical care collections) for Medical Care. The budget also requests $3.5 billion 

in mandatory budget authority in 2019 for the Choice Program. 

The budget’s request for mandatory funding to continue the Choice Program, or 

its successor, is fully offset by proposed reductions to certain Veterans’ benefits programs. 

This budget request will ensure the Nation’s Veterans receive high-quality health 

care and timely access to services. I urge Congress to support and fully fund the 

Department’s 2018 and 2019 AA budget requests - these resources are critical to enabling the Department to meet the increasing needs of our Veterans. 

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Increasing our focus and efforts in order to improve how we execute our mission 

is critical. Veterans have unique needs, and the services VA provides to Veterans 

often cannot be found in the private sector. VHA provides support to Veterans 

through various services, including primary care, specialty care, peer support, crisis 

lines, transportation, the Caregivers program, homelessness services, vocational 

support, behavioral health integration, medication support, and a VA-wide electronic 

medical record system. These services and supports are unparalleled. With the continued support of Congress, VA will supplement its services through private-sector 

health care, but we realize it is not a replacement for the services VA provides to 

Veterans. 

We are already implementing bold changes in the agency. We are working hard 

to ensure employees are held accountable to the highest of standards. On May 31, 

2017, Secretary Shulkin highlighted the activities and direction of the agency since 

his appointment in February 2017. My written statement will address those activities specific to VHA and how the FY 2018 budget request will assist in those efforts. 

Access to Care and Quality of Care 

VA is taking multiple steps to expand capacity at our facilities by focusing on staffing, space, and productivity. The FY 2018 Budget request provides $72.3 billion 

in discretionary funding (including medical care collections). The request supports 

an increase in total outpatient visits - 114 million, compared to 110 million projected 

in 2017; provides health care to over 7.0 million unique patients - up from 6.9 million in 2017; and expands medical facilities through leasing and improves current 

infrastructure through non-recurring maintenance. 

Veterans now have same-day services for primary care and mental health care at 

all VA medical centers across our system. I am also committed to ensuring that any 

Veteran who requires urgent care will receive timely care. We are also increasing 

transparency and empowering Veterans to make more informed decisions about 

their health care through our new Access and Quality Tool (available at 

www.accesstocare.va.gov). This Tool allows Veterans to access transparent and easy 

to understand wait-time and quality-care measures for VA health care, a tool that 

is unparalleled across the health care industry. That means Veterans can quickly 

and easily compare access and quality measures across VA facilities and make informed choices about where, when, and how they receive their health care. Further, 

they will now be able to compare the quality of VA medical centers to local private 

sector hospitals. This Tool will take complex data and make it transparent to Veterans. This new Tool will continue to improve as we receive feedback from Veterans, 

employees, Veterans Service Organizations (VSO), Congress, and the media. 

Addressing Veteran Suicide 

Every suicide is tragic, and regardless of the numbers or rates, one Veteran suicide is too many. Suicide prevention is VA’s highest clinical priority, and we continue to spread the word throughout VA that ‘‘Suicide Prevention is Everyone’s 

Business.’’ The 2018 Budget requests $8.4 billion for Veterans’ mental health services, an increase of 6 percent above the 2017 level. It also includes $186.1 million 

for suicide prevention outreach. VA recognizes that Veterans are at an increased 

risk for suicide and has implemented a national suicide prevention strategy to address this crisis. VA is bringing the best minds in the public and private sectors 

together to improve our effort and determine the next steps in implementing the 

Eliminating Veteran Suicide Initiative. VA’s suicide prevention program is based on 

a public health approach and recognition that suicide prevention requires ready access to high quality mental health services, supplemented by programs that address 

the risk for suicide directly. Showing its commitment to suicide prevention as everyone’s business, VA now requires SAVE Training (The acronym ‘‘SAVE’’ summarizes 

the steps needed to take an active and valuable role in suicide prevention: Signs 

of suicidal thinking, Ask questions, Validate the person’s experience, and Encourage 

treatment and Expedite getting help) annually for all employees at VA medical centers, and we are rolling out the training for all VA employees to include Central 

Office, the Veterans Benefits Administration, and the National Cemetery Administration. Every employee will be able to recognize and respond to signs of crisis and 

know how to expedite getting the individual Veteran into care. 

As part of VA’s commitment to put forth resources, services, and technology to reduce Veteran suicide, VA initiated the Recovery Engagement and Coordination for 

Health Veterans Enhanced Treatment (REACH VET). This new program was 

launched by VA in November 2016 and was fully implemented in February 2017. 

REACH VET uses a new predictive model in order to analyze existing data from 

Veterans’ health records to identify those who are at a statistically elevated risk for 

suicide, hospitalization, illnesses, and other adverse outcomes. Not all Veterans who 

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are identified have experienced suicidal ideation or behavior. However, REACH VET 

allows VA to provide support and pre-emptive enhanced care in order to reduce the 

likelihood that the challenges these Veterans face will become a crisis. 

Care in the Community 

We recognize that we must address how the Choice Program is accessed, and we 

are committed to streamlining and improving how Veterans can access and utilize 

it. We believe redesigning community care will result in a strong VA that can meet 

the special needs of our Veteran population. A redesigned community care program 

will not only improve access and provide greater convenience for Veterans, but will 

also transform how VA delivers care within our facilities. Where VA excels, we want 

to make sure that the tools exist to continue performing well in those areas. Veterans need VA, and for that reason, community care access must be guided by principles based on clinical need and quality. 

Since the start of the Choice Program, over 1.7 million Veterans have received 

care through the Program. In FY 2015, VA issued more than 380,000 authorizations 

to Veterans through the Choice Program. In FY 2016, VA issued more than 

2,000,000 authorizations to Veterans to receive care through the Choice Program, 

more than a five-fold increase in the number of authorizations from 2015 to 2016. 

Looking at early data for 2017, it is expected that Veterans will benefit even more 

this year than last year from the Choice Program. In the first five months of FY 

2017, we have seen a more than 36 percent increase from the same period in FY 

2016 in terms of the number of Choice authorizations. In addition to increasing the 

number of Veterans accessing care through the Choice Program, VA is working to 

increase the number of community providers available through the Program. In 

April 2015, the Choice Program network included approximately 200,000 providers 

and facilities. As of March 2017, the Choice Program network has grown to over 

430,000 providers and facilities, a more than 150 percent increase during this time 

period. 

As these numbers demonstrate, demand for community care is high. In 2018, VA plans on a total of $13.2 billion to support community care for Veterans. Community 

care will be funded by a discretionary appropriation of $9.4 billion for the Medical 

Community Care account ($254 million above the enacted advance appropriation) 

and $256 in estimated collections, plus $2.9 billion in new mandatory budget authority for the Choice Program. This, combined with a planned $626 million in carryover balances in the Veterans Choice Fund, would have provided a total of $13.2 

billion in 2018 for community care. However, as of June 9, 2017, $9.2 billion of the 

Choice Fund has been obligated and $7.1 billion has been expended. These levels 

represent a significant acceleration of funds being expended from the Veterans 

Choice Fund, and consequently, the Secretary has updated the estimates VA previously put forth regarding when Choice Program funds would be fully obligated. 

In March 2017, VA issued the highest number of authorizations in a month since 

the start of the program, followed closely by April and May. Over the three-month 

period between March and May 2017, VA issued nearly 800,000 authorizations for 

Choice Program care, a 32-percent increase over the same time period in 2016. As 

a result, VA anticipates that Choice Program funds will be fully obligated sooner 

than previously expected. Based on VA’s latest risk-adjusted cost estimates and volume projections, the program will be unable to carry over the previously estimated 

$626 million, resulting in a need for the total $3.5 billion in new mandatory budget 

authority to continue the Choice Program in FY 2018. The 2018 budget proposes 

a funding mechanism to continue this program, or its successor, to ensure that we 

can maintain and improve upon the gains in Veterans’ access to health care. 

VA will continue to partner with Congress to develop a community care program 

that addresses the challenges we face in achieving our common goal of providing 

the best health care and benefits we can for our Veterans. We have also worked 

with and received crucial input from Veterans, community providers, VSOs, and 

other stakeholders in the past, and we will continue doing so going forward 

Electronic Health Record 

Having a Veteran’s complete and accurate health record in a single common Electronic Health Record (EHR) system is critical to that care, and to improving patient 

safety. VA’s current Veterans Information Systems and Technology Architecture 

(VistA) system is in need of major modernization to keep pace with the improvements in health information technology and cybersecurity, and software development is not a core competency of VA. On June 5, 2017, the Secretary announced 

that VA will start the process of adopting the same EHR system as the Department 

of Defense (DoD), now known as MHS GENESIS, which at its core consists of 

Cerner Millennium. VA’s adoption of the same EHR system as DoD will ultimately 

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result in all patient data residing in one common system and enable seamless care 

between the Departments without the manual and electronic exchange and reconciliation of data between two separate systems. 

Of course, VA has unique needs that are different from DoD’s. For this reason, 

VA will not simply be adopting the identical EHR that DoD uses, but we intend to 

be on a similar Cerner platform. VA clinicians will be very involved in how this 

process moves forward and in the implementation of the system. Furthermore, VA 

must obtain interoperability not only with DoD but also with our academic affiliates 

and community partners, many of whom are on different information technology 

platforms. 

Therefore, we are embarking on creating something that has not been done before 

- that is an integrated product that, while utilizing the DoD platform, will require 

a meaningful integration with other vendors to create a system that serves Veterans 

in the best possible way. This is going to take the cooperation and involvement of 

many companies and thought leaders, and can serve as a model for the Federal government and all of healthcare. 

Medical and Prosthetic Research 

As the nation’s only health research program focused exclusively on the needs of 

Veterans, VA research continues to play a vital role in the care and rehabilitation 

of our men and women who have served in uniform. Building on more than 90 years 

of discovery and innovation, VA research has a proud track record of transforming 

VA health care by bringing new evidence-based treatments and technologies into everyday clinical care. Innovative VA studies in areas such as basic and clinical 

science, rehabilitation, research methodology, epidemiology, informatics, and implementation science improve health care for both Veterans and the general public. The 2018 Budget includes $640 million for development of innovative and cuttingedge medical research for Veterans, their families, and the Nation. One example includes continuing the Million Veteran Program (MVP), a groundbreaking genomic 

medicine program, in which VA seeks to collect genetic samples and general health 

information from one million Veterans. The goal of MVP is to discover how genomic 

variation influences the progression of disease and response to different treatments, 

thus identifying ways to improve treatments for individual patients. These insights 

will improve care for Veterans and all Americans. 

Chronic pain is prevalent among Veterans, and VA has experienced many of the 

problems of opiate misuse and addiction that have made this a major clinical and 

public-health problem in the U.S. As VA continues to reduce excessive reliance on 

opiate medication and responds to the requirements of the Comprehensive Addiction 

Recovery Act (CARA), VA will expand pain-management research in 2018 in two 

areas. VA is testing and implementing complementary and integrative approaches 

to treating chronic pain which builds on a successful State of the Art Conference 

in late 2016 on non-opioid therapies for chronic musculoskeletal pain. In a second, 

longer-term initiative, VA is working on other drug models and current drugs in the 

market to test their efficacy for treating pain. A study being developed under the 

Learning Healthcare Initiative is being launched that will evaluate the impact of 

implementing a new tool to identify Veterans at high risk of adverse effects from 

their opiate medication. 

Ending Veterans Homelessness 

VA’s homelessness research initiative develops strategies for identifying and engaging homeless Veterans. Researchers also work to ensure homeless Veterans receive proper housing, a full range of physical and mental health care, and other relevant services. They are using existing data to identify and engage Veterans who 

are currently homeless, and to develop strategies to identify and intervene on behalf 

of Veterans at risk for homelessness. 

In FY 2018, VA is investing $1.7 billion in programs to assist homeless Veterans 

and prevent at-risk Veterans from becoming homeless. Funding provided for specific 

programs that reduce and prevent Veteran homelessness include $543 million for 

Housing and Urban Development-Veterans Affairs Supportive Housing (HUD– 

VASH) for case management and supportive services to support about 93,000 vouchers; $320 million for Supportive Services for Veteran Families (SSVF); and $257.5 

million for Grant and Per Diem program, including program liaisons. 

Conclusion 

VA is committed to providing the highest quality care, that our Veterans have 

earned and deserve. I appreciate the hard work and dedication of VA employees, 

our partners from Veterans Service Organizations-who are important advocates for 

Veterans-our community stakeholders, and our dedicated VA volunteers. I respect 

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the important role that Congress has in ensuring that Veterans receive the quality 

health care and benefits that they rightfully deserve. I look forward to continuing 

our strong collaboration and partnership with this Subcommittee, our other committees of jurisdiction, and the entire Congress, as we work together to continue to enhance the delivery of health care services to our Nation’s Veterans. 

Mr. Chairman, Members of the Subcommittee, this concludes my remarks. Thank 

you again for the opportunity to testify. My colleague and I will be happy to respond 

to any questions from you or other Members of the Subcommittee. 

f 

Statements For The Record 

HEALTH NET FEDERAL SERVICES, LLC 

BILLY R. MAYNARD, PRESIDENT AND CEO 

RE: Letter correcting 062317 Record from House Veterans’ Affairs Subcommittee 

on Health during the hearing entitled, ‘‘FY 2018 Department of Veterans Affairs 

Budget Request for the Veterans Health Administration’’ 

Dear Chairman Wenstrup, 

I am writing with regard to the testimony provided by Dr. Poonam Alaigh, M.D., 

Acting Under Secretary of Health, Veterans Health Administration, Department of 

Veterans Affairs before the House Veterans Affairs Subcommittee on Health during 

the hearing entitled, ‘‘FY 2018 Department of Veterans Affairs Budget Request for 

the Veterans Health Administration’’ held on June 23, 2017. 

During the hearing, in response to a question from Congressman Bilirakis regarding prompt payment of providers, Dr. Alaigh stated that ‘‘Our (VA’s) payment to the 

TPAs (Third Party Administrators) is within thirty days. The TPAs then have to 

pay the provider.’’ 

This statement is factually incorrect. Under the Veterans Choice Program, the 

TPAs pay the provider claims first from their own funds then invoice the VA for 

reimbursement. The correct process is as follows: 

• A veteran is referred to the Choice program by the VA. • The veteran calls the Health Net Federal Services (HNFS) Veterans Choice Call 

Center to confirm eligibility. 

• HNFS locates a VCP provider who can accept the veteran as a patient. 

• HNFS schedules appointment on behalf of veteran and faxes the provider information about the appointment, including the authorization number, veteran 

contact details and additional details given to HNFS by VA. 

• The provider treats the veteran and submits a claim (electronically or mailed) 

to HNFS. 

• Separately, the provider faxes medical documentation to HNFS. HNFS receives 

and processes the claim and pays the provider. 

• Only then does HNFS invoice the VA for reimbursement for the paid claim. 

• On average, VA reimburses HNFS within thirty days of invoice. 

Working in this way, over the last 18 months, HNFS has reimbursed community 

providers supporting eligible veterans located throughout the states and VA regions 

we are responsible for more than $1.2 billion in paid claims - all of which has been 

paid by our company in advance of any reimbursement from VA. On average, our 

company has maintained a balance of not less than $125 million paid in advance 

on behalf of the US Government in support of Choice Program health care costs. 

At times, the balance of paid claims we have maintained has exceeded $250 million 

pending adjudication through the invoicing process of the VA. 

Fulfilling our responsibilities as a Veterans Choice Program (VCP) contractor has 

required HNFS, with the full support of our publicly-traded parent, Centene Corporation, to make extraordinary capital commitments that are unique and effectively unprecedented for a government contractor. In fact, it is fair to say that not 

many companies, and certainly not many government-sector contractors, would even 

have the ways and means to make such advance payment commitments. 

I respectfully request that this letter be submitted for the record for the June 23, 

2017 Health Subcommittee hearing. Thank you for this opportunity to set the record 

straight. Serving the health care needs of those who serve our great country has 

been the singular mission of our company for nearly 30 years. We are honored every 

day to have the opportunity to serve our nation’s veterans as a partner with the 

VA in the Veterans Choice Program. 

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Sincerely, 

Billy R. Maynard 

President and CEO 

Health Net Federal Services, LLC 

Æ 

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