U.S. GOVERNMENT PUBLISHING OFFICE

26–285 PDF WASHINGTON : 2018

S. HRG. 115–276 

THE FISCAL YEAR 2018 BUDGET FOR 

VETERANS’ PROGRAMS 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

JUNE 14, 2017 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JOHNNY ISAKSON, Georgia, Chairman 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

DEAN HELLER, Nevada 

BILL CASSIDY, Louisiana 

MIKE ROUNDS, South Dakota 

THOM TILLIS, North Carolina 

DAN SULLIVAN, Alaska 

JON TESTER, Montana, Ranking Member 

PATTY MURRAY, Washington 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

RICHARD BLUMENTHAL, Connecticut 

MAZIE K. HIRONO, Hawaii 

JOE MANCHIN III, West Virginia 

THOMAS G. BOWMAN, Staff Director 1

ROBERT J. HENKE, Staff Director 2

TONY MCCLAIN, Democratic Staff Director 

Majority Professional Staff 

Amanda Meredith 

Gretchan Blum 

Leslie Campbell 

Maureen O’Neill 

Adam Reece 

David Shearman 

Jillian Workman 

Minority Professional Staff 

Dahlia Melendrez 

Cassandra Byerly 

Jon Coen 

Steve Colley 

Simon Coon 

Michelle Dominguez 

Eric Gardener 

Carla Lott 

Jorge Rueda 

1Thomas G. Bowman served as Committee majority Staff Director through September 5, 

2017, after being confirmed as Deputy Secretary of Veterans Affairs on August 3, 2017. 2 Robert J. Henke became the Committee majority Staff Director on September 6, 2017. 

(III) 

C O N T E N T S 

WEDNESDAY, JUNE 14, 2017 

SENATORS 

Page 

Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia ............................ 1 

Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana ...................... 2 

Moran, Hon. Jerry, U.S. Senator from Kansas ..................................................... 66 

Sanders, Hon. Bernard, U.S. Senator from Vermont ........................................... 69 

Rounds, Hon. Mike, U.S. Senator from South Dakota ......................................... 72 

Manchin, Hon. Joe, III, U.S. Senator from West Virginia ................................... 73 

Heller, Hon. Dean, U.S. Senator from Nevada ..................................................... 75 

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 78 

Boozman, Hon. John, U.S. Senator from Arkansas .............................................. 80 

Tillis, Hon. Thom, U.S. Senator from North Carolina .......................................... 82 

Blumenthal, Hon. Richard, U.S. Senator from Connecticut ................................ 83 

WITNESSES 

Shulkin, Hon. David J., MD, Secretary of Veterans Affairs, U.S. Department 

of Veterans Affairs, accompanied by: Edward Murray, Acting Assistant 

Secretary for Management and Chief Financial Officer; Richard Chandler, 

Deputy Assistant Secretary, IT Resource Management; Mark Yow, Chief 

Financial Officer, Veterans Health Administration; James Manker, Acting 

Principal Deputy Under Secretary for Benefits, Veterans Benefits Administration; and Matthew Sullivan, Deputy Under Secretary for Finance and 

Planning and Chief Financial Officer, National Cemetery Administration .... 4 

Prepared statement .......................................................................................... 7 

Response to prehearing questions submitted by Hon. Johnny Isakson ....... 15 

Response to posthearing questions submitted by: 

Hon. Johnny Isakson .................................................................................... 110 

Hon. Jon Tester ............................................................................................. 121 

Hon. Bill Cassidy .......................................................................................... 134 

Hon. Patty Murray ........................................................................................ 135 

Hon. Joe Manchin III ................................................................................... 136 

Hon. Mazie K. Hirono ................................................................................... 138 

INDEPENDENT BUDGET REPRESENTATIVES

Blake, Carl, Associate Executive Director, Government Relations, Paralyzed 

Veterans of America ............................................................................................. 88 

Prepared statement of IBVSOs ....................................................................... 90 

Acosta, LeRoy, Assistant National Service Director, Disabled American 

Veterans ................................................................................................................ 94 

Prepared statement .......................................................................................... 96 

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

Foreign Wars of the United States ..................................................................... 99 

Prepared statement .......................................................................................... 100 

OTHER VETERANS SERVICE ORGANIZATIONS

Rowan, John, National President, Vietnam Veterans of America ....................... 103 

Prepared statement .......................................................................................... 105 

Page

IV 

APPENDIX 

Chenelly, Joseph R., National Executive Director, AMVETS (American Veterans); prepared statement ................................................................................. 141 

(1) 

THE FISCAL YEAR 2018 BUDGET FOR 

VETERANS’ PROGRAMS 

WEDNESDAY, JUNE 14, 2017 

U.S. SENATE, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 2:41 p.m., in room 

418, Russell Senate Office Building, Hon. Johnny Isakson, Chairman of the Committee, presiding. 

Present: Senators Isakson, Moran, Boozman, Heller, Rounds, 

Tillis, Tester, Murray, Sanders, Brown, Blumenthal, and Manchin. 

OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN, 

U.S. SENATOR FROM GEORGIA 

Chairman ISAKSON. I call this meeting of the Senate Veterans’ 

Affairs Committee to order. I apologize again for being a little bit 

late, but I wanted to make sure we were on the right track and 

I did not mess anything up. 

I want to welcome Secretary Shulkin, who has had a great start. 

I do not think anybody in this administration started out with a 

unanimous vote he received. You cannot do any better than unanimous when you get confirmed. I think the vote last week on accountability was extraordinary, and the way we got to the decision, 

working together hand in hand, was extraordinary. I commend the 

Ranking Member on his help in doing the same. 

We have got some other things to do today to talk about, budgetwise, and we will have some other decisions to make. We can keep 

the same tempo, same discipline, and the same commitment to 

making sure we all know what each other knows before they happen rather than finding out after the fact, which we will all be an 

awful lot better off. 

I welcome Dr. Shulkin and the other members of the VA staff 

that are here today. I appreciate all that they had done in our 

meeting the other day to explain where we are going with the Veterans Administration, which is upward and outward and further 

ahead all along. 

I am not going to make a long statement at all, except to say a 

couple of things. I do not want to make this David Shulkin Day, 

but one other thing I have to brag about, the Cerner decision and 

getting our electronic medical records issue solved after years of 

unwillingness to address it is extraordinary. I think, from what I 

have heard, there are already signs that people are coming together who in the past had not been together to make sure this 

happens and works efficiently for our veterans and for the DepartVerDate Mar 15 2010 16:16 Jul 12, 2018 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 Z:\ACTIVE\061417.TXT PAULIN
2 

ment of Defense and the Department of Veterans Affairs at the 

same time. 

It was silly to have two different agencies in the same government serving the same soldiers, fighting for the same country and 

the same Constitution that had two medical systems that were not 

interoperable, one to the other, and where our veterans who fought 

for us would literally fall in a hole going from active duty from the 

Department of Defense to Veterans Affairs. I think this move to 

Cerner is going to prove to be a tremendous move economically for 

the VA and benefit-wise for our veterans. There is no possible way 

to do any better than that. So, I commend you on that decision as 

well. 

With that, instead of getting into details, I am going to ask for 

an opening statement from the Ranking Member, Jon Tester. 

OPENING STATEMENT OF HON. JON TESTER, RANKING 

MEMBER, U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Mr. Chairman, and thanks for having this hearing. I think it is important to say that our thoughts 

are with the colleagues who were with the victims this morning. 

We wish a speedy recovery for Congressman Scalise and everybody 

else who was injured, and a big, big thank-you to the Capitol Police 

officers who work every day to make sure this place is a safe place. 

Our thoughts are with them. 

Now, Secretary Shulkin, I want to thank you for being here, and 

I want to thank you for being here with your VA team. We spoke 

last week at some length about the future of the Choice Program, 

and I hope I made my perspective clear: the Choice Program was 

intended to supplement care, provided, directed by the VA, not replace it, not now and not into the future. 

I worry that the budget proposed by this administration starts us 

down a path of unfettered choice that will hollow out the VA. In 

doing so, it proposes to increase funding for community care by a 

third, while proposing that the VA’s own hospitals receive an increase that is less than half of the medical inflation rate—not 

much. 

Further, the budget does absolutely nothing to address VA’s 

aging infrastructure. If we are starving VA’s hospitals for funding 

used to hire staff and actually provide care for veterans while also 

denying them money to address the environmental care concerns, 

we know what that outcome is going to be. Soon enough, there will 

not be any quality VA hospitals staffed by quality providers, and 

the VA care will become nothing more than a voucher plan to send 

veterans into the private sector to hunt for a doctor who has the 

time and the capacity and the knowledge to treat them. That is not 

what our veterans need, and it is not what the veterans want to 

happen. For a rural State like Montana, it would truly be a 

disaster. 

We need to be honest. Each year, more and more rural hospitals 

are at the risk of closing, and if there are rollbacks to recent Medicaid expansions, it is likely that these closures would accelerate. 

We cannot assume that private care will work in rural communities where there are no providers in the first place or where the 

third-party administrators (TPAs) do not have sufficient networks. 

3 

We know that the vast majority of veterans using Choice over 

the last 2 years are eligible due to long wait lines, not because they 

live too far from a VA facility. Data shows that rural veterans are 

not just choosing Choice as much, but they actually do depend on 

VA care. 

Now, based on your request yesterday, we may have to shift additional funds around and out of VA care accounts to get the 

Choice Program through the fiscal year. For months, we have been 

asking about the Choice Program spend rate and the amount of 

funds, the amount of remaining funds. We were never provided 

with those answers we needed to make informed decisions, and 

now we are in a difficult spot. 

Mr. Secretary, no one wants to delay care for veterans—no one— 

and we will act appropriately and in a timely manner to solve this 

problem. But, for that to happen this late in the game is a bit frustrating to me, and my frustration is compounded by a budget that 

cuts services that veterans rely on, makes cuts to education oversight, makes cuts to information technology (IT), which impact 

every business line and how the department operates. I am most 

concerned that it appears that these cuts are being made in order 

to pay for certain veterans to get private care. 

The new policies proposed in this budget to pay for private care 

are simply untenable. To put forward a proposal that would, without warning, stop earned benefits payments to severely disabled 

vets is unacceptable. In this case, we are not talking about folks 

milking the system for government-funded compensation that they 

do not need or do not deserve. To get the individual unemployment 

benefit payment, it must be determined that a veteran is unable 

to engage in substantive work as a direct result of service to their 

country. 

President Trump’s budget proposes that we just stop paying 

these veterans at a time when more Americans are having to work 

longer in their lives to make ends meet and all in the name of finding more money for Choice. That is a nonstarter, and I hope we can 

get your commitment today to keep this important benefit in place. 

I look forward to working with my colleagues on both sides of the 

aisle to address these concerns and look forward to hearing from 

you and how you intend to prioritize funding for veterans who get 

care and benefits direction from the VA. 

Finally, I would like to wish the U.S. Army a happy birthday. 

I look forward to your testimony, Secretary Shulkin. 

With that, thank you, Mr. Chairman. 

Chairman ISAKSON. Secretary, welcome. Let me introduce those 

you brought with you to back you up and accompany you along the 

way, which we appreciate them being here too. Edward Murray, 

thank you for being here today as Acting Assistant Secretary for 

Management and Chief Financial Officer; Richard Chandler, Deputy Assistant Secretary, Resource Management; Mark Yow, Chief 

Financial Officer, Veterans Health Administration; James Manker, 

Acting Principal Deputy Under Secretary for Benefits; and Mr. 

Matthew Sullivan, Deputy Under Secretary for Finance and Planning and Chief Financial Officer, National Cemetery Administration. 

Secretary Shulkin, the floor is yours. 

4 

STATEMENT OF HON. DAVID J. SHULKIN, M.D., SECRETARY, 

U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED 

BY EDWARD MURRAY, ACTING ASSISTANT SECRETARY FOR 

MANAGEMENT AND CHIEF FINANCIAL OFFICER; RICHARD 

CHANDLER, DEPUTY ASSISTANT SECRETARY, IT RESOURCE 

MANAGEMENT; MARK YOW, CHIEF FINANCIAL OFFICER, 

VETERANS HEALTH ADMINISTRATION; JAMES MANKER, 

ACTING PRINCIPAL DEPUTY UNDER SECRETARY FOR BENEFITS, VETERANS BENEFITS ADMINISTRATION; AND MATTHEW SULLIVAN, DEPUTY UNDER SECRETARY FOR FINANCE 

AND PLANNING AND CHIEF FINANCIAL OFFICER, NATIONAL 

CEMETERY ADMINISTRATION 

Secretary SHULKIN. Well, thank you, Chairman Isakson, Ranking 

Member Tester, and other Members of the Committee. 

As you can see, I brought a big team with me because I know 

you are going to have lots of questions, in particular, with the 

opening statements, I really do look forward to having a meaningful discussion and getting to some solutions and some closure on 

some of these issues. 

I also did want to echo the Ranking Member’s concern that this 

is a sad day for the Nation where public servants who work as 

hard as I know all of you do have to worry about their personal 

safety, and our thoughts and prayers are with the Congressman 

and the staff and the Capitol Police as well. 

Thank you again for allowing us to be here today. What we want 

to talk about today is the 2018 President’s budget and the 2019 advanced appropriations, and all of this is in way of showing support 

for veterans. We appreciate the legislation that recently had been 

passed. As you know, you passed just within the past week, the accountability bill, and that went through the House yesterday. We 

are looking forward to actually next Tuesday bringing it for a signature for the President, which is good news. 

We also appreciate your support for the Veterans Choice Improvement Act that you supported and for providing us, really for 

the first time in a long time, the full 2017 budget. This has really 

allowed us to make real progress for veterans, and we are, again, 

grateful for that support. 

I have submitted the full written statement for the record, so let 

me just start by thanking you again for allowing us to participate 

in the hearing last week. It seems like we were just here with you, 

but I thought it was an excellent hearing, a good discussion on 

Choice. That type of discussion and dialog is going to allow us to 

help get it right for veterans. 

When I testified before the House Veterans’ Affairs Committee 

on March 7, we had $2.0 billion in the Choice account. Less than 

a month and a half later, when the President signed the Choice Extension Act into law, our Choice account was at $1.5 billion. Today, 

that account is at $821 million. 

As we know, more veterans than ever are using Choice. We have 

authorized 8.2 million Community Care appointments since January of this year. That is 2.6 million more than last year or a 46 

percent increase. In fact, March, April, and May were the largest 

months ever for Choice, and frankly, that happened because we 

fixed so many of the problems that we have all been working to fix 

5 

with Choice. We have been increasing our use of Choice. One of the 

reasons why is the 2017 budget, as you may remember, actually 

had $2 billion less in Community Care, so we have been putting 

more through Choice. 

Two years ago—I am sure you are going to remember in July 

2015, we had too little money in our Community Care accounts 

within the VA, which we solved with your help by accessing unused 

funds in the Choice account, so we transferred money from Choice 

into Community Care. We now have too little money in the Choice 

account, which we are working to solve, again, working with you, 

with legislative authority to replenish funds into the Choice 

account. 

This is the situation that we have described before, where for a 

single purpose of providing care in the community, we have two 

checking accounts, and I will tell you, I wish it were easier than 

it is. We have to figure out how to balance these two checking accounts at all times. Obviously, it is not a science; it is an art. We 

are having difficulty with that once again. That is why we need to 

work with you to solve it. 

The Veterans CARE Program that we outlined for you last week 

will solve this recurring problem permanently by modernizing and 

consolidating all of the Community Care accounts, including 

Choice. The President’s budget in 2018 and 2019 provides additional funds for Choice and the resources necessary to continue the 

ongoing modernization of VA. It requests $186.5 billion for VA, 

$104.3 billion in mandatory funding, and $82.1 billion in discretionary funding, for a total increase of $6.4 billion or 3.6 percent 

over 2017. 

It provides $2.9 billion in mandatory funding to continue the 

Choice Program in 2018 plus a 7.1 percent increase in discretionary 

funding for VHA to improve patient access and timeliness of care. 

It supports the strengthening of foundational services as well as 

modernization in consolidating VA Community Care through the 

Veteran CARE Program announced last week, so veterans can 

make the right decisions about their care together with their physician or provider, giving them yet another reason to choose VA. 

This budget reflects the President’s strong personal commitment 

to the Nation’s veterans. It is also a budget we need to achieve my 

five priorities as Secretary: providing greater choice for veterans; 

modernizing our systems; focusing our resources toward what is 

most important for veterans; improving the timeliness of our services; and suicide prevention. 

We are already taking steps to meet the challenges that we face. 

At the President’s direction, we have established a VA Accountability Office. The recent decisions made by the Senate and the 

House will help us with that. 

We have recently removed two medical center directors and three 

other senior executive service leaders. We simply will not tolerate 

employees who act counter to our values or put veterans at risk. 

I recently announced a new Fraud, Waste, and Abuse Prevention 

Advisory Committee, which will be set up and running later this 

summer. 

I have also directed the VA Central Office remain under a hiring 

freeze—those are for administrative positions—as we consolidate 

6 

program offices, implement shared services, and realign overhead 

to get more money back to the field. 

We now have same-day services for primary care and mental 

health at all of our medical centers. Veterans can now access waittime data for their local VAs using an online easy-to-use tool to understand access and quality. No other health system in the country 

has this type of transparency. 

We have made it easier for veterans to fill online health care applications, so much easier, in fact, that since last summer, we have 

received eight times as many online applications than the year 

before. 

Last month, we were able to process a disability claim in just 3 

days—I said that right: a disability claim processed in 3 days— 

using a new process called Decision Ready Claims. We will be introducing Decision Ready Claims nationally September 1. 

At our regional offices, we will be completely paperless for claims 

by mid-2018. 

A few months ago, the Veterans Crisis Line had a call rollover 

rate of more than 30 percent. Today, that rate is less than 1 

percent. 

We have launched a new predictive modeling tool called REACH 

VET allowing VA to provide proactive support for veterans who are 

at higher risk for suicide. 

We are also launching a new initiative this summer, Getting to 

Zero, to help us end veteran suicide. This is my top clinical 

priority. 

But, to keep moving forward, we are going to need your help. We 

have identified over a thousand facilities that are either vacant or 

underutilized, and we are working now to move forward with 142 

of those facilities. With your help, we could do more of the same. 

We need Congress to fund our IT modernization to keep our legacy systems from failing and to replace VistA with the system already in use by the Department of Defense. This will ultimately 

put all patient data in one shared system, enabling seamless care 

between the VA and DOD, without manual and electronic exchange 

and reconciliation of data between separate systems. 

We also need Congress to authorize and overhaul our broken and 

failing claims appeals process. We have worked closely with VSOs 

and other stakeholders to draft a proposal to modernize the system, 

and we were pleased to see the House unite behind the bill last 

month. Now we just need the Senate to act. 

Most of all, we need Congress to ensure the continued success of 

Choice for veterans. Veterans are responding to our modernization 

efforts by choosing VA more than before. To keep up with those 

choices, we need to fully fund Choice and help us modernize and 

consolidate VA Community Care through the Veterans CARE Program. The Veterans CARE Program will coordinate care so that 

veterans get the right care at the right time with the right provider, whether in a VA facility or from a high-performing VA Community Care provider. We just need your help to make it happen, 

including funding, to keep up with veterans as they choose VA. 

Thank you, and we look forward to your questions today. 

[The prepared statement of Secretary Shulkin follows:] 

7 

PREPARED STATEMENT OF HON. DAVID J. SHULKIN, M.D., SECRETARY, 

U.S. DEPARTMENT OF VETERANS AFFAIRS

GOOD AFTERNOON, CHAIRMAN ISAKSON, RANKING MEMBER TESTER, AND DISTINGUISHED MEMBERS OF THE SENATE COMMITTEE ON VETERANS’ AFFAIRS. Thank you 

for the opportunity to testify today in support of the President’s 2018 Budget and 

2019 Advance Appropriation (AA) Request and to define my priorities to continue 

the dynamic transformation within the Department of Veterans Affairs (VA). I am 

accompanied today by Edward Murray, Acting Assistant Secretary for Management 

and Acting Chief Financial Officer; Richard Chandler, Deputy Assistant Secretary, 

IT Resource Management; Mark Yow, Chief Financial Officer for the Veterans 

Health Administration; James Manker, Acting Principal Deputy Under Secretary for 

Benefits in the Veterans Benefits Administration; and Matthew Sullivan, Deputy 

Under Secretary for Finance and Planning for the National Cemetery Administration. I also want to thank Congress for providing the Department its full 2017 budget prior to the start of the Fiscal Year—this is significant and has been extremely 

beneficial to our ability to provide services and care to Veterans. The 2018 budget 

request fulfills the President’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. 

FISCAL YEAR (FY) 2018 BUDGET REQUEST

The President’s 2018 budget requests $186.5 billion for VA—$82.1 billion in discretionary funding (including medical care collections), of which $66.4 billion was 

previously provided as the 2018 AA for Medical Care. The discretionary request is 

an increase of $4.3 billion, or 5.5 percent, over 2017. It will improve patient access 

and timeliness of medical care services for over 9 million enrolled Veterans, while 

improving benefits delivery for our Veterans and their beneficiaries. The President’s 

2018 budget also requests $104.3 billion in mandatory funding, of which $103.9 billion was previously provided, such as disability compensation and pensions, and for 

continuation of the Veterans Choice Program (Choice Program). 

For the 2019 AA, the budget requests $70.7 billion in discretionary funding for 

Medical Care and $107.7 billion in 2019 mandatory advance appropriations for Compensation and Pensions, Readjustment Benefits, and Veterans Insurance and Indemnities benefits programs in the Veterans Benefits Administration. The budget 

also requests $3.5 billion in mandatory budget authority in 2019 for the Choice 

Program. 

This budget request will ensure the Nation’s Veterans receive high-quality health 

care and timely access to benefits and services. I urge Congress to support and fully 

fund our 2018 and 2019 AA budget requests—these resources are critical to enabling the Department to meet the increasing needs of our Veterans. 

MODERNIZING VA

As you all know, I was part of the VA team for the last year and a half prior 

to being confirmed as the Secretary of Veterans Affairs. I came to VA during a time 

of crisis, when it was clear Veterans were not getting the timely access to high-quality health care they deserved. I soon discovered that years of ineffective systems and 

deficiencies in workplace culture led to these problems. I know that the organization 

has made significant progress in improving care and services to Veterans. But I also 

know that VA needs more changes to the way we do business for Veterans and the 

country as a whole, in order for all to say, ‘‘That is a different organization now.’’ 

VA needs to continue to fix numerous areas of the business, including access, claims 

and appeals processing, and many of our core functions, to ensure that the basics 

are done correctly. Beyond that, VA has to deliver to Veterans revolutionary leaps 

in care, benefits, and services. Congress, along with our VA employees, Veterans 

Service Organizations (VSO), and private industry, will play a critical role in making those revolutionary leaps a reality. 

Focus on Execution 

Above all else, VA needs to perform its core functions well. When Veterans arrive 

at a VA facility for care, they must be treated with respect, see a clean and modern 

facility, be seen by their provider on time, and understand what the next steps for 

their care will be. Veterans should be able to receive clear and accurate information 

about their claims and understand where they are in the process. We must ensure 

that this is every Veteran’s experience every time they interact with VA. Where we 

fall short, we will hold employees accountable, ensure we are good stewards of the 

taxpayer dollar, and ask for Congress’s support for legislative fixes where needed. 

8 

Make Bold Change 

We know it is paramount that we increase our focus and intensify the efforts to 

improve how we execute our mission—Veterans should and do expect that from us. 

We also recognize that incremental change is not sufficient to achieve the additional 

improvements VA and Veterans need and demand for restoring the trust of Veterans and the American public. 

As I have noted, VA is a unique national resource that is worth saving, and I am 

committed to doing just that. Veterans have unique needs, and the services VA provides to Veterans often cannot be found in the private sector. The Veterans Health 

Administration (VHA) provides support to Veterans through 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. We also know that VA hospitals perform well on quality compared to 

non-VA hospitals. In a study published in the Journal of American Medical Association (JAMA) Internal Medicine in April, researchers compared hospital-level quality 

data on 129 VA hospitals and 4,010 non-VA hospitals obtained through the Centers 

for Medicare and Medicaid’s website. They found VA hospitals had better outcomes 

than non-VA hospitals on six of nine patient safety indicators, and there were no 

significant differences on the other three indicators. VA hospitals also had better 

mortality and readmission rates than non-VA hospitals. 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 and working 

with Congress to provide us with greater authority and flexibility to do that. We 

are also working with Congress on appeals reform and on a long-term solution for 

providing greater community care options. I will discuss these efforts in greater detail below. 

FIVE PRIORITIES

As I prepared for my confirmation hearing earlier this year, I identified my top 

priorities to address as Secretary. These areas have shaped the first several months 

of my tenure and provide focus for our attention and resources, and the foundation 

for rebuilding trust with our Veterans. We will also use the budgeting process to 

support our strategy by shifting resources toward our ‘‘foundational services’’ that 

make VA unique while maintaining support to our strategic priorities. 

Priority 1: Greater Choice for Veterans 

The Choice Program is a critical program that has increased access to care for 

millions of Veterans. Coming into this new administration, extending the Choice 

Program was one of my top priorities for quick action, as VA anticipated that based 

on Veteran program participation, there would be an estimated $1.1 billion in unobligated funds left on the original expiration date of August 7, 2017. On April 19, 

2017, the President signed into law the Veterans Choice Program Improvement Act 

(Public Law 115–26), allowing the Choice Program to continue until the Veterans 

Choice Fund is exhausted. Without this legislation, VA would have been unable to 

use funding specifically appropriated for the Choice Program by Congress, so we 

commend Congress for passing this legislation swiftly and in a bipartisan manner. 

This legislation also provides VA and Congress more time to develop a long-term 

solution for community care. 

Since the start of the Choice Program, over 1.6 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 fivefold 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 quarter of FY 2017, 

we have seen a more than 30 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. 

9 

As these numbers demonstrate, demand for community care is high. In 2018, VA plans to spend 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), plus $2.9 billion in new mandatory budget authority for the Choice Program. This, combined with an estimated $626 million in carryover balances in the 

Veterans Choice Fund, provides a total of $13.2 billion in 2018 for community 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. However, we do need your help. 

One such area is in modernizing and consolidating community care. Veterans deserve better, and now is the time to get this right. We are committed to moving care 

into the community where it makes sense for the Veteran. The ultimate judge of 

our success will be our Veterans, and our only measure of success will be our Veterans’ satisfaction. With your help, we can continue to improve Veterans’ care in 

both VA and the community. 

Empower Veterans through Transparency of Information 

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 the most 

transparent and easy to understand wait-time and quality-care measures 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, VSOs, Congress, 

and the media. 

Priority 2: Modernizing our System 

Infrastructure Improvements and Streamlining 

In 2018, VA will focus on fixing VA’s infrastructure while we transform our health 

care system to an integrated network to serve Veterans. This budget requests 

$512.4 million in Major Construction funding as well as $342.6 million in Minor 

Construction for priority infrastructure projects. This funding supports projects including a new outpatient clinic in Livermore, CA, as well as gravesite expansions 

in Sacramento, CA; Bushnell, FL; Elwood, IL; Calverton, NY; Phoenix, AZ; and 

Bridgeville, PA. VA is also requesting $953.8 million to fund more than 2,000 medical leases in FY 2018, an increase of $141.9 million over the FY 2018 AA, and $862 

million for activation of new medical facilities. In 2018, VA is seeking Congressional 

authorization of 27 major medical leases. The majority of these leases have been included in previous budget requests, some dating back to the FY 2015 budget submission. These major medical leases are vital to establish new points of care, expand 

sites of care, replace expiring leases, and expand VA’s research capabilities. 

The 2018 budget submission includes proposed legislative requests that if enacted, 

would increase the Department’s flexibility to meet its capital needs. These proposals include: 1) increasing from $10 million to $20 million the dollar threshold for 

minor construction projects; 2) modifying title 38 to eliminate statutory impediments to acquiring joint facility projects with DOD and other Federal agencies; and 

3) expanding VA’s enhanced use lease (EUL) authority to give VA more opportunities to engage the private sector and local governments to repurpose underutilized 

VA property. 

The Department is also a key participant in the White House Infrastructure Initiative to explore additional ways to modernize and obtain needed upgrades to VA’s 

real property portfolio to support our continued delivery of quality care and services 

to our Nation’s Veterans. We are excited about the opportunity to transform the way 

we approach our infrastructure. 

Electronic Health Record Interoperability and IT Modernization 

The 2018 Budget continues VA’s investment in technology to improve the lives of 

Veterans. The planned IT investments prioritize the development of replacements 

for specific mission critical legacy systems, as well as operations and maintenance 

of all VA IT infrastructures essential to deliver medical care and benefits to Veterans. The request includes $358.5 million for new development to replace four speVerDate Mar 15 2010 16:16 Jul 12, 2018 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6621 Z:\ACTIVE\061417.TXT PAULIN
10 

cific mission critical legacy systems, including the Financial Management System, 

and establish an Integrated Project Team to develop the requirements and acquisition strategy for a new enterprise health information platform. It also invests $340 

million for information security to protect Veterans’ information and improve VA’s 

information networks’ resilience. 

The 2018 budget submission includes a proposed legislative request that if enacted, would increase the Departments ability to apply agile program management 

to the dynamics of modern Information Technology development requirements. To 

do this, the Department recommends advancing the transfer threshold from $1 million to $3 million between development project lines, which equates to less than 1 

percent of the Development account. Through the Certification process, Congress 

will maintain visibility of proposed changes. 

VA recognizes that a Veteran’s complete health history is critical to providing 

seamless, high-quality, integrated care, and benefits. Interoperability is the foundation of this capability, by making relevant clinical data available at the point of care 

and enabling clinicians to provide Veterans with prompt, effective care. Today, VHA, 

the Veterans Benefits Administration (VBA), and the Department of Defense (DOD) 

share more medical information than any public or private health care organization 

in the country. We have developed and deployed, in close collaboration with DOD, 

the Joint Legacy Viewer (JLV). JLV is available to all clinicians in every VA facility. 

It is a web-based user interface that provides clinicians with an intuitive display 

of DOD and VA health care data on a single screen. VA and DOD clinicians can 

use JLV to access the health records of Veterans, Active Duty, and Reserve Servicemembers from all VA, DOD, and any third party community providers who participate in Health Information Exchanges where a patient has received care. Multiple 

releases of Community Care applications, including JLV-Community Viewer, Community Provider Portal, and Virtru Pro Secure Email have enhanced care coordination with Community Providers through multiple methods of exchanging health 

records and multiple modes of communication improving the care the Veteran receives and allowing Community Providers not in Health Information Exchanges the 

ability to share medical documentation. 

VA will complete the next iteration of the VistA Evolution Program, VistA 4, in 

2018. VistA 4 will bring improvements in efficiency and interoperability, and will 

continue VistA’s award-winning legacy of providing a safe, efficient health care platform for providers and Veterans. VistA Evolution funds have enabled investments 

in systems and infrastructure that support interoperability, networking and infrastructure sustainment, continuation of legacy systems, and efforts such as clinical 

terminology standardization. These investments are critical to the maintenance and 

deployment of the existing and future modernized VistA and essential to operational 

capability. That said our current VistA system is in need of major modernization 

to keep pace with the improvement in health information technology and cybersecurity, and software development. 

I promised a decision on our EHR system by July 1st, and I have honored that 

commitment by announcing that, after much deliberation, VA will adopt the same 

EHR system as 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 

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. Still, VA has unique needs and many 

of those are different from the DOD. 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. 

Another critical system that will touch the delivery of all health and benefits is 

our new financial management system, which is under development. The 2018 budget continues modernizing our financial management system by transforming the Department from numerous stovepipe legacy systems to a proven, flexible, shared 

service business transaction environment. The budget requests $83 million in Information Technology funds and $61.6 million for business process re-engineering to 

support Financial Management Business Transformation (FMBT) across the Department. 

Priority 3: Focus Resources More Efficiently 

Strengthening of Foundational Services in VA 

VA is committed to providing the best access to care for Veterans. To deliver the 

full care spectrum as defined in VA’s medical benefits package, VA will focus on its 

foundational services—those areas in which it can excel—and build community partnerships for complementary services. VA developed the following guiding principles, 

11 

centered on improving the health, well-being, and experience of Veterans receiving 

care from VA and in the community. These principles include: 

• Enabling VA to provide access to high-quality care for Veterans, by balancing 

services provided by VA and the community given changing demands for care and 

resource limitations; • Promoting operational efficiency and simplicity, while supporting VA’s clinical 

care, education, and research missions; and • Allowing facilities to meet the changing needs of Veterans in a flexible way. 

High-performing organizations cannot excel at every capability and thus must 

make decisions about how best to invest its resources. VA will therefore further define and grow its foundational services to excel in the provision of clinical care to 

Veterans. 

Investing in foundational services within the Department is not limited to only 

health care. For over a decade, VA’s National Cemetery Administration (NCA) has 

achieved the highest customer satisfaction rating of any organization—public or private—in the country. They achieved this designation through the American Customer Satisfaction Index six consecutive times. The President’s 2018 Budget recognizes the need to nurture and advance this unprecedented success with a request 

for $306.2 million for NCA in 2018, an increase of $20 million (7 percent) over 2017. 

This request will support the 1,881 FTE needed to meet NCA’s increasing workload 

and expansion of services. In 2018, NCA will inter approximately 133,600 Veterans 

and eligible family members, care for over 3.7 million gravesites, and maintain 

9,400 acres. NCA will continue to memorialize Veterans by providing 366,000 

headstones and markers, distributing 702,000 Presidential Memorial Certificates 

and expanding the Veterans Legacy program to communities across the country. VA 

is committed to investing in NCA infrastructure, particularly to keep existing national cemeteries open and to construct new cemeteries consistent with burial policies approved by Congress. In addition to NCA’s funding, the 2018 request includes 

$255.9 million in major construction funds for six gravesite expansion projects. 

When all new cemeteries are opened, nearly 95 percent of the total Veteran population—about 20 million Veterans—will have access to a burial option in a Veterans’ 

cemetery within 75 miles of their home. 

VA/DOD/Federal Coordination 

VA has proposed legislation to eliminate certain statutory impediments to VA 

more effectively pursuing joint projects with other Federal agencies, including DOD. 

Today, medical facilities that are not specifically under the jurisdiction of the Secretary require specific statutory authorization for optimal collaboration. I look forward to working with Congress to: (1) enhance our ability to coordinate with DOD 

and other Federal agencies; (2) improve the access, quality, and cost effectiveness 

of direct health care provided to Veterans, Servicemembers, and their beneficiaries; 

(3) permit joint capital asset planning and capital investments to design, construct, 

and utilize shared medical facilities; and (4) provide authority for VA to procure the 

use of joint medical facilities for itself and other Federal agencies like DOD, and 

to transfer funds between VA and other Federal agencies for such initiatives. 

Deliver on Accountability and Effective Management Practices 

Another critical area in which VA is serious about making significant changes relates to employee accountability. The vast majority of employees are dedicated to 

providing Veterans the care they have earned and deserve. It is unfortunate that 

certain employees have tarnished the reputation of VA and so many who have dedicated their lives to serving our Nation’s Veterans. We will not tolerate employees 

who deviate from VA’s I-CARE values and underlying responsibility to provide the 

best level of care and services to them. We support Congress’ ongoing efforts to provide VA with the tools it needs to take timely action against employees who perform 

poorly or engage in misconduct. Where employees engage in inappropriate behavior, 

do not perform the duties of their job, are engaged in illegal activities, or otherwise 

do not meet the standards we expect of VA employees, we want the ability to ensure 

they can be promptly removed. Certain laws hamper our ability to optimally hold 

our employees accountable and remove those individuals that run afoul of my intent 

for the Department to function as a high-performing organization. We support legislation that is consistent with the following principles: 

• Increase flexibility to remove, demote, or suspend VA employees for poor performance or misconduct; 

• Provide authority to recoup bonuses of employees for poor performance or 

misconduct; 

• Enable recovery of relocation expenses that occur through fraud or malfeasance; 

and 

12 

• Ensure that VA has the ability to retain high performers by paying them a salary that is competitive with the private sector and performance awards that are 

commensurate with other Federal agencies. 

We thank the Senate for passing critical accountability legislation, S. 1094,—all 

signs point to new accountability rules for VA being the law of the land soon, but 

while that process continues, we are also focused on updating internal hiring practices. VHA is the largest health care system in the United States, and in an industry where there is a national shortage of health care providers, VHA faces competition with the commercial sector for scarce resources. Historically, VA has followed 

hiring practices that have proven unduly burdensome. Over the past year, VHA’s 

business process improvement efforts have resulted in a more efficient hiring process. We were able to reduce the time it took to hire Medical Center Directors by 

40 percent and obtained approval from the Office of Personnel Management (OPM) 

for critical position pay authority for many of our senior health care leaders. We recognize there is much work left to do. As we strive to find internal solutions, we look 

forward to working together on legislation to reform recruitment and compensation 

practices to stay competitive with the private sector and other employers. 

To ensure that VA’s management practices are effective, I have announced a 

major initiative to improve our ability to detect and prevent fraud, waste, and abuse 

within VA. The initiative includes: 

• forming a fraud, waste, and abuse advisory committee comprised of experts 

from the private sector and other government organizations; 

• identifying cutting edge tools and technologies available in the private sector; 

and 

• coordinating all fraud, waste, and abuse detection and reporting activities 

through a single office. 

With these improvements, VA has the potential to save millions of taxpayer dollars and more effectively serve America’s Veterans. I look forward to updating you 

in the future regarding this initiative. 

Priority 4: Improve Timeliness of Services 

Access to Care and Wait Times 

VA is committed to delivering timely and high quality health care to our Nation’s 

Veterans. 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. 

In March 2017, 96.82 percent of appointments, 5.15 million appointments, were 

completed within 30 days of the clinically-indicated or veteran’s-preferred date, and 

as of April 15, 2017, VHA has reduced and the Electronic Wait List from 56,271 entries to 22,383 entries, a 60.2 percent reduction between June 2014 and April 2017. 

The Electronic Wait List reflects the total number of all patients for whom appointments cannot be scheduled in 90 days or less. 

In 2018, VA will expand Veteran access to medical care by increasing medical and 

clinical staff, improving its facilities, and expanding care provided in the community. The 2018 Budget requests a total of $75.2 billion in funding for Veterans’ medical care, which includes the following: 

• $69.0 billion in discretionary budget authority ($2.65 billion above the 2018 AA 

enacted level of $66.4 billion and a $4.6 billion (7.1 percent) increase over the 2017 

enacted level); 

• $2.9 billion in mandatory budget authority to continue the Veterans Choice Program; and 

• $3.3 billion in medical care collections. 

The 2018 request will support nearly 315,000 medical care staff, an increase of 

over 7,000 above the 2017 level. 

Through the Choice Program, VHA and its contractors created more than 3.6 million authorizations for Veterans to receive care in the private sector from February 1, 2016 through January 31, 2017. This represents a 23 percent increase in 

authorizations when compared to the period February 1, 2015 through January 31, 

2016. When looking at overall appointment data not specific to the Choice Program, 

the March 15, 2017, pending appointment data set shows VA has increased the 

number of overall pending appointments ‘‘in house’’ by nearly 1.8 million over the 

same data the prior year. According to the same data, the number of appointments 

scheduled greater than 30 days from the Veterans clinically indicated data or preferred date has decreased by 3.9 percent (19,645) since the beginning of FY 2017. 

13 

Accelerating Performance on Disability Claims 

Since 2013, VA has made remarkable progress toward reducing the backlog of disability compensation claims pending over 125 days and is working to use more effectively the resources provided by Congress. VBA’s 2018 budget request of $2.8 billion 

allows VBA to maintain the improvements made in claims processing over the past 

several years. This budget supports the disability compensation benefits program for 

4.6 million Veterans and 420,000 Survivors. VBA implemented new professional 

standards for Veterans Service Representatives (VSR) on March 1, 2017. In 

May 2016, VBA implemented the National Work Queue (NWQ) process. This allows 

VBA to prioritize and quickly distribute disability compensation claims according to 

processing capacity within VBA’s regional footprint, regardless of the Veteran’s 

place of residence. The NWQ process enables VA to more effectively balance the 

workloads nationally, relative to the productive capacity at each regional office. This 

means that Veterans who live in a location where claims decisions take longer, VBA 

can appropriately adjust capacity to match the changes in claims volume. In FY 

2017, VBA added non-rating related claims to the NWQ. VBA has completed nearly 

1.7 million non-rating claims from October 2016 through the end of April 2017. The 

effort to address non-rating claims has resulted in a 269,000 claim reduction in the 

dependency claims inventory since August 2015, from 359,000 to less than 90,000. 

To continue improving disability compensation claim processing, VBA is currently 

piloting an initiative called Decision Ready Claims (DRC). The DRC initiative offers 

veterans and survivors faster claims decisions in which VSOs and other accredited 

representatives assist Veterans with ensuring all supporting medical evidence is included with the claim at the time of submission. The DRC initiative empowers Veterans by allowing them to receive medical examinations as early as possible in the 

claims process. This initiative also enhances partnerships with VSOs by improving 

access and capabilities to assist with gathering all required evidence and information to accelerate claims decisions. Submission of claims submitted through the DRC 

process will result in claim decisions within 30 days of submission to VA. 

Decisions on Appeals 

The current VA appeals process undoubtedly needs further improvements for our 

Nation’s Veterans. As of April 30, 2017, VA had 470,546 pending appeals. The average processing time for all appeals resolved by VA in FY 2016 was approximately 

3 years. For those appeals that were decided by the Board of Veterans’ Appeals (the 

Board) in FY 2016, on average, Veterans waited at least 6 years from filing their 

Notice of Disagreement until the Board’s decision was issued that year. The 2018 request of $155.6 million for the Board continues the funding level enacted for 2017, which was a 42 percent increase over 2016. In combination with carryover resources from 2017, the requested funding will support a total of 1,050 FTE, 

an increase of 164 FTE above the 2017 estimate of 886 FTE. This request maintains 

the increased budgetary authority the Board received in 2017. In addition, VBA’s 

request of $185 million for appeals processing maintains its current level of appeals 

FTE at 1,495. This funding level in tandem with sweeping legislative reform initiates a long-term strategy aimed at improving the timeliness of appeals for Veterans 

and is the best policy option for taxpayers. 

Without significant legislative reform to modernize the appeals process, Veteran 

wait times and the cost to taxpayers will only increase. Comprehensive legislative 

reform is necessary to replace the current lengthy, complex, confusing VA appeals 

process with a new process that makes sense for Veterans, their advocates, VA, and 

other stakeholders. This reform is crucial to enable VA to provide the best service 

to Veterans and is one of my top priorities. 

VA worked collaboratively with VSOs and other stakeholders to design this new 

process for Veterans who disagree with a VA decision. The result of that work was 

a legislative proposal that was introduced in the 114th Congress and has been reintroduced in the 115th Congress. The proposed process: (1) establishes multiple options for Veterans instead of the single option available today; (2) provides early resolution of disagreements and improved notice as to which option might be best; (3) 

eliminates the inefficient churning of appeals that is inherent in the current process; (4) features quality feedback loops to VBA; and (5) improves transparency by 

clearly defining VBA as the claims agency and the Board as the appeals agency in 

VA. This clear definition between VBA and the Board also provides workload transparency for better workload/resource projections, and efficient use of resources for 

long-term savings. 

The new process, described in the legislation currently pending, will provide a 

modernized process going forward. However, VA is also committed to concurrently 

reducing the pending inventory of legacy appeals. VA has worked collaboratively 

with stakeholders to identify opt-ins that would make the new process available to 

14 

Veterans who would otherwise have an appeal in the legacy process. After assessing 

these various options, and collaborating with our partners, we have identified two 

opt-ins that we intend to implement to address the issue of the legacy appeals 

inventory. 

The legislation must be enacted now to fix this process. It has wide stakeholder 

support and the longer we wait to enact this legislative reform, the more appeals 

enter the current, broken system. The status quo is not acceptable for our Nation’s 

Veterans. The new process will provide much needed comprehensive reform to modernize the VA appeals process and provide Veterans a decision on their appeal that 

is timely, transparent, and fair. 

Priority 5: Suicide Prevention—Eliminating 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 implemented a national suicide prevention strategy to address 

this crisis. VA is bringing the best minds in the public and private sectors together 

to determine the next steps in implementing the Eliminating Veteran Suicide Initiative. VA’s suicide prevention program is based on a public health approach that is 

ongoing, utilizing universal, selective, indicated strategies while recognizing that 

suicide prevention requires ready access to high quality mental health services, supplemented by programs that address the risk for suicide directly. VA’s strategy for 

suicide prevention requires ready access to high quality mental health (and other 

health care) services supplemented by programs designed to help individuals and 

families engage in care and to address suicide prevention in high-risk patients. 

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 

are identified have experienced suicidal ideation or behavior. However, REACH VET 

allows VA to provide support and pre-emptive enhanced care in order to lessen the 

likelihood that the challenges these Veterans face will become a crisis. 

Other than Honorable Expansion 

We know that 14 of the 20 Veterans who on average commit suicide each day did 

not, for various reasons, receive care within VA. Our goal is to more effectively promote and provide care and assistance to such individuals to the maximum extent 

authorized by law. In that regard, VA intends to expand access to emergent mental 

health care for former Servicemembers, who separated from active duty with other 

than honorable (OTH) administrative discharges. This initiative specifically focuses 

on expanding access to former Servicemembers with OTH administrative discharges 

who are in mental health distress and may be at risk for suicide or other adverse 

behaviors. VA estimates there are more than 500,000 former Servicemembers with 

OTH administrative discharges. As part of this initiative, former Servicemembers 

with OTH administrative discharges who present to VA seeking mental health care 

in emergency circumstances for a condition the former Servicemember asserts is related to military service would be eligible for evaluation and treatment for their 

mental health condition. Such individuals may access the system for emergency 

mental health services by visiting a VA emergency room, outpatient clinic, Vet Center, or by calling the Veterans Crisis Line. Services may include: medication management/pharmacotherapy, lab work, case management, psycho-education, and psychotherapy. We intend to carry this initiative out within our existing resources because it is the right thing to do for Veterans. 

CLOSING

Thank you for the opportunity to appear before you today to address our 2018 

budget and 2019 Advance Appropriations budget requests and to provide you with 

the priorities that I am taking to ensure VA is viewed with pride from Veterans 

and beneficiaries for the services provided to them. I ask for your steadfast support 

in funding our full FY 2018 and FY 2019 AA budget requests and continued partnership in making bold changes to improve our ability to serve Veterans. I look forward to your questions. 

15 

RESPONSE TO PREHEARING QUESTIONS SUBMITTED BY HON. JOHNNY ISAKSON TO

HON. DAVID SHULKIN, SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

APPEALS REFORM

Question 1. In June 2016, then Deputy Secretary Sloan Gibson sent a letter regarding VA’s proposed appeals reform legislation to the Senate Committee on Veterans’ Affairs, including several attachments. One attachment contains this information: 

Is the legislation enough to solve the current appeals problem without new 

money? 

. . . . The legislation is an effective fix for new appeals, but alone is insufficient to resolve the current pending inventory. 

In execution, if VA received no new funding for legacy appeals, VA must 

either keep the promise of the new legislation (125 day/365 day processing) 

and allow legacy appeals to languish OR prioritize legacy appeals, some of 

which will have been pending for years when the legislation takes effect, 

and delay action on the new framework appeals—which will impact the 

Board [of Veterans’ Appeals] and also increase [the Veterans Benefits Administration’s] pending rating claim inventory and claims backlog. 

The answer is NO. The legislation alone frees up some existing resources 

to work appeals, but these resources are insufficient to clear the legacy inventory alone. 

(Emphasis added.) 

a. If the appeals reform legislation is enacted this calendar year, what level of 

funding would VA need to ensure that legacy appeals will not ‘‘languish’’ and by 

what date would VA need to have that funding made available? 

Response. In fiscal years (FY) 2015 and 2016, Congress provided funding for additional staff that included a total of 300 full-time equivalent (FTE) employees for appeals processing at the Veterans Benefits Administration (VBA). In FY 2017, the 

Board of Veterans’ Appeals (Board) received funding for an additional 242 FTE. As 

the result of hiring falling short of goals, the Board projects to have carryover of 

$15,609,600 from FY 2017, which the Board intends to utilize for personnel costs 

in FY 2018. By utilizing carryover, the Board’s FY 2018 annualized FTE level is estimated to be 1,050, which is 164 FTE higher than the FY 2017 current estimate. 

VA continues to assess the current and future allocation of FTE to work appeals 

to ensure that the pending legacy appeals inventory is addressed in a timely and 

efficient manner. Whether VA will need additional resources for appeals after enactment of appeals reform legislation is contingent upon resource allocation decisions 

made by the Department of Veterans Affairs and the Administration during the annual budget process and cannot be predicted at this time. 

b. What steps—other than potentially adding resources—is VA taking to speed up 

processing of legacy appeals, such as information technology improvements or making sure appeals staff work only on appeals, and what impact are those initiatives 

expected to have on the inventory of legacy appeals? 

Response. VA is committed to reducing the pending inventory of legacy appeals. 

In January 2017, VBA realigned its appeals policy and oversight of its national appeals operations under a single office, the Appeals Management Office (AMO). The 

realignment promotes increased accountability of appeals performance and establishes a clear division of labor between claims and appeals work, with dedicated appeals FTE. Under this realignment, specific guidance has been disseminated instructing field offices that appeals staff must maintain authorized staffing levels 

and complete appeals production work exclusively. VBA’s appeals productivity 

through May 31, 2017, has increased by 32% over FY 2016 production during the 

same period. This realignment allows VBA to focus on internal people, process and 

technology appeals initiatives, and implementation of appeals reform legislation if 

enacted. Unlike VBA, which adjudicates both claims and appeals, the Board only 

adjudicates appeals. The Board monitors its personnel resources to ensure they are 

focused on the Board’s mission of holding hearings and deciding appeals. 

Additionally, we have worked with our congressional committees and stakeholder 

partners to modify the design of the draft appeals reform legislation to provide opportunities for Veterans who would otherwise have an appeal in the legacy process 

to opt-in to the new process. The availability of these opt-ins ensure that as many 

Veterans as possible benefit from the streamlined features of the new process, while 

simultaneously assisting with the elimination of the inventory of legacy appeals. 

The Board is also committed to modernizing appeals processing technology to optimize efficiency to best serve Veterans and their families and to ensure the seamless 

16 

transfer of appeals between jurisdictions by leveraging industry best practices and 

Human Centered Design principles. The Board is fortunate to have Digital Service 

at VA leading the technical approach to this effort. While modernized technology is 

part of increasing efficiency in appeals processing, comprehensive legislative reform 

is required to ensure Veterans receive a timely decision on their appeal, which is 

why the opt-ins that allow Veterans who would otherwise have a legacy appeal to 

enter the new process offer a good potential opportunity to speed processing of the 

pending legacy appeals inventory. 

Question 2. In May 2017, the Congressional Budget Office provided a cost estimate regarding H.R. 2288, the Veterans Appeals Improvement and Modernization 

Act of 2017, which includes this information: ‘‘VA also expects that the efficiencies 

of the new system would allow the agency to continue processing legacy appeals 

under the current system, very gradually reducing the existing backlog, without the 

need for additional employees. (Reducing the backlog in a more expedited manner 

would require more employees and would have a substantial cost.)’’ 

a. Please clarify whether VA intends, if the appeals reform legislation is enacted, 

to ‘‘very gradually’’ reduce the inventory of existing appeals or to address them in 

a ‘‘more expedited manner.’’ 

Response. If the appeals reform legislation is enacted, VA remains committed to 

reducing the pending inventory of legacy appeals as quickly and efficiently as possible. VA intends to resource the modernized system to maintain timely processing 

in the new process and then allocate all remaining appeals resources to address the 

inventory of legacy appeals. VA also worked collaboratively with stakeholders to 

identify opt-ins that will make the new process available to more Veterans. The optin features of the legislation will assist VA with more quickly and efficiently addressing the legacy appeals inventory. 

b. In response to post-hearing questions in May 2016, VA indicated that, if the 

appeals reform proposal is enacted without added resources, ‘‘at least 214,837 appeals will take longer than 9 years to be resolved’’ and ‘‘some of these legacy appeals 

will take 28 years to be resolved.’’ Is this in line with what would be expected if 

VA ‘‘very gradually’’ reduces the inventory of legacy appeals? If VA has more recent 

modeling data on this scenario, please provide copies. 

Response. Depending upon legislative reform and available resources, VA intends 

to address the legacy appeals inventory as quickly and efficiently as possible. Without significant legislative reform to modernize the appeals process, VA projects that 

Veteran wait times and the cost to taxpayers will continue to increase over time. 

The goal is to eliminate the inventory of legacy appeals in a timely manner following enactment of the appeals modernization legislation, while also maintaining 

timely processing in the new process. Prioritization, assessment of resource requirements in the annual budget process, and the opt-in features of the new process will 

assist VA in accomplishing that goal. However, due to the nature of the complex, 

inefficient and outdated legacy process, VA projects that there will be an inventory 

of legacy appeals for a substantial amount of time, regardless of the amount of resources made available to legacy appeals processing. VA continues to refine its forecast modeling, to include based on annual budget levels. 

MEDICAL CARE

Question 3. The Budget Justification shows an aggregate number of full-time 

equivalent employees (FTE) in the Medical Support and Compliance account for fiscal years 2016 through 2019. For each office within the Medical Support and Compliance account, please provide the total number of FTE for fiscal year 2016 and 

the estimate number of FTE for fiscal years 2017 through 2019. 

Response. See ‘‘FTE by Program Office’’ table. 

17 

Question 4. In 2017 the Veterans Health Administration (VHA) consolidated 

three Veterans Integrated Service Networks (VISN). Please provide the number of 

FTE within each of those VISN’s prior to consolidation and the total number of FTE 

in the new consolidated VISN. 

Response. See attached file 


614q1VAiq3FTE.eps
18 

Question 5. The Budget Justification indicates that VHA created a new office, the 

Medical Center Solutions (MCS) office. Please describe in detail the duties of this 

office, the number of FTE associated with this office, and the estimated budget request for MCS. 

Response. Member Services-Medical Center Solutions (MCS) office will provide for 

and support the development of comprehensive VA Medical Call Center capability 

solutions with applicability across the VHA enterprise. MCS, the first of its kind in 

VHA, will provide leadership and management for the purposes of improving access 

to clinical care and services by positively affecting the myriad of complexities associated with VA Medical Center and VISN-wide call centers. When activated effective 

1QFY 2018, MCS will initially provide primary care appointment scheduling and 

call center-based nurse triage call center support for all (8) VISN 1 VA medical centers with the intent of expanding services to remaining VA Health Networks. This 

will result in system-wide, standardized improvements in access to clinical care and 

services, improved first contact resolution and an improved Veteran experience. The 

FY 2018 transition is being effected by a planned transfer of existing resources and 

FTEE from VISN 1 to MS-MCS that when combined with existing MS-MCS resources (1 FTEE and $2.691M) will establish the needed capability to provide comprehensive call centers services to VISN 1 while providing the basis for expanding 

services to remaining VISNs. The consolidation of VISN1 call center operations 

under MCS represents an organizational realignment and is FTEE and cost neutral. 

Question 6. The Veterans Access, Choice, and Accountability Act of 2014 gave 

VHA the authority to enter into provider agreements to provide Veterans with care 

in the community. While the vast majority of that care is provided through the Patient Centered Community Care (PC3) contract, in 2016 VHA started using the provider agreement authority by entering into local agreements at the VA medical centers (VAMC). 

a. Please provide the total number of provider agreements VHA has entered into 

broken out by VAMC. 

Response. Please see spreadsheet that follows: 


614q1VAiVISNonb.eps
19 

Count of Active Provider Agreements as of June 6, 2017 

Station 

Count of 

Provider 

Agreements 

(402) Togus, ME ............................................................................................................................................ 681 

(405) White River Junction, VT ...................................................................................................................... 361 

(518) Bedford, MA ......................................................................................................................................... 60 

(523) VA Boston HCS, MA ............................................................................................................................. 183 

(608) Manchester, NH ................................................................................................................................... 158 

(631) VA Central Western Massachusetts HCS ............................................................................................ 168 

(650) Providence, RI ...................................................................................................................................... 112 

(689) VA Connecticut HCS, CT ...................................................................................................................... 180 

(528 A4) Batavia, NY .......................................................................................................................................... 1 

(528 A8) Albany, NY ........................................................................................................................................... 21 

(528) Bath, NY .............................................................................................................................................. 9 

(528) Canandaigua, NY ................................................................................................................................. 22 

(528) Syracuse, NY ........................................................................................................................................ 107 

(528) Western New York, NY ......................................................................................................................... 60 

(526) Bronx, NY ............................................................................................................................................. 6 

(561) New Jersey HCS, NJ ............................................................................................................................. 210 

(620) VA Hudson Valley HCS, NY .................................................................................................................. 33 

(630) New York Harbor HCS, NY ................................................................................................................... 10 

(632) Northport, NY ....................................................................................................................................... 136 

(460) Wilmington, DE .................................................................................................................................... 192 

(503) Altoona, PA .......................................................................................................................................... 258 

(529) Butler, PA ............................................................................................................................................. 71 

(542) Coatesville, PA ..................................................................................................................................... 139 

(562) Erie, PA ................................................................................................................................................ 142 

(595) Lebanon, PA ......................................................................................................................................... 104 

(642) Philadelphia, PA .................................................................................................................................. 67 

(646) Pittsburgh, PA ...................................................................................................................................... 371 

(693) Wilkes-Barre, PA .................................................................................................................................. 145 

(512) Baltimore HCS, MD .............................................................................................................................. 139 

(517) Beckley, WV .......................................................................................................................................... 79 

(540) Clarksburg, WV .................................................................................................................................... 70 

(581) Huntington, WV .................................................................................................................................... 73 

(613) Martinsburg, WV .................................................................................................................................. 83 

(688) Washington, DC ................................................................................................................................... 140 

(558) Durham, NC ......................................................................................................................................... 177 

(565) Fayetteville, NC .................................................................................................................................... 60 

(590) Hampton, VA ........................................................................................................................................ 65 

(637) Asheville, NC ........................................................................................................................................ 108 

(652) Richmond, VA ...................................................................................................................................... 222 

(658) Salem, VA ............................................................................................................................................ 38 

(659) Salisbury, NC ....................................................................................................................................... 95 

(508) Atlanta, GA .......................................................................................................................................... 240 

(509) Augusta, GA ......................................................................................................................................... 112 

(521) Birmingham, AL ................................................................................................................................... 129 

(534) Charleston, SC ..................................................................................................................................... 235 

(544) Columbia, SC ....................................................................................................................................... 188 

(557) Dublin, GA ............................................................................................................................................ 174 

(619) Central Alabama Veterans HCS, AL .................................................................................................... 193 

(679) Tuscaloosa, AL ..................................................................................................................................... 41 

(516) Bay Pines, FL ....................................................................................................................................... 215 

(546) Miami, FL ............................................................................................................................................. 71 

(548) West Palm Beach, FL .......................................................................................................................... 144 

(573) Gainesville, FL ..................................................................................................................................... 401 

(672) San Juan, PR ....................................................................................................................................... 160 

(673) Tampa, FL ............................................................................................................................................ 201 

(675) Orlando, FL .......................................................................................................................................... 72 

(596) Lexington, KY ....................................................................................................................................... 45 

(603) Louisville, KY ....................................................................................................................................... 40 

(614) Memphis, TN ........................................................................................................................................ 104 

(621) Mountain Home, TN ............................................................................................................................. 160 

(626) Middle Tennessee HCS, TN .................................................................................................................. 129 

(506) Ann Arbor, MI ....................................................................................................................................... 145 

(538) Chillicothe, OH ..................................................................................................................................... 74 

20 

Count of Active Provider Agreements as of June 6, 2017—Continued 

Station 

Count of 

Provider 

Agreements 

(539) Cincinnati, OH ..................................................................................................................................... 126 

(541) Cleveland, OH ...................................................................................................................................... 179 

(552) Dayton, OH ........................................................................................................................................... 142 

(757) Columbus, OH ...................................................................................................................................... 105 

(515) Battle Creek, MI ................................................................................................................................... 441 

(553) Detroit, MI ............................................................................................................................................ 28 

(583) Indianapolis, IN ................................................................................................................................... 330 

(610 A4) Ft. Wayne, IN ....................................................................................................................................... 156 

(610) Northern Indiana HCS, IN .................................................................................................................... 1 

(655) Saginaw, MI ......................................................................................................................................... 279 

(537) Jesse Brown VAMC (Chicago), IL ......................................................................................................... 69 

(550) Danville, IL ........................................................................................................................................... 57 

(556) Captain James A Lovell FHCC ............................................................................................................. 1 

(578) Hines, IL ............................................................................................................................................... 310 

(585) Iron Mountain, MI ................................................................................................................................ 288 

(607) Madison, WI ......................................................................................................................................... 55 

(676) Tomah, WI ............................................................................................................................................ 39 

(695) Milwaukee, WI ...................................................................................................................................... 76 

(589 A4) Columbia, MO ...................................................................................................................................... 250 

(589) Eastern KS HCS, KS ............................................................................................................................. 192 

(589) Kansas City, MO .................................................................................................................................. 101 

(589) Wichita, KS .......................................................................................................................................... 43 

(657 A4) Poplar Bluff, MO .................................................................................................................................. 140 

(657 A5) Marion, IL ............................................................................................................................................. 58 

(657) St. Louis, MO ....................................................................................................................................... 168 

(667) Topeka, KS ........................................................................................................................................... 1 

(502) Alexandria, LA ...................................................................................................................................... 39 

(520) Gulf Coast HCS, MS ............................................................................................................................ 85 

(564) Fayetteville, AR .................................................................................................................................... 123 

(580) Houston, TX .......................................................................................................................................... 203 

(586) Jackson, MS ......................................................................................................................................... 93 

(598) Little Rock, AR ..................................................................................................................................... 54 

(623) Muskogee, OK ...................................................................................................................................... 120 

(629) New Orleans, LA .................................................................................................................................. 113 

(635) Oklahoma City, OK ............................................................................................................................... 162 

(667) Shreveport, LA ...................................................................................................................................... 202 

(504) Amarillo, TX ......................................................................................................................................... 24 

(549) Dallas, TX ............................................................................................................................................ 15 

(671) San Antonio, TX ................................................................................................................................... 45 

(674) Temple, TX ........................................................................................................................................... 29 

(740) VA Texas Valley Coastal Bend HCS ..................................................................................................... 4 

(756) El Paso, TX .......................................................................................................................................... 21 

(501) New Mexico HCS .................................................................................................................................. 96 

(644) Phoenix, AZ .......................................................................................................................................... 195 

(649) Northern Arizona HCS .......................................................................................................................... 144 

(678) Southern Arizona HCS .......................................................................................................................... 73 

(436) Montana HCS ....................................................................................................................................... 316 

(442) Cheyenne, WY ...................................................................................................................................... 53 

(554) Denver, CO ........................................................................................................................................... 184 

(575) Grand Junction, CO .............................................................................................................................. 92 

(660) Salt Lake City, UT ................................................................................................................................ 576 

(666) Sheridan, WY ....................................................................................................................................... 90 

(463) Anchorage, AK ...................................................................................................................................... 21 

(531) Boise, ID .............................................................................................................................................. 51 

(648) Portland, OR ........................................................................................................................................ 257 

(653) Roseburg, OR ....................................................................................................................................... 102 

(663) VA Puget Sound, WA ............................................................................................................................ 399 

(668) Spokane, WA ........................................................................................................................................ 105 

(687) Walla Walla, WA .................................................................................................................................. 64 

(692) White City, OR ..................................................................................................................................... 67 

(459) Honolulu, HI ......................................................................................................................................... 175 

(570) Fresno, CA ............................................................................................................................................ 65 

(612) N. California, CA .................................................................................................................................. 164 

21 

Count of Active Provider Agreements as of June 6, 2017—Continued 

Station 

Count of 

Provider 

Agreements 

(640) Palo Alto, CA ........................................................................................................................................ 376 

(654) Reno, NV .............................................................................................................................................. 103 

(662) San Francisco, CA ............................................................................................................................... 110 

(593) Las Vegas, NV ..................................................................................................................................... 129 

(600) Long Beach, CA ................................................................................................................................... 24 

(605) Loma Linda, CA ................................................................................................................................... 401 

(664) San Diego, CA ...................................................................................................................................... 415 

(691) Greater Los Angeles HCS ..................................................................................................................... 144 

(437) Fargo, ND ............................................................................................................................................. 334 

(438) Sioux Falls, SD ..................................................................................................................................... 175 

(568) Black Hills HCS, SD ............................................................................................................................. 62 

(618) Minneapolis, MN .................................................................................................................................. 176 

(636 A6) Des Moines, IA ..................................................................................................................................... 119 

(636) Iowa City, IA ........................................................................................................................................ 314 

(636) Nebraska-W Iowa, NE .......................................................................................................................... 316 

(656) St. Cloud, MN ...................................................................................................................................... 132 

Total ................................................................................................................................... 20,215 

Source: VCP Provider Agreement Sharepoint 

Only displaying agreements in an active status 

b. What processes are in place to ensure the provider agreements do not duplicate 

care available in the PC3 contract? 

Response. Currently Provider Agreements may only be used under the Veterans 

Choice Program (VCP) to provide medical care to our Nations Veterans. Provider 

Agreements are used to provide care and services that are not available through the 

contractor network. There are instances, when Provider Agreements are used to provide services that may be available through the PC3 Contract for Choice, those circumstance occur when the contractor has returned referrals they are unable to 

schedule. In addition, recently the Office of Community Care has allowed facilities 

to utilize Provider Agreements when a facility has identified a certain percentage 

of returns from the contractor for specific categories of care and the facility has 

identified they have active provider agreements for those categories of care and adequate staffing to schedule the Veterans identified, this new process ensures Veterans are receiving the medical care needed in a more timely manner. 

Question 7. The Budget Justification identifies the creation of a VHA transitional 

care program office as one of its 2017–2019 goals. Please describe in detail the duties of this office, the number of FTE associated with this office, the estimated budget request for this office, and a projected timeline for its creation. 

Response. VHA had the goal of realigning the Federal Recovery Coordination Program (FRCP) under Care Management and Social Work (CM/SW), and Transition 

and Care Management Services, to integrate care coordination services under one 

leadership. At this time, a new VHA transitional care program office is not under 

development. VA continues to provide assistance to transitioning Servicemembers 

and Veterans (SM/V) and their families through Transition and Care Management 

Services and the FRCP. These programs work in coordination to assist wounded 

SM/V to navigate the recovery care continuum. 

Transition and Care Management (TCM) Services leads two national programs: 

• The VA Liaison Program consists of 43 VA Liaisons for Health Care at 21 Military Treatment Facilities (MTF) to facilitate ongoing VA health care for ill and injured Servicemembers transitioning from Department of Defense (DOD) to VA. 

Since the inception of the program, VA Liaisons for Healthcare have coordinated 

over 84,000 transitions. In fiscal year (FY) 2016, VA Liaisons for Healthcare coordinated 11,130 transitions; provided 22,906 professional consultations and 2,412 briefings; and ensured Servicemembers transitioning from DOD to VA received timely 

access to care by ensuring 100 percent of Servicemembers who wanted VA 

healthcare had an initial VA appointment scheduled at the VA healthcare facility 

of their choice; 89 percent had appointments scheduled prior to leaving the MTF. 

• The TCM Program consists of a TCM team at each VA Medical Center to provide comprehensive and specialized transition assistance and ongoing case management services to Post-9/11 Veterans as they reintegrate into their home communities and into VA health care. VA has approximately 400 TCM case managers naVerDate Mar 15 2010 16:16 Jul 12, 2018 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6621 Z:\ACTIVE\061417.TXT PAULIN
22 

tionwide providing case management services to almost 30,000 Veterans. In FY 

2016, 90 percent of these Veterans were contacted regarding their individualized 

care management plan, resulting in over 347,000 contacts. 

The FRCP was developed as a joint program by VA and DOD, in January 2008, 

to provide care coordination services to SM/V who were severely wounded, ill, or injured after September 11, 2001. The program utilizes Federal Recovery Coordinators 

(FRCs), either social workers or nurses funded by VA Central Office, to monitor and 

coordinate clinical services, including facilitating and coordinating medical appointments; and non-clinical services, such as providing assistance in obtaining financial 

benefits or special accommodations needed by program enrollees and their families. 

Question 8. The Comprehensive Addiction and Recovery Act of 2016 requires 

naloxone prescriptions and related education to be provided free of charge to Veterans. 

a. The Budget Justification does not clearly state whether or not this reduction 

in co-pays is reflected in the estimated medical care collections. Please provide a detailed analysis of the expected reduction in estimated medical care collections for 

2017 and 2018, including any impact caused by the reduction in copays for naloxone 

prescriptions. 

Response. The Naloxone prescriptions and related education analysis was performed after the FY 2017 and FY 2018 medical care collections budgets were formulated. As such, there was no reduction explicitly incorporated into the FY 2017 & 

FY 2018 budgets as a result of the elimination of copayments for Naloxone prescriptions or outpatient visits pertaining solely to the education. Further, the number of 

Naloxone kits dispensed to Veterans has remained stable over the past three years 

with the percent of billable prescriptions assumed stable through FY 2026. The resulting impact of the copayment on the Pharmacy portion is only ∼0.03% of the FY 

2017 First Party Rx estimated collections. These impacts will be explicitly incorporated into the baseline collections forecasting when using FY 2017 data for future 

medical care collections budgets. 

b. The Budget Justification states that over 50,000 naloxone kits have been dispensed as of January 2017 and that naloxone distribution will continue to expand. 

However, the 2017 current estimate for naloxone distribution is listed as $0. For 

2018 and 2019, the Budget Justification includes $25 million a year for naloxone 

distribution. Please provide additional details on the expected naloxone kit distribution for 2017 and provide details for the $25 million requested, to include expected 

number of Veterans receiving overdose education and the estimated number of 

naloxone kits to be distributed. 

Response. See table below. 

Fiscal Year 

Naloxone Kits 

Distributed Drug Cost 

Distribution/ 

Dispensing Cost Total Cost 

FY-16 ................................................................. 48,462 $8,622,450 $169,925 $8,792,375 

FY-17* ............................................................... 62,037 $7,310,048 $225,194 $7,535,242 

FY-18** ............................................................. 68,241 $9,174,283 $259,316 $9,433,599 

FY-19** ............................................................. 75,065 $10,091,710 $296,507 $10,388,217 

* FY-17 estimated based on YTD distribution 

** FY-18/19 assume 10% increase in usage and current contract price stabilization 

Question 9. Please provide a sample of the preconception care counseling template 

found in the Computerized Patient Record System described in Volume II, VHA– 

191. 

Response. Attached is the sample of the preconception care counseling template 

found in the Computerized Patient Record System described in Volume II, VHA– 

191 requested below. 

23 


614q1VAiVA-PCC1.eps

VA-WH PRECONCEPTION CARE COUNSELING (PCC) TEMPLATE 

The new Preconception Care Counseling Template was developed by the Veterans Affair's Office of 

Women's Health Services with input from the Preconception Care Workgroup. For women of 

reproductive age, preconception care is an essential part of comprehensive health care. Given that half 

of all pregnancies in the United States are unplanned, women's reproductive intentions should be 

considered at each clinical encounter and preconception and contraceptive care should be offered as 

appropriate to help women attain their reproductive goals. 

Preconception care involves identifying and modifying medical, behavioral, and social risk factors to 

optimize a woman's health before, during, and after pregnancy. Some factors (e.g., folic acid 

supplementation) must be acted on before conception occurs or early in pregnancy for maximal impact 

on the health of the mother and fetus. The template is designed to improve the process and 

documentation of this care to enhance the provision of high quality care to reproductive age women 

Veterans who desire or are considering pregnancy. The template pre-populates with structured data 

from CPRS/VistA when available, allows ordering from the template itself, and provides guidance 

regarding next steps for women with particular risk factors who require additional work up and 

referrals. 

It is anticipated that it will be used during primary care visits, preconception care visits, and gynecology 

visits. This will allow a clinician and woman Veteran to work together, using shared decision-making to 

work collaboratively to identify and implement strategies to address her risks and optimize her 

pregnancy health. 

The template has the following sections: 

Reproductive Life Plan 

II. Obstetrical History 

Ill. Gynecological History 

IV. Medical History 

V. Mental Health History 

VI. Surgical History 

VII. Medication 

VIII. Vaccinations 

IX. Family and Genetic History 

X. Exposure History 

XI. Social History and Home Environment 

XII. Assessment and Plan 
24 


614q1VAiVA-PCC2.eps

Screenshot of the template: 

Each section expands with content that is of relevance to preconception counseling. Appropriate note 

text is built as items are checked and ordered: 
25 


614q1VAiVA-PCC3.eps

Sample Completed Note: 

REPRO~UCTI\!E LI.F.E :k'LAN 

Pregnsn~y de :sire!!!: 

Pati.·e-nt i·ndicat,es she weald l.i.ke til bec!Cl!'.e pregn .. ant i!!:!. the f'u.ture ~ but 

n-ot in the next yo:=ar _ 

Th2. pat-ient w.as c·ou:.n=::eJ:.ed :t:·egarding a re-c-omm-e.nded: int-er.;.e.1 ·cf at 1-ea.st 

1.8 rocnths :frD-P.'l bi_rt:h t:·o the- next pr.e-gnanC:}"-

The p-ati.ent. was sdvi.sed t_a t-al:e a dai.l::t"' f·ol.:ic e.-cid suppLe!!ient- o-r 

pre-nata..~ mul t:i vit:anri.n/m:ul_timine-r·a1 supplement_ 

<JBST'ZTIUCJU. HISTORY 

G~avi.-da: 

:P·ara·: 

1 

PREGN.!'..NCY HISTORY 

Ps·t:i.e.nt ha.s a hi:s·t:.ors,-< of a. stillbirt-h or a child/fetuS! ;;.;i th s: 

~slformet:ion. C.cunsel-ed re-gard1ng the nee.ci f-or r;en-e-ti.t: cDnsmlt.a·ti-on and 

an Obsrt-e: 't-z: i.cs consult . 

GYN!:CDL...~IC'..2..L HI.BTORY 

Pat-ie-:nt.. we:s scr-eel'led f-ar Ghlaroydi<L 

Pe:ti-ent has e. hist.c.rJr of ;;;umen·orrhea/oligo:menor~:he-a,. C:::runse-~·ed regard.inq 

the: need f·o.r a {~ynecc':!"l-Gq~' c-onsult_ 

MEDICAL HISTOaY 

P.ati-ent was ccnJ.:n:se1ed rega:r:·dinq the- nee.d f.o,r HIV s.c:r.ee-ni..l'J.g pri..cr t-o 

pre-crnancy _ P.T~/" .S-c::r-een ol::dere.-tL 

:Pa:ti.e-nt- hs.s hist-o-r-y o:f a.gtl::l!r'ie . .snd wes cou..":t:Seled about p:reqnancy rit=~k§ 

r-elate-d tc asth.."""la and the i:rnp;::;::::tance of -g~ c-c:n't~-ol_ 

ME...l-l'!'AL HE·J...LTH HIS''I'OP.Y 

.Pa.t-i--ent has a :rn:ent.a:.l health -discr'{je-:r a:nd i.s p.lan:ni:."J.'g' a pre-gnancy_ 

-a:;.-unse,l.e.d reg.ardin-gr pr,eg:nsncy .I:i.sks and -:the :ne.-ed for & t.:::::e.ament- p.la...~ fa.r 

be,f'cr-e a.,-q-d du~·i.ng pregnancy fr-o-m her l!P.ent-al heal--ch p::::o-vi.de.z: _ 

SU~GICAL HIST-ORY 

Pa.t-i.ent- :has a histo:r:y of havin.g a .LEEP a:r: ecme p_!:'C-c-edur.e-_ Counseled 

pa.ti.-ent about pa-:=::l±.b-l.e i.n:cre.ssed. risk f·o:r s-e-c:c-nd t.r:imest.er pz:·~r.u:.ncy 

loss and im;po:ct-.ance of eaz:ly pr·enatal car-e-. 

MEDICAIIO!Il HISTORY 
26 

Question 10. What percentage of women veteran gender-specific care is provided 

at VA facilities and what percentage is provided through non-VA care? Please break 

out each category included under gender-specific health care for fiscal year 2017 as 

well as projections for fiscal year 2018. 

Response. See table below. 


614q1VAiVA-PCC4.eps 614q1VAiOBGYN.eps
27 

Question 11. Please provide an updated list of VA medical facilities that have a 

gynecologist on staff and whether they are full-time, part-time, or contracted. 

Response. See attached. 


614q1VAi_St_OBG1.eps
28 

Question 12. Current law allows VA to cover care for newborns of eligible women 

Veterans for the first seven days after birth. Please provide a breakout of the average number of days VA has covered care for newborns and the total cost of this care 

in fiscal year 2017 and projections for fiscal year 2018. 

Response. To reiterate this data only relates to the newborn care, it does not include any expenditure for services provided to the mother. On average, VA authorizations in FY 2017 covered 3 days for inpatient newborn care. Please refer to the 

table below. 

Neonates Average Length of Stay Obligations $m 

Actual FY 2016 ..................................... 2,705 3.44 $19.82 

Annualized FY 2017 .............................. 2,264 3.10 $16.67 

Estimated FY 2018 ............................... 2,176 3.02 $16.04 

CONSTRUCTION

Question 13. The Budget Justification requests authorization for 27 leases in 

2018. Twenty-one of these leases were submitted in prior years but were not authorized. Six are new lease requests. Three leases in Pontiac, Michigan; Birmingham, 

Alabama; and Mission Bay, California were requested in previous budgets but are 

not included in the 2018 request. Please provide additional details for removing 

these three leases from the Budget Justification. 

Response. In preparing the FY 2018 Budget Request, lease requirements previously authorized but not yet in the solicitation process were reviewed and validated to assure optimum use of alternatives. The following three leases pending authorization were removed from the request after this review. 

1. Outpatient Clinic Lease Birmingham, AL—Expanding community care and 

additional efficiencies realized at the local medical center mitigate the need for 

this 89,900 Net Useable Square Feet (NUSF) lease. 

2. Research Lease Mission Bay, CA—Use of available space on the medical 

center campus and private partnering solutions are being pursued to meet this 

research space need. 


614q1VAi_St_OBG2.eps
29 

3. Outpatient Clinic Lease Pontiac, MI—This replacement/expansion lease is 

being re-scoped which will reduce the size of the lease under the Major Lease 

threshold. 

Question 14. Please provide a detailed breakout of the judgment fund payments 

for 2017 and the estimated judgment fund payments for 2018. 

Response. On January 25, 2017, VA reimbursed the Department of the Treasury 

for Contract Disputes Act Claims in the total amount of $9 million as follows: 

(1) $4,019,844.67—For a claim against the Menlo Park, CA, Seismic Corrections 

project. 

(2) $4,050,306.54—For two claims against the Denver, CO, New Medical Facility 

project. 

In FY 2018, VA will use the Judgment Fund to reimburse the Department of the 

Treasury for Contract Disputes Act Claims in the amount of $10 million for claims 

related to the Menlo Park, CA, project and the Orlando, FL, New Medical Facility 

project. 

Question 15. For the major construction staff request, please provide the total 

number of FTE for fiscal year 2016 and the estimated number of FTE for fiscal 

years 2017 and 2018. 

Response. For the major construction staff request, the total number of FTE in 

FY 2016 was 115. The estimated number for FY 2017 is 139 FTE, and for FY 2018 

the estimate is 197 FTE. Note the appropriation language was changed in FY 2017 

to allow major construction staff funding to include support for contracting officers 

working directly on major construction projects to ensure alignment with the program they are supporting. 

Question 16. Please provide a list of the non-recurring maintenance projects included in the $1.9 billion request for 2018. Specifically break out the projects included in the ‘‘second bite’’ $1.3 billion portion of the request for 2018 advance appropriations. 

Response. Attached is the list of ‘‘first bite’’ and ‘‘second bite’’ NRM projects for 

FY 2018. NRM projects that have had design funded in years prior to SCIP 2018, 

and only needing construction funding to complete, are mostly funded in the ‘‘first 

bite.’’ Design of newly scored SCIP projects is funded in the ‘‘second bite,’’ as well 

as some projects prior to FY 2018. 

30 

Planned 2018 Non-Recurring Maintenance Projects 

VISN Location ST Project Type Project Name - Short Description 

Total 

Estimated 

Cost 

($000) 

Planned 

FY 2018 

Obs 

($000) 

′′First 

Bite′′ 

($000) 

′′Second 

Bite′′ 

($000) 

1 Newington CT BT Emergency Generator #7 ........................................................................................................................ 678 600 600 1 Newington CT SCIP 2018 Replace the Boilers and Systems for Newington VAMC, Phase 1 ........................................................ 9,700 970 970 1 Newington CT SCIP 2018 Demolish Buildings 6,7, & 8 ................................................................................................................. 2,561 256 256 1 West Haven CT BT Yard Drain Tunnel Refurbishment ......................................................................................................... 685 500 500 1 West Haven CT BT West Haven SPS Chiller ......................................................................................................................... 825 750 750 1 West Haven CT CSI Fisher House Infrastructure and Prep ................................................................................................... 3,500 3,200 3,200 1 West Haven CT SCIP 2016 Renovate Mental Health Inpatient Unit ................................................................................................. 6,571 5,863 5,863 1 West Haven CT SCIP 2015 Replace and Upgrade Electrical Supervisory Control and Data Acquisition System ........................... 2,300 2,070 2,070 1 West Haven CT SCIP 2018 Refurbish Building Exterior For Building 1 ........................................................................................... 6,300 630 630 1 Bedford MA SCIP 2018 Replace Water Mains ............................................................................................................................. 3,300 330 330 1 Boston (JP) MA SCIP 2016 IT infrastructure upgrades JP ................................................................................................................ 2,200 2,000 2,000 1 Boston (JP) MA SCIP 2018 Install Site Security Systems Campus Wide Jamaica Plain ................................................................. 7,150 715 715 1 Boston (WR) MA SCIP 2013 Building 5 Fire and Safety Improvements ............................................................................................ 2,400 2,200 2,200 1 Boston (WR) MA SCIP 2012 EM Infrastructure Backup Water supply ............................................................................................... 1,650 1,500 1,500 1 Boston (WR) MA BT FCA Window Replacement ..................................................................................................................... 766 701 701 1 Boston (WR) MA SCIP 2013 Site Security Installation WR ................................................................................................................. 7,600 7,000 7,000 1 Boston (WR) MA SCIP 2015 FCA HVAC Upgrade PH3 ........................................................................................................................ 5,060 5,400 5,400 1 Boston (WR) MA SCIP 2015 FCA Electrical Upgrade WR, PH 3 ......................................................................................................... 4,840 4,356 4,356 1 Boston (WR) MA SCIP 2018 IT infrastructure upgrades WR .............................................................................................................. 3,300 330 330 1 Boston (WR) MA SCIP 2018 Construct Central Chiller Plant West Roxbury ...................................................................................... 9,850 985 985 1 Brockton MA SCIP 2013 Install Sprinkler System ......................................................................................................................... 2,000 1,800 1,800 1 Brockton MA SCIP 2013 FCA Replace Damaged Doors and Upgrade Card Access System Phase 2 ......................................... 2,200 2,050 2,050 1 Brockton MA SCIP 2016 Improve Site Parking Roadway and Drainage Systems ........................................................................ 3,410 3,100 3,100 1 Brockton MA SCIP 2018 Central Chiller Plant Phase 1 ............................................................................................................... 9,900 990 990 1 Northampton MA Pending OOC Water System Improvement & Legionella Prevention Phase 1 ............................................................. 4,981 4,000 4,000 1 Northampton MA Pending OOC Replace HVAC System Building 4 Upper ............................................................................................... 3,800 3,500 3,500 1 Northampton MA Pending OOC Upgrade Building 5 Electrical and HVAC Systems ............................................................................... 1,600 1,500 1,500 1 Northampton MA Pending OOC Exterior Site Improvements .................................................................................................................... 4,396 4,000 4,000 1 Northampton MA BT Exterior Wayfinding ................................................................................................................................ 720 650 650 1 Northampton MA BT Occupational Therapy wing Asbestos Abatement ................................................................................. 40 28 28 1 Northampton MA BT Ward 4 Lower Upgrades ........................................................................................................................ 778 670 670 1 Northampton MA Pending OOC Electrical Distribution System Upgrade Phase I ................................................................................... 5,050 4,600 4,600 1 Togus ME CSI Provide Infrastructure to Fisher House .................................................................................................. 1,351 1,351 1,351 1 Togus ME SCIP 2016 Install Legionella Mitigation Infrastructure ........................................................................................... 4,235 3,876 3,876 

31 

1 Togus ME SCIP 2018 Relocate Primary Care Clinic to B205 .................................................................................................. 5,500 550 550 1 Togus ME SCIP 2018 Correct Stormwater System Deficiencies throughout Campus .............................................................. 3,710 371 371 1 Togus ME SCIP 2018 Replace Damaged Roofs and Masonry .................................................................................................. 4,845 485 485 1 Togus ME SCIP 2018 Repair Damaged Windows and Entranceway Doors .............................................................................. 4,405 441 441 1 Manchester NH BT Replace OR Suite Doors ......................................................................................................................... 360 300 300 1 Manchester NH SCIP 2016 Replace Aboveground Storage Tanks .................................................................................................... 1,164 1,063 1,063 1 Manchester NH BT Building #2 demolishing ....................................................................................................................... 495 425 425 1 Manchester NH SCIP 2018 Renovate Building 1, 3rd Floor for Dental ............................................................................................ 2,914 291 291 1 Providence RI SCIP 2015 Renovate Wing 2C & 3C for Dentistry .................................................................................................. 9,210 8,560 8,560 1 Providence RI SCIP 2013 Renovate Space for Relocation of Inpatient Pharmacy ........................................................................ 2,237 2,013 2,013 1 Providence RI SCIP 2014 FCA Pavement Repairs .......................................................................................................................... 2,600 2,507 2,507 1 Providence RI BT Repair and Upgrade 5B and 6B Isolation Suite HVAC System ............................................................ 670 600 600 1 Providence RI SCIP 2016 Install Legionella Remediation System ................................................................................................. 3,500 3,250 3,250 1 White River Junction VT Pending OOC Renovate Clinical Lab ............................................................................................................................ 6,200 6,026 6,026 1 White River Junction VT SCIP 2017 Underground Utility Replacement .......................................................................................................... 7,700 7,000 7,000 1 White River Junction VT BT Acute Mental Health PH2 ...................................................................................................................... 990 900 900 1 White River Junction VT SCIP 2015 Repair and Upgrade Building 1 Heating, Ventilation, and Air Conditioning (Phase II) ...................... 5,227 4,758 4,758 2 East Orange N BT Upgrade men’s bathrooms& Drinking Fountains .................................................................................. 889 800 800 2 East Orange NJ Pending OOC Improve outpatient Environment (4D) ................................................................................................... 2,854 2,594 2,594 2 East Orange NJ BT Storage Building .................................................................................................................................... 440 400 400 2 East Orange NJ BT Legionella Plumbing Field Study ........................................................................................................... 140 140 140 2 Lyons NJ BT Tuckpoint & Waterproofing B 1, 2, 53 .................................................................................................. 350 315 315 2 Lyons NJ BT Repair & Repave Roadways .................................................................................................................. 540 500 500 2 Lyons NJ BT Demolish Bldg 18 .................................................................................................................................. 440 400 400 2 Lyons NJ BT Replace Porch Roofs & Woodwork Bldg 10, 11 .................................................................................... 577 525 525 2 Lyons NJ BT Repair Brick Facade—B-135 ................................................................................................................ 550 500 500 2 Lyons NJ BT Repair Sidewalks Phase II ..................................................................................................................... 450 450 450 2 Lyons NJ BT Replace Steps & Railings ...................................................................................................................... 550 500 500 2 Lyons NJ CSI Digital Radiography Room (K113 LY) .................................................................................................... 500 500 500 2 Lyons NJ BT Upgrade Generator & Transfer Switches ............................................................................................... 605 550 550 2 Albany NY BT Structural Repairs at Chapel Windows ................................................................................................. 116 101 101 2 Albany NY BT Roof Improvements & Misc Work .......................................................................................................... 669 669 669 2 Albany NY SCIP 2017 Radiology Master Plan ........................................................................................................................... 3,740 3,400 3,400 2 Albany NY SCIP 2015 Renovate 6B for Dialysis ....................................................................................................................... 7,262 6,631 6,631 2 Albany NY Pending OOC Renovate for CLC phase 4 .................................................................................................................... 5,741 473 473 2 Batavia NY SCIP 2016 Replace Fire Alarm System .................................................................................................................... 3,150 2,700 2,700 2 Batavia NY SCIP 2016 Replace Roofs Batavia .......................................................................................................................... 2,950 2,700 2,700 2 Batavia NY SCIP 2018 Improve Potable Water Distribution Systems Batavia, Bldgs #1 & 5 .................................................. 2,300 2,070 2,070 2 Bath NY BT Upgrade 104 Sprinklers and Hot Water ................................................................................................ 935 850 850 2 Bath NY SCIP 2017 Replace Roof/Renovate Wood Molding, B76 .......................................................................................... 1,225 1,125 1,125 

32 

Planned 2018 Non-Recurring Maintenance Projects—Continued 

VISN Location ST Project Type Project Name - Short Description 

Total 

Estimated 

Cost 

($000) 

Planned 

FY 2018 

Obs 

($000) 

′′First 

Bite′′ 

($000) 

′′Second 

Bite′′ 

($000) 

2 Bath NY SCIP 2017 FCA Renovate Main Kitchen, B24 .......................................................................................................... 1,375 1,250 1,250 2 Bath NY OOC Renovate CLC 3 ..................................................................................................................................... 5,200 4,750 4,750 2 Bath NY BT Improve Accessibility & Install 2nd Floor Handicap Accessible Bathroom, B-32 ................................ 20 20 20 2 Bath NY SCIP 2018 B76 Renovations .................................................................................................................................... 3,000 300 300 2 Bronx NY Pending OOC Combined Heat & Power Plant Construction ........................................................................................ 18,000 18,000 18,000 2 Bronx NY Pending OOC Renovate CLC for Polytrauma Ph 3 ....................................................................................................... 4,380 3,900 3,900 2 Bronx NY SCIP 2016 Modernize ER ......................................................................................................................................... 4,194 3,724 3,724 2 Bronx NY OOC Renovate CLC Recreation & Dining Area .............................................................................................. 3,850 3,500 3,500 2 Bronx NY SCIP 2017 Renovate ICU ......................................................................................................................................... 4,900 4,500 4,500 2 Bronx NY OOC Correct Safety Deficiencies at Loading Dock ........................................................................................ 2,750 2,500 2,500 2 Bronx NY OOC Replace Air Handling Units, Phase 4 .................................................................................................... 5,400 5,100 5,100 2 Bronx NY SCIP 2013 Replace Air Handler Units, Phase 3 (for GG, 2B, 2C, 2G) ................................................................... 3,150 2,500 2,500 2 Bronx NY SCIP 2014 Renovate for New Learning Center ........................................................................................................ 5,335 4,850 4,850 2 Bronx NY OOC Replace Existing Boilers #1 & 2 ........................................................................................................... 4,300 4,000 4,000 2 Bronx NY SCIP 2016 Replace/Install Parking Lot/Street Lights Ph 2 ..................................................................................... 2,950 2,600 2,600 2 Bronx NY BT Install 20 KW Roof-Mounted Wind Turbine System .............................................................................. 594 500 500 2 Brooklyn NY SCIP 2015 Install Secondary Main Water Supply Line ............................................................................................ 1,540 1,400 1,400 2 Brooklyn NY SCIP 2017 Renovate Outpatient Pharmacy(SA) ....................................................................................................... 1,040 950 950 2 Brooklyn NY SCIP 2017 Upgrade Elevators .................................................................................................................................. 3,000 3,000 3,000 2 Brooklyn NY SCIP 2017 Bldg 2 Replace Pressure Relief Valve and Condensate Pumps ........................................................... 1,200 1,080 1,080 2 Brooklyn NY SCIP 2015 Upgrade Life Safety/Critical Branch Electrical Distribution ................................................................. 7,260 7,260 7,260 2 Brooklyn NY BT Replace Air & Vacuum Compressor ...................................................................................................... 935 850 850 2 Brooklyn NY BT Laundry Plant Storm Disposal ............................................................................................................... 805 750 750 2 Brooklyn NY Pending OOC Renovate C3 and D3 Ward(SA) ............................................................................................................. 6,545 5,950 5,950 2 Brooklyn NY OOC Laundry Mechanical Room Upgrade (SA) .............................................................................................. 2,100 1,910 1,910 2 Buffalo NY SCIP 2016 Replace High Pressure Water Risers, Bldg #1 ...................................................................................... 1,600 2 2 2 Buffalo NY SCIP 2017 Fuel Oil Tanks Replacement .................................................................................................................. 1,095 975 975 2 Buffalo NY Pending OOC Improve Potable Water Systems ............................................................................................................ 2,420 2,200 2,200 2 Buffalo NY Pending OOC Upgrade HVAC SPS ................................................................................................................................ 1,320 1,200 1,200 2 Buffalo NY BT Sub-Basement Safety Improvements ..................................................................................................... 275 250 250 2 Buffalo NY SCIP 2018 Renovate 9th Floor B Wing .................................................................................................................... 4,650 465 465 2 Canandaigua NY BT Upgrade HVAC B3 .................................................................................................................................. 250 200 200 2 Canandaigua NY BT Heating Upgrades for B7 and B8 ......................................................................................................... 475 400 400 2 Canandaigua NY BT Design and Install Backflow prevention on campus ............................................................................ 950 800 800 

33 

2 Canandaigua NY BT Provide Electrical Upgrades ................................................................................................................... 800 800 800 2 Canandaigua NY SCIP 2017 Replace Roofs Stationwide .................................................................................................................... 1,350 1,350 1,350 2 Canandaigua NY BT Fire Department Upgrades ..................................................................................................................... 860 750 750 2 Canandaigua NY BT Renovations to Support Swing Space Development .............................................................................. 50 50 50 2 Canandaigua NY BT Relocate Grounds and Transportation ................................................................................................... 595 500 500 2 Canandaigua NY OOC Renovate 6A for Member Services ......................................................................................................... 6,500 6,000 6,000 2 Canandaigua NY SCIP 2018 Replace Primary Electrical Distribution System .................................................................................... 2,500 250 250 2 Castle Point NY SCIP 2016 Renovate STP Replace Trinkling Filter .................................................................................................. 1,480 1,200 1,200 2 Castle Point NY SCIP 2018 Upgrade Central Air Conditioning Plant Chilled Water Units and Distribution Main .......................... 4,400 440 440 2 Montrose NY SCIP 2014 Install Elevator Building 29 .................................................................................................................. 1,800 1,500 1,500 2 Montrose NY SCIP 2013 Replace aging steam distribution equipment for Buildings 3. 4 & 12 ............................................... 3,795 3,450 3,450 2 Montrose NY SCIP 2016 Correct Deficiencies with SPS Area in Building 7 FDR ........................................................................ 1,285 1,090 1,090 2 Montrose NY SCIP 2018 Install new Temperature, pH, and Flow measuring devices on Domestic Water Systems at FDR ...... 2,465 247 247 2 New York NY Pre-SCIP Admitting Area/ ER Expansion Phase 2 ................................................................................................ 3,850 3,500 3,500 2 New York NY SCIP 2017 Replace Chiller Phase II ........................................................................................................................ 3,800 3,430 3,430 2 New York NY SCIP 2015 Renovate Research Area/ Animal Lab ................................................................................................... 5,500 4,090 4,090 2 New York NY SCIP 2017 Correct Accessibilities Ph I .................................................................................................................... 5,375 3,400 3,400 2 New York NY SCIP 2018 Correct Accessibility Deficiencies PH1 .................................................................................................. 5,375 538 538 2 Northport NY SCIP 2015 Replace Primary Electrical Distribution Phase 1 .................................................................................. 9,971 9,063 9,063 2 Northport NY OOC Upgrade Sewage Treatment Plant, Phase 1 ......................................................................................... 2,860 1,230 1,230 2 Northport NY SCIP 2015 Renovate Roads Project 4 ..................................................................................................................... 4,695 4,268 4,268 2 St. Albans NY SCIP 2013 Laundry Heat Recovery SA ..................................................................................................................... 1,975 1,800 1,800 2 Syracuse NY BT Demolish Abandoned Piping in Sub Basement ..................................................................................... 295 265 265 2 Syracuse NY OOC Upgrade Chiller Plant Switchgear ......................................................................................................... 2,525 2,300 2,300 2 Syracuse NY SCIP 2015 Laboratory Renovations .......................................................................................................................... 3,510 3,150 3,150 4 Wilmington DE SCIP 2017 Replace AHU’s Serving Nuclear Medicine and the Lab ........................................................................ 1,100 1,000 1,000 4 Wilmington DE SCIP 2017 Correct ICU Heat and Facility-Wide Humidification .............................................................................. 2,200 2,000 2,000 4 Wilmington DE SCIP 2017 Renovate Building 13 ............................................................................................................................ 3,850 3,500 3,500 4 Wilmington DE Pending OOC Renovate the Auditorium ....................................................................................................................... 1,100 1,000 1,000 4 Wilmington DE Pending OOC Renovate 2 East .................................................................................................................................... 2,200 2,000 2,000 4 Wilmington DE SCIP 2017 Provide Chiller Plant Redundancy ......................................................................................................... 2,200 2,000 2,000 4 Wilmington DE SCIP 2016 Convert the Special Procedures Room to an Operatory ........................................................................ 4,400 4,000 4,000 4 Wilmington DE Pending OOC Evaluate and Replace Roofs Throughout the Facility ........................................................................... 2,200 2,000 2,000 4 Wilmington DE SCIP 2014 Study and Correct Domestic Water Storage .......................................................................................... 5,540 4,200 4,200 4 Wilmington DE SCIP 2014 Renovate the First Floor of Building 1 for Primary Care ...................................................................... 6,600 6,000 6,000 4 Wilmington DE SCIP 2017 Assess and Replace Steam and Condensate Distribution Piping ........................................................ 3,300 3,000 3,000 4 Altoona PA BT Make Fire Safety Improvements ............................................................................................................ 356 324 324 4 Altoona PA BT Correct Air Conditioning Deficiencies in Biomedical Shop & Mailroom ............................................... 160 146 146 4 Altoona PA SCIP 2017 Replace Keying System For Outbuildings .............................................................................................. 1,745 1,587 1,587 4 Altoona PA BT Provide For Green Environmental Management (GEM), Phase 1 .......................................................... 500 455 455 

34 

Planned 2018 Non-Recurring Maintenance Projects—Continued 

VISN Location ST Project Type Project Name - Short Description 

Total 

Estimated 

Cost 

($000) 

Planned 

FY 2018 

Obs 

($000) 

′′First 

Bite′′ 

($000) 

′′Second 

Bite′′ 

($000) 

4 Altoona PA BT Facility Chlorination System .................................................................................................................. 300 270 270 4 Altoona PA BT Provide Security Upgrades, Phase 2 ..................................................................................................... 605 550 550 4 Altoona PA BT Replace Space Signage ......................................................................................................................... 622 566 566 4 Altoona PA BT Provide Electronic Signage .................................................................................................................... 398 362 362 4 Altoona PA BT Paint Walls ............................................................................................................................................. 242 220 220 4 Altoona PA SCIP 2017 Correct Retro-commissioning Discrepancies Phase 2 ........................................................................... 3,722 3,384 3,384 4 Butler PA SCIP 2015 Renovate Building 6 .............................................................................................................................. 3,045 1,750 1,750 4 Coatesville PA Pending OOC Renovate Building 58 ............................................................................................................................ 8,800 8,000 8,000 4 Coatesville PA BT Update Campus Water Lines ................................................................................................................. 490 190 190 4 Coatesville PA SCIP 2018 Correct Electrical Deficiencies (PH2) ..................................................................................................... 2,225 2,000 2,000 4 Coatesville PA BT Remove Fuel storage tanks ................................................................................................................... 470 400 400 4 Coatesville PA Pending OOC Hospice Oxygen System ......................................................................................................................... 1,100 900 900 4 Coatesville PA BT FCA Repairs Bldg 14 ............................................................................................................................. 485 425 425 4 Coatesville PA BT Tree Management & Sidewalks Oval 1 ................................................................................................. 495 450 450 4 Coatesville PA Pending OOC SPS Satellite Storage Rooms ................................................................................................................. 1,100 900 900 4 Coatesville PA SCIP 2015 Replace Steam & Condensate Mains—Oval 2 & Outlying Branches .................................................. 3,000 2,700 2,700 4 Coatesville PA SCIP 2017 Upgrade HVAC System B/57 .................................................................................................................. 2,200 1,690 1,690 4 Coatesville PA BT Correct FCA Deficiencies Building 10 ................................................................................................... 350 300 300 4 Coatesville PA BT Roof Fall Protection Systems Evaluation & Upgrades .......................................................................... 600 500 500 4 Coatesville PA SCIP 2017 Exterior Signage & Wayfinding Campus Wide ...................................................................................... 1,870 1,750 1,750 4 Coatesville PA SCIP 2018 Renovate Building 58—A Floor ............................................................................................................. 4,950 495 495 4 Coatesville PA SCIP 2018 Correct Electrical Deficiencies—Phase 2 ............................................................................................. 2,225 2,002 2,002 4 Erie PA SCIP 2016 Renovate Exterior Building—Masonry, Windows, Sunshades ............................................................... 2,200 2,000 2,000 4 Erie PA Pending OOC Replace Roofs ........................................................................................................................................ 1,815 1,650 1,650 4 Erie PA SCIP 2015 New Central Chiller Plant ...................................................................................................................... 9,680 8,800 8,800 4 Erie PA SCIP 2013 Renovate Fourth Floor (Design) ............................................................................................................. 4,950 4,500 4,500 4 Erie PA SCIP 2015 Correct Retro-Commissioning Project Findings ..................................................................................... 1,100 100 100 4 Lebanon PA SCIP 2015 Renovate 1-4C for Multi-purpose Area ................................................................................................. 2,200 2,200 2,200 4 Lebanon PA OOC Replace Electrical Substation ................................................................................................................ 4,500 4,000 4,000 4 Lebanon PA Pending OOC Correct Physical Security Issues ............................................................................................................ 3,300 3,000 3,000 4 Lebanon PA OOC Renovate Food Service Kitchen .............................................................................................................. 3,830 3,500 3,500 4 Lebanon PA SCIP 2015 Renovate Primary Care/Specialty Clinic Building 17 ............................................................................ 1,950 1,750 1,750 4 Lebanon PA SCIP 2017 Replace Chillers ..................................................................................................................................... 3,850 3,500 3,500 4 Lebanon PA SCIP 2017 Renovate Bldg. 22 ................................................................................................................................. 5,000 4,500 4,500 

35 

4 Lebanon PA SCIP 2015 Renovate 1-4C for Patient Activity Area ............................................................................................... 2,200 1,900 1,900 4 Lebanon PA SCIP 2015 Renovate for MOVE! program ................................................................................................................ 3,300 3,000 3,000 4 Lebanon PA SCIP 2018 Correct Physical Security Issues Phase 1 ............................................................................................. 3,300 2,970 2,970 4 Lebanon PA SCIP 2018 Correct Facade Issues Phase 3 ............................................................................................................. 3,300 330 330 4 Lebanon PA SCIP 2018 Retro-Commissioning Corrections .......................................................................................................... 3,300 330 330 4 Philadelphia PA SCIP 2017 Modernize Dental Exam Rooms ............................................................................................................. 1,884 1,713 1,713 4 Philadelphia PA BT Relocate On-Call Rooms ........................................................................................................................ 550 500 500 4 Philadelphia PA Pre-SCIP Correct Building Facade Deficiencies .................................................................................................... 8,000 7,800 7,800 4 Philadelphia PA SCIP 2017 Architectural Improvements for Wards 5 and 6 ................................................................................... 2,973 2,543 2,543 4 Philadelphia PA BT Upgrade Toilets 1st Floor ...................................................................................................................... 225 200 200 4 Philadelphia PA CSI Upgrade CLC Unit C Ph 2 ..................................................................................................................... 4,400 4,000 4,000 4 Philadelphia PA SCIP 2017 Correct FCA for Lightning Protection ..................................................................................................... 1,100 737 737 4 Philadelphia PA SCIP 2017 Renovate Building 1 7th Floor for Mental Health ................................................................................. 3,190 2,900 2,900 4 Philadelphia PA SCIP 2017 Address EmergencyPower0 Deficiencies in Building 1 ......................................................................... 4,600 4,200 4,200 4 Philadelphia PA CSI Women’s Imaging Center ....................................................................................................................... 2,200 2,000 2,000 4 Philadelphia PA BT Install Security Fencing at Parking Garage Bldg 28 ............................................................................ 278 216 216 4 Philadelphia PA SCIP 2016 Renovate Specialty Clinics .................................................................................................................... 3,500 3,300 3,300 4 Philadelphia PA OOC Upgrade Patient Environment NHCU ..................................................................................................... 1,700 1,200 1,200 4 Philadelphia PA CSI Replace Catheterization Lab .................................................................................................................. 1,100 1,000 1,000 4 Philadelphia PA SCIP 2017 Upgrade Halls and Wall Phase 1 .......................................................................................................... 2,200 2,000 2,000 4 Philadelphia PA BT Radiology Rooms .................................................................................................................................... 563 500 500 4 Pittsburgh PA SCIP 2018 Renovate Building One-10 East for Architectural, Mechanical and Electrical Deficiencies ................ 5,250 525 525 4 Pittsburgh PA SCIP 2018 Replace Elevators in Building 51 and Building 50 at Heinz Division ................................................. 3,420 342 342 4 Pittsburgh PA SCIP 2018 Replace Air Handling Units serving Operating Rooms (AC12 & AC13) ............................................... 9,600 960 960 4 Pittsburgh (UD) PA SCIP 2015 Install Wayfinding Signage at UD and HZ Campuses .......................................................................... 5,500 5,000 5,000 4 Pittsburgh (UD) PA SCIP 2017 Replace Domestic Water Branch Piping at UD and HZ ........................................................................ 22,000 20,000 20,000 4 Wilkes-Barre PA OOC Replace Exterior Windows ...................................................................................................................... 4,800 4,400 4,400 4 Wilkes-Barre PA SCIP 2015 Improve Wayfinding and Signage .......................................................................................................... 1,650 1,500 1,500 4 Wilkes-Barre PA SCIP 2015 Renovate 2 West Rehab ........................................................................................................................ 5,600 5,000 5,000 4 Wilkes-Barre PA SCIP 2017 Correct FCA Electrical Deficiencies ....................................................................................................... 4,400 4,000 4,000 4 Wilkes-Barre PA SCIP 2015 Construct New Chiller Plant .................................................................................................................. 6,000 5,000 5,000 4 Wilkes-Barre PA SCIP 2013 Renovate 8 East for Nursing Administration ........................................................................................ 3,800 3,455 3,455 4 Wilkes-Barre PA Pending OOC Building 1 HVAC, Phase 2 ..................................................................................................................... 4,950 4,500 4,500 4 Wilkes-Barre PA OOC Improve Landscaping ............................................................................................................................. 1,000 900 900 4 Wilkes-Barre PA SCIP 2017 Install Fence and Gates ........................................................................................................................ 2,200 180 180 4 Wilkes-Barre PA SCIP 2017 Renovate 2 North- Radiology ................................................................................................................. 3,300 300 300 5 Washington DC SCIP 2018 Correct FCA Infrastructure Deficiencies and Functional Deficiencies in Research B4 , Phase IV ...... 4,295 430 430 5 Washington DC SCIP 2018 Replace Walk-In Refrigerators and Freezers in Patient Kitchen, Morgue, Pharmacy, Lab and Research. 2,765 277 277 

36 

Planned 2018 Non-Recurring Maintenance Projects—Continued 

VISN Location ST Project Type Project Name - Short Description 

Total 

Estimated 

Cost 

($000) 

Planned 

FY 2018 

Obs 

($000) 

′′First 

Bite′′ 

($000) 

′′Second 

Bite′′ 

($000) 

5 Washington DC SCIP 2018 Replace and Upgrade Room Air Distribution Terminal Devices and Controls to Correct FCA deficiency. 1,962 196 196 5 Washington DC SCIP 2018 Renovate MICU 4B for Patient Privacy and Correction of FCA Deficiencies ........................................ 9,617 962 962 5 Washington DC SCIP 2018 Correct Seismic, Structural, and Facility Condition Deficiencies in Building 1 ................................... 2,745 275 275 5 Washington DC SCIP 2016 Correct NFPA 70 (NEC) Code Deficiencies in all Secondary Distribution Panels and Separate 

Branch Circuits for Critical, Life Safety and Equipment Branches.

3,028 2,750 2,750 

5 Washington DC SCIP 2014 Renovate Research Labs, Phase 3 ........................................................................................................ 2,691 2,427 2,427 5 Washington DC SCIP 2016 Replace and Upgrade Outside Distribution for Site Storm and Sanitary Sewer System ..................... 3,700 3,400 3,400 5 Washington DC SCIP 2016 Upgrade Sprinkler System for Building #6 ........................................................................................... 2,462 2,262 2,262 5 Washington DC SCIP 2016 Upgrade Chiller Plant and Cooling Tower ............................................................................................. 8,800 8,000 8,000 5 Baltimore MD BT Upgrade and Repair CLC Heating Boilers ............................................................................................. 450 450 450 5 Baltimore MD OOC Upgrade Emergency Switchgear and Distribution ................................................................................. 200 1,800 1,800 5 Baltimore MD BT Replacement of Exterior Breezeway Precast Concrete Paver Sidewalk System .................................... 715 650 650 5 Baltimore MD SCIP 2013 Convert Semi-Private Beds to Private 3A ............................................................................................. 8,800 8,000 8,000 5 Baltimore MD BT Upgrade SPD Closet HVAC ..................................................................................................................... 770 700 700 5 Baltimore MD BT Loch Raven Drainage Corrections ......................................................................................................... 770 700 700 5 Baltimore MD SCIP 2017 Upgrade and Renovate OR Suite ........................................................................................................... 6,710 6,100 6,100 5 Baltimore MD SCIP 2016 Convert 6A Semi-Private Mental Health Beds to Private ..................................................................... 8,290 7,461 7,461 5 Baltimore MD SCIP 2018 Upgrade Building Air Handler Units and Improve Heating, Ventilating, and Air Conditioning Systems. 5,170 517 517 5 Baltimore MD SCIP 2018 Convert 3B Semi Private Beds to Private ............................................................................................. 7,040 704 704 5 Perry Point MD BT Expand Fire House for EMS ................................................................................................................... 330 300 300 5 Perry Point MD SCIP 2016 Upgrade Fire Alarm System Campus Wide—Phase 1—Patient Buildings .......................................... 7,416 6,674 6,674 5 Perry Point MD BT Emergency Steam Condensate System Repairs .................................................................................... 550 500 500 5 Perry Point MD Pending OOC Improvements to Bldg 361 Urgent Care Clinic (UCC) .......................................................................... 5,060 4,600 4,600 5 Perry Point MD BT PP Enhanced Dining .............................................................................................................................. 660 600 600 5 Perry Point MD SCIP 2014 Convert Bldg 364B for Residential Rehabilitation Treatment Program ............................................... 2,640 2,400 2,400 5 Perry Point MD BT Waterproof Tunnel to Bldg 364 ............................................................................................................. 880 800 800 5 Perry Point MD SCIP 2016 Replace Boiler No. 2 at Perry Point ...................................................................................................... 1,484 1,336 1,336 5 Perry Point MD SCIP 2016 Upgrade Medical Gas Systems .............................................................................................................. 1,912 1,721 1,721 5 Perry Point MD SCIP 2018 Replace Main Transformers and Switchgear at Perry Point Substation .............................................. 1,276 128 128 5 Perry Point MD SCIP 2018 Renovate Building 15H for Mental Health Homeless Staff and Voluntary Service .............................. 4,040 404 404 5 Perry Point MD SCIP 2018 Replace Chilled Water along Avenue D to Correct FCA Deficiency ...................................................... 4,796 480 480 5 Perry Point MD SCIP 2018 Upgrade HVAC at Bldg 4H to Correct FCA Deficiency .......................................................................... 2,751 275 275 

37 

5 Beckley WV SCIP 2018 Upgrade Boiler Plant System ................................................................................................................. 3,850 385 385 5 Beckley WV SCIP 2018 Correct High Voltage Deficiencies ......................................................................................................... 4,840 484 484 5 Beckley WV SCIP 2018 Corrections to Medical Gas System ....................................................................................................... 1,600 160 160 5 Beckley WV SCIP 2018 Correct Domestic Water Supply System ................................................................................................ 3,025 303 303 5 Clarksburg WV OOC Modernize Specialty Clinics ................................................................................................................... 6,380 5,844 5,844 5 Clarksburg WV OOC Construct Replacement Chiller Plant .................................................................................................... 7,976 7,251 7,251 5 Clarksburg WV SCIP 2018 Replace Deficient Domestic Water Riser Building 1 ............................................................................. 2,200 220 220 5 Huntington WV SCIP 2018 Upgrade and Correct FCA Deficiencies for Campus Building Management System ........................... 6,278 628 628 5 Huntington WV SCIP 2018 Repair and Upgrade Buildings 23 and 23R to Correct FCA Deficiencies ............................................ 7,069 707 707 5 Huntington WV SCIP 2018 Improve Facility Safety and Security ..................................................................................................... 2,700 270 270 5 Huntington WV SCIP 2015 Construct Secondary Access Road ........................................................................................................ 2,905 2,600 2,600 5 Huntington WV SCIP 2016 Correct Boiler Plant Steam Deficiencies ............................................................................................... 3,005 2,705 2,705 5 Huntington WV SCIP 2016 Replace Mechanical Systems Bldg 4 .................................................................................................... 4,235 3,850 3,850 5 Huntington WV SCIP 2015 Replace Air Handling Units Bldgs 1&1S ............................................................................................... 2,109 1,900 1,900 5 Huntington WV BT Improve Signage and Wayfinding .......................................................................................................... 999 850 850 5 Huntington WV CSI Construct RRTP Building ....................................................................................................................... 4,840 4,400 4,400 5 Huntington WV SCIP 2015 Replace Windows Bldg 1S ..................................................................................................................... 1,500 1,500 1,500 5 Martinsburg WV SCIP 2018 Relocate Electrical Feeder for Physical Security Compliance ............................................................... 2,785 279 279 5 Martinsburg WV SCIP 2018 Repair Steam Piping from Buildings 217, 318 & 328 to Boiler Plant ................................................ 1,534 153 153 5 Martinsburg WV OOC Renovate Building 305 for Fiscal .......................................................................................................... 1,540 1,400 1,400 5 Martinsburg WV BT Construct Internet Cafe Healing Garden ............................................................................................... 710 600 600 5 Martinsburg WV BT Renovate 217 for Veterans’ Music Room .............................................................................................. 890 800 800 5 Martinsburg WV OOC Renovate Building 317, Post Theater .................................................................................................... 2,075 1,900 1,900 6 Durham NC Pending OOC Correct High Priority FCA Deficiencies .................................................................................................. 3,850 3,500 3,500 6 Durham NC Pending OOC Install Security Fence ............................................................................................................................ 1,100 1,050 1,050 6 Durham NC BT Renovate Utility Space in Basement ..................................................................................................... 545 500 500 6 Durham NC BT Renovate Access Improvement Spaces ................................................................................................. 570 570 570 6 Durham NC Pending OOC Expand PACU ......................................................................................................................................... 2,870 2,600 2,600 6 Durham NC BT Correct Life Safety Deficiencies ............................................................................................................. 395 350 350 6 Durham NC Pending OOC Pharmacy Processing Renovation .......................................................................................................... 1,925 1,925 1,925 6 Durham NC BT Install Lightning and Fall Protection .................................................................................................... 700 700 700 6 Durham NC BT Renovate OR Locker Rooms ................................................................................................................... 715 650 650 6 Durham NC Pending OOC Replace Roofs Phase II .......................................................................................................................... 2,300 2,150 2,150 6 Fayetteville NC SCIP 2018 Renovate Intensive Care Unit ................................................................................................................ 5,028 4,528 4,528 6 Fayetteville NC SCIP 2017 Renovation of 1A corridor and offices .................................................................................................. 790 700 700 6 Fayetteville NC SCIP 2017 Renovate Nursing Area 1A ..................................................................................................................... 1,114 1,000 1,000 6 Fayetteville NC SCIP 2014 Replace AHUs in A-wing Basement ...................................................................................................... 2,500 2,250 2,250 6 Fayetteville NC SCIP 2014 Replace Windows Bldg 1 ....................................................................................................................... 2,400 2,160 2,160 6 Fayetteville NC SCIP 2013 Renovate Lab, Radiology and Pharmacy High Traffic Areas ................................................................ 3,520 3,200 3,200 6 Salisbury NC SCIP 2018 Renovate Building 2 for Medical Surgical Modernization ..................................................................... 6,002 5,402 5,402 

38 

Planned 2018 Non-Recurring Maintenance Projects—Continued 

VISN Location ST Project Type Project Name - Short Description 

Total 

Estimated 

Cost 

($000) 

Planned 

FY 2018 

Obs 

($000) 

′′First 

Bite′′ 

($000) 

′′Second 

Bite′′ 

($000) 

6 Salisbury NC SCIP 2014 Install New Steam Control Valves at Existing Convectors Buildings 2, 3, and 4 ............................... 1,665 1,498 1,498 6 Salisbury NC SCIP 2014 Replace Chilled Water Lines Building 3 ............................................................................................... 2,080 1,872 1,872 6 Salisbury NC SCIP 2016 Replace Campus Fire Alarm System ..................................................................................................... 4,285 3,900 3,900 6 Salisbury NC SCIP 2013 Construct Water Tower ........................................................................................................................... 3,250 2,925 2,925 6 Salisbury NC SCIP 2018 Renovate Building 2 for Medical Surgical Modernization ..................................................................... 6,002 5,452 5,452 6 Salisbury NC BT Resurface Station Roadways and Repair Sidewalks ............................................................................. 992 992 992 6 Salisbury NC BT Road Access Modifications at Building 3 ............................................................................................. 300 300 300 6 Salisbury NC SCIP 2016 Correct Information Technology FCA Deficiencies ................................................................................. 3,500 3,100 3,100 6 Hampton VA BT Access Control Prime Clinics ................................................................................................................. 165 150 150 6 Hampton VA SCIP 2013 Implement Master Plan Design and Building Systems Upgrade, Building 110 .................................. 8,900 8,091 8,091 6 Hampton VA SCIP 2016 Improve Data Distribution/Security/Infrastructure ................................................................................. 1,650 1,500 1,500 6 Hampton VA OOC Replace Natural Gas Line and Initial ESPC Pay Down ......................................................................... 1,730 1,655 1,655 6 Hampton VA CSI Construct New MRI Facility ................................................................................................................... 900 819 819 6 Hampton VA BT Renovate Prime Clinics for PACT Alignment ......................................................................................... 153 140 140 6 Richmond VA SCIP 2018 Upgrade Pharmacy to USP 800 ............................................................................................................. 1,045 105 105 6 Richmond VA BT Pharmacy Giant Omni-Cell .................................................................................................................... 15 15 15 6 Richmond VA BT Parking Access Improvement ................................................................................................................. 550 500 500 6 Richmond VA SCIP 2016 Renovate for Operating Rooms .............................................................................................................. 8,725 7,900 7,900 6 Richmond VA BT Secure 3D with PACS ............................................................................................................................. 75 75 75 6 Richmond VA BT Radiology Mobile MRI Awning ............................................................................................................... 150 150 150 6 Richmond VA BT Roof Replacement .................................................................................................................................. 750 750 750 6 Richmond VA OOC Replace Air Handlers SCI ...................................................................................................................... 2,725 2,450 2,450 6 Richmond VA BT Canteen Renovations ............................................................................................................................. 550 500 500 6 Richmond VA BT Remodel Admin Space ........................................................................................................................... 996 905 905 6 Richmond VA BT Remodel Support Spaces ....................................................................................................................... 945 900 900 6 Richmond VA BT Fisher House Exterior Painting .............................................................................................................. 15 15 15 6 Richmond VA SCIP 2014 Improve Patient Privacy 4B ................................................................................................................... 3,700 3,370 3,370 6 Richmond VA OOC Renovate Spinal Cord Injury Unit for Privacy ....................................................................................... 5,720 5,200 5,200 6 Richmond VA Pending OOC Replace HVAC Systems 2 and 5 ........................................................................................................... 1,980 180 180 6 Richmond VA Pending OOC SPS/OR Vertical Transportation ............................................................................................................. 1,650 150 150 6 Salem VA SCIP 2016 Replace Roofs and Tuckpoint ................................................................................................................ 6,000 5,480 5,480 6 Salem VA BT Renovate Basement Building 8 ............................................................................................................. 750 675 675 6 Salem VA BT Construct Simulation Center Building 4 ............................................................................................... 938 900 900 6 Salem VA BT Replace Finishes Various Buildings ...................................................................................................... 550 550 550 

39 

7 Birmingham AL SCIP 2018 Correct Critical Mechanical and Plumbing Deficiencies by Replacing Aging and Deteriorating 

Steam Distribution Systems.

5,500 550 550 

7 Birmingham AL SCIP 2014 Install New Interior Finishes—Blind Rehabilitation Center ................................................................. 3,850 3,500 3,500 7 Birmingham AL SCIP 2016 Replace Information Technology Cabling Infrastructure ....................................................................... 2,200 1,980 1,980 7 Birmingham AL SCIP 2016 Replace/Upgrade Pressure Piping and Hot Water Distribution System ................................................ 6,600 5,940 5,940 7 Birmingham AL SCIP 2016 Replace Air Handling Units—Phase IV ................................................................................................. 4,400 3,960 3,960 7 Birmingham AL BT Upgrade Negative Pressure Rooms ....................................................................................................... 830 750 750 7 Montgomery AL BT Renovate Building 90 Therapeutic Pool for Fitness Center .................................................................. 330 300 300 7 Montgomery AL BT Replace Air Handling Equipment and add Generator, Bldg. 1 ............................................................ 825 750 750 7 Montgomery AL BT Upgrade Restrooms with Water Conservation Measures, Phase 2 ....................................................... 820 734 734 7 Montgomery AL SCIP 2018 Renovate Inpatient Medicine Unit for privacy—Building 1, floor 4. ................................................... 9,290 929 929 7 Tuscaloosa AL SCIP 2018 Masonry Restoration .............................................................................................................................. 5,960 596 596 7 Tuscaloosa AL BT Improve Building 12 (Warehouse) ......................................................................................................... 239 206 206 7 Tuscaloosa AL SCIP 2016 Replace HVAC Systems .......................................................................................................................... 2,807 2,359 2,359 7 Tuscaloosa AL SCIP 2017 Improve in Building 3 ............................................................................................................................ 2,580 862 862 7 Tuscaloosa AL BT Improve Courtyard Building 1 ............................................................................................................... 283 265 265 7 Tuscaloosa AL BT Install Legionella Precautions ............................................................................................................... 858 780 780 7 Tuscaloosa AL SCIP 2016 Electrical Upgrades ................................................................................................................................ 1,664 1,498 1,498 7 Tuscaloosa AL OOC A/E Legionella Survey/Assessment Design Phase II Tuscaloosa ........................................................... 6,700 6,200 6,200 7 Tuskegee AL BT Improve Facility Condition Assessment Findings-Plumbing Upgrades ................................................. 985 895 895 7 Tuskegee AL SCIP 2018 Repair the Roof on Buildings #3,#3A,#4A,#65,#83,#88,#97,#120 and #129 ...................................... 2,204 220 220 7 Tuskegee AL SCIP 2018 Repair FCA Electrical Deficiencies in Buildings #5,#12,#14 ................................................................ 1,795 180 180 7 Tuskegee AL SCIP 2018 Repair Electrical FCA Deficiencies in Buildings #65 and #68 ............................................................. 2,260 226 226 7 Tuskegee AL SCIP 2018 Replace Refrigeration Equipment for Building #120 and #97 ............................................................. 1,426 143 143 7 Atlanta GA SCIP 2018 Correct Infrastructure, Patient Safety, and FCA Deficiencies in Mechanical, Electrical, and Architectural in Research and the Medical Center. 9,930 993 993 7 Atlanta GA SCIP 2018 Replace Campus Fire Alarm System ..................................................................................................... 2,370 237 237 7 Atlanta GA BT Bariatric Bedroom .................................................................................................................................. 350 290 290 7 Atlanta GA OOC Correct Emergency Care Deficiencies .................................................................................................... 7,145 6,255 6,255 7 Atlanta GA BT Correct Piping Deficiencies, Phase II .................................................................................................... 810 736 736 7 Atlanta GA SCIP 2016 Renovate and Expand Oncology Medical Specialty Services ................................................................ 3,350 3,015 3,015 7 Atlanta GA SCIP 2016 Renovate and Expand Medical/Surgical Inpatient Services on 6th Floor Building 1C Nursing Tower 6,576 5,918 5,918 7 Atlanta GA OOC Upgrade Elevators Building 1A & 1B .................................................................................................... 3,700 3,350 3,350 7 Augusta GA OOC Renovate and Upgrade Operating Rooms, Phase 1 .............................................................................. 9,995 9,086 9,086 7 Augusta GA SCIP 2016 Replace Emergency Generator Systems Uptown ................................................................................... 2,814 2,558 2,558 7 Dublin GA SCIP 2014 Implement Retro Commissioning Recommendations ............................................................................ 1,815 1,650 1,650 7 Dublin GA SCIP 2016 Correct Information Technology Infrastructure Deficiencies ................................................................. 1,814 1,656 1,656 7 Dublin GA SCIP 2016 Install Emergency Power Generator ....................................................................................................... 3,780 3,500 3,500 7 Dublin GA SCIP 2016 Renovate 26A for Swing Space Functions ............................................................................................ 2,354 2,150 2,150 7 Charleston SC SCIP 2018 Replace E&F Buildings and Building Frame Seismic ........................................................................... 9,887 989 989 

40 

Planned 2018 Non-Recurring Maintenance Projects—Continued 

VISN Location ST Project Type Project Name - Short Description 

Total 

Estimated 

Cost 

($000) 

Planned 

FY 2018 

Obs 

($000) 

′′First 

Bite′′ 

($000) 

′′Second 

Bite′′ 

($000) 

7 Charleston SC SCIP 2018 Fire alarm Ph 2 /life safety improvements removal fire dampers, quick response head replacement, dry system replacement. 9,977 998 998 7 Charleston SC SCIP 2018 Expand/Replace Direct Digital Control .................................................................................................. 5,486 549 549 7 Charleston SC SCIP 2018 Address Potential Legionella Issues (Phase II) ..................................................................................... 9,991 999 999 7 Charleston SC SCIP 2018 Correct Structural Seismic Deficiencies to the Medical Center (Building 1) ....................................... 9,901 990 990 7 Charleston SC SCIP 2018 Renovate electrical/telephone closet upgrades (separation of ENG and IT) ........................................ 9,890 989 989 7 Charleston SC SCIP 2018 Update Mechanical Systems .................................................................................................................. 9,842 984 984 7 Charleston SC SCIP 2016 Renovate Canteen Kitchen ..................................................................................................................... 1,000 900 900 7 Charleston SC SCIP 2016 Construct Patient Surgical Elevator ...................................................................................................... 2,500 2,250 2,250 7 Charleston SC SCIP 2017 Correct/Repair External Architectural Barriers and Structures ............................................................. 6,380 5,800 5,800 7 Charleston SC SCIP 2016 Renovation of Common and Support Areas in Building 1 ................................................................... 5,000 4,500 4,500 7 Charleston SC SCIP 2016 Overhaul/Replace Elevators ................................................................................................................... 2,500 2,250 2,250 7 Charleston SC SCIP 2017 Remove ACM throughout VAMC ............................................................................................................. 1,128 1,000 1,000 7 Charleston SC SCIP 2015 Correct Security Deficiencies ................................................................................................................. 3,195 2,700 2,700 7 Columbia SC SCIP 2018 Replace Hot Water Piping ...................................................................................................................... 2,182 218 218 7 Columbia SC SCIP 2016 Upgrade Elevator Systems ..................................................................................................................... 1,685 1,450 1,450 7 Columbia SC BT Implement Lab Energy Conservation Measures .................................................................................... 660 600 600 8 Bay Pines FL SCIP 2014 Replace Air Conditioning System B-102 PH I (Multi-Phase) ................................................................ 1,764 1,210 1,210 8 Bay Pines FL SCIP 2014 Replace Roof Building 102 .................................................................................................................... 1,221 1,221 1,221 8 Bay Pines FL SCIP 2012 Renovate Patient Wards B100, 3C & 4A .............................................................................................. 8,262 7,511 7,511 8 Bay Pines FL SCIP 2017 Resolve SPS Temp, Humidity, Air Change and Air Flow Deficiencies .................................................. 3,513 3,193 3,193 8 Bay Pines FL SCIP 2018 Replace Domestic Water Mains ............................................................................................................. 3,839 384 384 8 Gainesville FL OOC Install Parking Garage Fall Protection .................................................................................................. 2,210 714 714 8 Gainesville FL OOC Renovate Ambulatory Care Area ............................................................................................................ 6,300 5,670 5,670 8 Gainesville FL SCIP 2018 Replace Air Handler Unit No. 3 ............................................................................................................. 9,950 995 995 8 Gainesville FL SCIP 2018 Replace Air Handler Unit No. 2 ............................................................................................................. 9,900 990 990 8 Lake City FL SCIP 2018 Renovate Common Area Restrooms ....................................................................................................... 2,750 275 275 8 Lake City FL SCIP 2018 Replace Windows and Weather Protection ............................................................................................ 9,900 990 990 8 Lake City FL SCIP 2018 Expand Electrical Distribution ............................................................................................................... 9,900 990 990 8 Lake City FL SCIP 2018 Replace Site Water Distribution ............................................................................................................ 7,000 700 700 8 Miami FL SCIP 2018 Replace pneumatics with direct digital control .................................................................................... 9,079 5,530 5,530 8 Miami FL BT Renovate locker and rest rooms for staff ............................................................................................. 901 901 901 8 Miami FL SCIP 2017 Replace coolers and refrigerators ......................................................................................................... 2,020 1,087 1,087 8 Miami FL SCIP 2018 Replace Duct work and piping and conduct duct cleaning building 1 ............................................... 8,346 7,199 7,199 

41 

8 Miami FL SCIP 2017 Renovate Ambulatory surgery ................................................................................................................ 1,418 882 882 8 Miami FL SCIP 2017 Renovate inpatient Mental Health 4th Floor A & B .............................................................................. 6,104 5,535 5,535 8 Miami FL BT Renovate Room B1023 .......................................................................................................................... 32 32 32 8 Miami FL BT Update spinal cord injury outdoor rehabilitation area ......................................................................... 352 317 317 8 Orlando FL BT Add Variable Air Volume and Environmental Controls at Viera OPC ................................................... 864 786 786 8 Orlando FL BT Correct Access and Stormwater Deficiencies—Viera ........................................................................... 925 836 836 8 Orlando FL SCIP 2017 Renovate Building 500 for Administration Space ................................................................................. 4,400 4,000 4,000 8 Orlando FL SCIP 2014 Renovate Building 500 for Veterans Benefit Administration Space ..................................................... 3,962 3,660 3,660 8 Tampa FL SCIP 2017 Upgrade Facility Security ....................................................................................................................... 4,600 4,000 4,000 8 Tampa FL SCIP 2017 Replace and Consolidate Domestic Water Distribution, Bldg 1 ........................................................... 6,112 5,557 5,557 8 Tampa FL BT Contractor Area Renovation ................................................................................................................... 45 31 31 8 Tampa FL SCIP 2018 Replace Air Handler Units 12, 20, 65 and 66, Building 1 .................................................................. 8,600 860 860 8 Tampa FL SCIP 2018 Replace Chilled Water System for Building #1 ..................................................................................... 9,100 910 910 8 West Palm Beach FL BT Replace Air Cooled Chillers in Operating Rooms .................................................................................. 669 669 669 8 West Palm Beach FL SCIP 2017 Provide Return Ducts and Controllers on Air Handler Units (AHU) ...................................................... 1,090 990 990 8 San Juan PR SCIP 2012 Provide New Environmental Integrated Waste Center ........................................................................... 3,610 3,310 3,310 8 San Juan PR BT Replace Air Handling Units at Various Sites ........................................................................................ 946 880 880 8 San Juan PR SCIP 2017 Upgrade Perimeter Fence Upgrade ........................................................................................................ 2,300 1,414 1,414 8 San Juan PR BT Repair Paver System and Add Canopy at Administrative Building ...................................................... 507 461 461 8 San Juan PR BT Replace Reheat System ......................................................................................................................... 890 800 800 8 San Juan PR BT Replace Exhaust Fans ........................................................................................................................... 739 688 688 8 San Juan PR CSI Site Prep for New Linear Accelerator .................................................................................................... 2,209 2,008 2,008 8 San Juan PR BT Install Non Structural Components and Equipment Seismic Correction and Remove Asbestos at 

Basement Area.

955 875 875 

8 San Juan PR SCIP 2018 Correct Nonstructural Components at OPA ........................................................................................... 3,800 380 380 9 Lexington—Leestown KY SCIP 2018 Renovate B29, 2nd Flr, for Women’s Health, C&P and Primary Cary .................................................. 7,400 6,730 6,730 9 Lexington—Leestown KY BT Chiller Plant Improvements ................................................................................................................... 310 310 310 9 Lexington—Leestown KY SCIP 2016 Renovate Building 28 for Specialty Care .............................................................................................. 9,474 8,641 8,641 9 Lexington—Leestown KY BT Construct Additional Parking B28 ......................................................................................................... 561 510 510 9 Lexington (CD) KY BT Replace Boiler Controls and Burners .................................................................................................... 437 378 378 9 Lexington (CD) KY BT Repair Pkg Garage Deck ........................................................................................................................ 880 800 800 9 Lexington (CD) KY SCIP 2013 Upgrade Physical Access Control System (PACS) and Site Security .................................................... 7,124 4,577 4,577 9 Lexington (CD) KY BT Activate OR for CT Surgery .................................................................................................................... 550 500 500 9 Lexington (CD) KY BT Renovate Chemo Infusion Ante-Room ................................................................................................... 446 401 401 9 Louisville KY BT Install Closed Circuit Security at Louisville Community Based Outpatient Clinics ............................. 500 500 500 9 Louisville KY BT Upgrade Motors Project ......................................................................................................................... 78 78 78 9 Louisville KY BT Renovate Area for Emergency Department Fast Track ......................................................................... 374 340 340 9 Louisville KY BT Renovate Building 3 for PRRC .............................................................................................................. 494 450 450 9 Louisville KY SCIP 2016 Replace AHUs, Ph 5 ............................................................................................................................... 2,500 2,250 2,250 9 Louisville KY SCIP 2016 Replace Fire Alarm System .................................................................................................................... 5,500 5,000 5,000 

42 

Planned 2018 Non-Recurring Maintenance Projects—Continued 

VISN Location ST Project Type Project Name - Short Description 

Total 

Estimated 

Cost 

($000) 

Planned 

FY 2018 

Obs 

($000) 

′′First 

Bite′′ 

($000) 

′′Second 

Bite′′ 

($000) 

9 Louisville KY BT Replace TIP Units in 23 IT Closets ....................................................................................................... 354 354 354 9 Louisville KY OOC OR Anesthesia Supply Head Replacement Rooms 1—6 ...................................................................... 1,328 1,195 1,195 9 Louisville KY BT Replace Steam Traps ............................................................................................................................. 90 90 90 9 Louisville KY BT Upgrade 6 South Reheats ..................................................................................................................... 440 400 400 9 Memphis TN SCIP 2018 Correct Plumbing Piping and Replace Fixtures .................................................................................... 9,185 919 919 9 Memphis TN SCIP 2018 Renovate Clinical Lab ............................................................................................................................ 7,409 741 741 9 Memphis TN BT Renovate Surgical Service ..................................................................................................................... 619 619 619 9 Memphis TN BT Install Equipment Pad for Voluntary Service Carts .............................................................................. 30 30 30 9 Memphis TN Pending OOC Renovate Building 1 for Primary Care .................................................................................................. 9,879 8,989 8,989 9 Memphis TN Pending OOC Renovate Building 1 Clinical Lab ......................................................................................................... 9,945 9,050 9,050 9 Memphis TN BT Replace Building 10 Rooftop AC Units ................................................................................................. 55 55 55 9 Memphis TN BT Upgrade Elevators for Oil Coolers and UV ............................................................................................ 189 189 189 9 Memphis TN BT Replace Automatic Doors ....................................................................................................................... 978 978 978 9 Memphis TN BT Renovate Physical Medicine & Rehabilitation Pool Area ...................................................................... 871 785 785 9 Memphis TN OOC Upgrade Spinal Cord Injury Patient Bathrooms .................................................................................... 1,678 1,526 1,526 9 Memphis TN BT Replace Building 1 and 1A Medical Vacuum Pump ............................................................................. 250 225 225 9 Memphis TN BT Replace Finishes for Halls and Walls ................................................................................................... 950 950 950 9 Memphis TN BT Replace Flooring and Ceilings for Safety and Infection Control .......................................................... 964 877 877 9 Mountain Home TN BT Replace Building 200 Roof .................................................................................................................... 950 893 893 9 Mountain Home TN OOC Replace AHU 3 For SPD Building 77 ..................................................................................................... 1,672 1,520 1,520 9 Mountain Home TN BT Renovate Building 160 Main Lobby ...................................................................................................... 901 825 825 9 Mountain Home TN BT Replacement of Signs Bldg 200/204/205/77/160 ................................................................................ 900 895 895 9 Mountain Home TN SCIP 2015 Correct Bldg 20 Condition & Environment Deficiencies for Clinical/Support Staff Recruitment & 

Training.

1,439 1,316 1,316 

9 Mountain Home TN BT Modify Pharmacy HVAC System for USP 800 & USP 797 Compliance ................................................. 825 750 750 9 Mountain Home TN BT Replace Facility Condition Assessment Deficient Elevators, Building 160 .......................................... 935 935 935 9 Mountain Home TN BT Renovate CLC Dining Room ................................................................................................................... 968 880 880 9 Mountain Home TN BT Renovate Halls & Walls, Building 200 Phase I .................................................................................... 929 851 851 9 Mountain Home TN BT Correct Facility Condition Assessment Exterior and Structural Deficiencies for Historic Chapel, Bldg 

13.

988 899 899 

9 Mountain Home TN BT Implementation of Electrical Infrastructure Upgrades—Phase 2 ........................................................ 948 862 862 9 Mountain Home TN BT Replace AHU and Upgrade Duct System in Primary Care, Bldg. 160 .................................................. 957 870 870 9 Murfreesboro TN BT Renovate Bathrooms .............................................................................................................................. 896 800 800 9 Murfreesboro TN BT Replace Air Handling Unit 12 ............................................................................................................... 840 750 750 

43 

9 Murfreesboro TN BT Replace Nuclear Medicine Air Handling Unit 4 .................................................................................... 728 650 650 9 Murfreesboro TN BT Upgrade Elevator Building 5 ................................................................................................................. 840 750 750 9 Murfreesboro TN SCIP 2016 Upgrade Security Measures ................................................................................................................... 1,760 1,600 1,600 9 Murfreesboro TN SCIP 2016 Upgrade Corridors and Waiting ............................................................................................................. 1,980 1,800 1,800 9 Murfreesboro TN BT Replace Flooring and Abatement .......................................................................................................... 658 658 658 9 Murfreesboro TN SCIP 2016 Abate Asbestos ...................................................................................................................................... 1,000 900 900 9 Murfreesboro TN SCIP 2018 Renovate Ward 1A ................................................................................................................................. 8,330 833 833 9 Nashville TN BT Cardiology Improvements ....................................................................................................................... 762 680 680 9 Nashville TN BT Replace AHU-3A for Sterile Processing Supply ..................................................................................... 840 750 750 9 Nashville TN BT Reconfigure Sterile Processing Supply Scope Processing ..................................................................... 358 300 300 9 Nashville TN BT Improvements for Surgical Clinic .......................................................................................................... 909 810 810 9 Nashville TN BT Expand Clinical Support ........................................................................................................................ 498 464 464 9 Nashville TN SCIP 2016 Upgrade Public Corridors and Waiting Rooms ...................................................................................... 1,980 1,710 1,710 9 Nashville TN SCIP 2016 Install Boiler System Condensing Economizer ...................................................................................... 1,205 1,105 1,105 9 Nashville TN SCIP 2016 Upgrade Energy Management System Infrastructure ............................................................................ 1,100 990 990 9 Nashville TN SCIP 2016 Upgrade Electrical Distribution ............................................................................................................. 3,300 3,000 3,000 

10 Fort Wayne IN BT Increase Fort Wayne Site Accessibility .................................................................................................. 775 705 705 10 Fort Wayne IN SCIP 2018 Remodel West Wing, 3rd Floor .............................................................................................................. 4,035 404 404 10 Indianapolis IN SCIP 2018 Modify Water Systems for Legionella Prevention .................................................................................. 2,750 275 275 10 Indianapolis IN SCIP 2015 Replace Air Handling Units and Correct Deficiencies .......................................................................... 9,240 8,400 8,400 10 Indianapolis IN BT Install Entrance Gate System ................................................................................................................ 200 175 175 10 Indianapolis IN BT Install A-Wing Reheat Victaulic Fittings ............................................................................................... 687 625 625 10 Indianapolis IN BT Upgrade Fire Suppression System ......................................................................................................... 990 900 900 10 Indianapolis IN BT Reconfigure Waiting Rooms ................................................................................................................... 990 900 900 10 Indianapolis IN SCIP 2015 Upgrade Building 1 for Accessibility ..................................................................................................... 9,900 9,000 9,000 10 Indianapolis IN Pending OOC Renovate Space for Veteran Centered Care .......................................................................................... 1,045 950 950 10 Marion IN SCIP 2017 Renovate 4th Floor, Building 138 ......................................................................................................... 9,600 8,640 8,640 10 Marion IN BT Improve Infrastructure Building 65 ....................................................................................................... 990 990 990 10 Marion IN SCIP 2015 Demolish Buildings 7, 10, 11, 18, 24, 60, 75, CC-2 ........................................................................... 8,800 8,000 8,000 10 Marion IN BT Renovate Atrium, Building 172 ............................................................................................................. 620 564 564 10 Marion IN BT Remodel Medication Rooms, Building 185 ........................................................................................... 307 279 279 10 Marion IN BT Replace Roof, Building 138 ................................................................................................................... 770 700 700 10 Marion IN SCIP 2018 Demolish Buildings 25, 42 and 122, Marion ........................................................................................ 4,537 454 454 10 Ann Arbor MI SCIP 2018 Upgrade Electrical Switchgear and Distribution ................................................................................... 2,200 220 220 10 Ann Arbor MI SCIP 2016 Renovate Intensive Care Units .............................................................................................................. 8,672 7,805 7,805 10 Ann Arbor MI BT Renovate Outpatient Pharmacy for Ambulatory Care Clinics ............................................................... 885 770 770 10 Ann Arbor MI BT Upgrade HVAC for SPS .......................................................................................................................... 945 850 850 10 Ann Arbor MI BT Chiller Plant Optimization ..................................................................................................................... 885 800 800 10 Ann Arbor MI BT Renovate Lab Service ............................................................................................................................ 900 750 750 10 Ann Arbor MI BT Install Gypboard Ceiling in SPS ............................................................................................................ 475 402 402 

44 

Planned 2018 Non-Recurring Maintenance Projects—Continued 

VISN Location ST Project Type Project Name - Short Description 

Total 

Estimated 

Cost 

($000) 

Planned 

FY 2018 

Obs 

($000) 

′′First 

Bite′′ 

($000) 

′′Second 

Bite′′ 

($000) 

10 Battle Creek MI BT Repair Gutters and Downspouts ............................................................................................................ 705 624 624 10 Battle Creek MI SCIP 2015 Install ADA Access, Various Buildings .................................................................................................. 1,971 1,760 1,760 10 Battle Creek MI BT Replace Water Heaters Various Buildings ............................................................................................. 666 555 555 10 Battle Creek MI BT Install Energy Efficient HVAC, B84 ....................................................................................................... 621 550 550 10 Battle Creek MI BT Install Water Monitoring System ........................................................................................................... 572 500 500 10 Battle Creek MI SCIP 2016 Replace Windows, Various Buildings .................................................................................................... 2,528 2,257 2,257 10 Battle Creek MI SCIP 2015 Renovate B83—2 for Patient Privacy ................................................................................................... 5,577 4,979 4,979 10 Battle Creek MI SCIP 2018 Replace Roofs, Various Buildings ......................................................................................................... 2,750 275 275 10 Battle Creek MI SCIP 2018 Correct Water Distribution Deficiencies for Legionella ......................................................................... 4,950 495 495 10 Detroit MI SCIP 2018 Upgrade Fire Alarm Notification System ............................................................................................... 2,750 275 275 10 Detroit MI SCIP 2018 Replace Poz Loc Fire Sprinkler Piping, Phase II ................................................................................... 2,240 224 224 10 Detroit MI SCIP 2016 Install Electrical Switchgear Enclosures ............................................................................................... 6,700 6,000 6,000 10 Detroit MI BT Installation of Simulation Lab for Education ........................................................................................ 500 450 450 10 Detroit MI BT Renovate Hallway A4 and B4 ................................................................................................................ 390 350 350 10 Saginaw MI SCIP 2016 Renovate 3rd Floor Building 1 .............................................................................................................. 6,225 5,600 5,600 10 Saginaw MI SCIP 2015 Pharmacy Renovation ............................................................................................................................ 1,500 1,390 1,390 10 Saginaw MI Pending OOC Medical Center Security and Controls Upgrades .................................................................................. 3,292 3,000 3,000 10 Saginaw MI Pending OOC Building 22 Sprinkler Replacement ....................................................................................................... 1,600 1,500 1,500 10 Saginaw MI SCIP 2015 Electrical Deficiencies and Improvements ............................................................................................ 1,000 875 875 10 Chillicothe OH SCIP 2018 Improve Water System to Reduce Risk of Legionella Contamination and Patient Injury .................... 9,999 1,000 1,000 10 Chillicothe OH BT Renovate Student Housing Buildings 15 and 16 ................................................................................. 988 889 889 10 Chillicothe OH BT Sanitary Sewer inspection and Repair .................................................................................................. 500 425 425 10 Chillicothe OH BT Upgrade IT Infrastructure to Support VoIP Phone System .................................................................... 550 484 484 10 Chillicothe OH OOC Demolish Buildings 2, 6, 10 & 11 ........................................................................................................ 1,300 1,170 1,170 10 Chillicothe OH SCIP 2016 Renovate Building 25 to Improve Efficiency ......................................................................................... 3,720 3,348 3,348 10 Chillicothe OH SCIP 2016 Address and Resolve Hazmat Deficiencies ........................................................................................... 2,860 2,540 2,540 10 Cincinnati OH SCIP 2018 Improve Exhaust System ........................................................................................................................ 4,875 488 488 10 Cincinnati OH SCIP 2018 Replace Hospital Steam Heating Systems, Phase II ............................................................................. 3,355 336 336 10 Cincinnati OH SCIP 2017 Relocate PM&R to Basement of Building #2 ........................................................................................ 1,200 1,072 1,072 10 Cincinnati OH SCIP 2017 Upgrade Water Systems for Legionella and Improve Water Efficiency ................................................. 1,200 1,056 1,056 10 Cincinnati OH BT Upgrade UPS and AC in Computer Room ............................................................................................. 605 550 550 10 Cincinnati OH BT Replace Operating Room Chillers .......................................................................................................... 880 795 795 10 Cincinnati OH BT Install PA Systems in Trailers ............................................................................................................... 242 220 220 10 Cleveland OH SCIP 2018 Replace Air Handling Unit AC-17&18 ................................................................................................... 6,900 690 690 

45 

10 Cleveland OH SCIP 2018 Upgrade Fire Alarm System ................................................................................................................... 4,000 400 400 10 Cleveland OH SCIP 2018 Replace CARES Tower Roof and Repair Overhangs .............................................................................. 5,950 595 595 10 Cleveland OH BT Renovate Boiler Plant Heat Recovery System ....................................................................................... 385 325 325 10 Cleveland OH BT Replace Automatic Transfer Switch 15 in Energy Center ..................................................................... 250 225 225 10 Cleveland OH BT Provide Chiller Plant Automatic Transfer Switch .................................................................................. 275 250 250 10 Cleveland OH BT Consolidate Chaplain Services .............................................................................................................. 440 400 400 10 Cleveland OH BT Expand Emergency Department Parking Area ....................................................................................... 440 400 400 10 Columbus OH BT Remodel Pharmacy IV Prep Room- FCA ................................................................................................ 915 800 800 10 Columbus OH BT Add Domestic Water Pressure Booster .................................................................................................. 208 190 190 10 Columbus OH BT Construct temporary chiller connection ................................................................................................. 510 464 464 10 Columbus OH SCIP 2015 Construct Chiller Plant .......................................................................................................................... 9,100 8,190 8,190 10 Columbus OH BT Increase Size of Smoking Shelter .......................................................................................................... 100 90 90 10 Columbus OH BT Expand Existing Emergency Distribution Panel Board and Add Cooling to Substation Room ............ 783 712 712 10 Dayton OH SCIP 2018 Renovate Laboratory, Building 310 ....................................................................................................... 8,602 860 860 10 Dayton OH SCIP 2018 Renovate Infrastructure for National Historical Archives, Building 116 .............................................. 4,400 440 440 10 Dayton OH SCIP 2018 Renovate TCU/ICU Space ....................................................................................................................... 4,950 495 495 10 Dayton OH SCIP 2016 Improve Campus Access and Security .................................................................................................. 4,500 4,100 4,100 10 Dayton OH BT Correct Arc Flash Deficiencies ............................................................................................................... 438 393 393 10 Dayton OH SCIP 2017 Renovate B410 East Wing ..................................................................................................................... 4,400 3,660 3,660 12 Chicago IL BT Renovate Sterile Processing .................................................................................................................. 970 900 900 12 Chicago IL SCIP 2016 Remodel Patient Admitting .................................................................................................................... 3,750 3,500 3,500 12 Chicago IL BT Replace Fire Pump Controller in Building #1-Damen ........................................................................... 210 185 185 12 Chicago IL BT Replace ATS for Elevators in Building #1-Damen ................................................................................ 185 135 135 12 Danville IL SCIP 2017 Remediate Legionella Station Wide Phase 1 ........................................................................................ 4,087 3,700 3,700 12 Danville IL BT Building 98 Exterior Ductwork Insulation .............................................................................................. 178 178 178 12 Danville IL SCIP 2014 Renovate 58-5 Endoscopy Suite ............................................................................................................ 1,871 1,750 1,750 12 Danville IL BT Legionella Continuous Temperature Monitoring System ....................................................................... 160 160 160 12 Danville IL BT Demolish Quarters 31, 32, 33 ............................................................................................................... 600 450 450 12 Hines IL BT Remodel Resident Kitchen, Bldg. 221 ................................................................................................... 56 50 50 12 Hines IL SCIP 2017 Legionella Suppression—Task Order #1 ............................................................................................... 3,450 3,000 3,000 12 Hines IL BT Install Patient Lifts, Multiple Locations ................................................................................................ 522 381 381 12 Hines IL BT Correct HVAC Central Supply and Storage Rooms ................................................................................ 598 500 500 12 Hines IL Pending OOC Upgrade Chilled Water System, Bldg. 200 ............................................................................................ 9,914 9,013 9,013 12 North Chicago IL SCIP 2018 Upgrade Water Distribution System ...................................................................................................... 6,500 650 650 12 North Chicago IL SCIP 2018 Improve Facility Accessibility ................................................................................................................. 4,815 482 482 12 North Chicago IL BT Construct Hemodialysis Area Building 133 ........................................................................................... 275 250 250 12 North Chicago IL BT Renovate Occupational Health Bldg 133 .............................................................................................. 330 300 300 12 North Chicago IL BT Oncology Renovation USP 800 Requirement ......................................................................................... 330 300 300 12 North Chicago IL BT Building 135 HR Renovation ................................................................................................................. 165 150 150 12 North Chicago IL SCIP 2017 Facility Roofs ......................................................................................................................................... 3,300 3,300 3,300 

46 

Planned 2018 Non-Recurring Maintenance Projects—Continued 

VISN Location ST Project Type Project Name - Short Description 

Total 

Estimated 

Cost 

($000) 

Planned 

FY 2018 

Obs 

($000) 

′′First 

Bite′′ 

($000) 

′′Second 

Bite′′ 

($000) 

12 North Chicago IL BT Chilled Water Efficiency Part 2 ............................................................................................................. 900 900 900 12 North Chicago IL BT Prosthetics Renovation .......................................................................................................................... 550 500 500 12 North Chicago IL SCIP 2017 Renovate Building 131-4 ‘‘A’’ Wing ...................................................................................................... 1,100 1,100 1,100 12 North Chicago IL OOC Renovate Audiology ................................................................................................................................ 1,320 1,200 1,200 12 North Chicago IL OOC Replace Chiller #5 ................................................................................................................................. 1,650 1,500 1,500 12 North Chicago IL CSI Construct Space for 1.5T MRI ............................................................................................................... 3,969 3,500 3,500 12 North Chicago IL BT Modify Chilled Water System Valves ..................................................................................................... 500 500 500 12 North Chicago IL BT Construct Misc Catwalks ....................................................................................................................... 120 120 120 12 North Chicago IL BT Repair Misc. Fire Suppression Systems in Various Bldgs .................................................................... 50 50 50 12 North Chicago IL OOC ATFP Measures—Gates and Fencing .................................................................................................... 3,000 300 300 12 North Chicago IL BT Expand Police Area Bldg. 133 ............................................................................................................... 220 20 20 12 Iron Mountain MI BT Install Server Room AHU ....................................................................................................................... 170 150 150 12 Iron Mountain MI BT Upgrade OPC Heat Exchangers ............................................................................................................. 255 225 225 12 Iron Mountain MI BT HVAC Pressurization Study .................................................................................................................... 638 600 600 12 Iron Mountain MI SCIP 2017 Install Potable Water Mixing Valves and Control Upgrades ................................................................. 1,330 1,250 1,250 12 Iron Mountain MI Pending OOC Renovate 5 West .................................................................................................................................... 2,000 1,850 1,850 12 Madison WI OOC Renovate 3B for Inpatient Ward ............................................................................................................ 4,918 4,500 4,500 12 Madison WI SCIP 2015 Renovate 3A/3C ..................................................................................................................................... 6,146 5,246 5,246 12 Madison WI SCIP 2018 Renovate 4B ........................................................................................................................................... 6,550 655 655 12 Milwaukee WI Pending OOC 112 Replace (3) Boilers ......................................................................................................................... 9,900 9,000 9,000 12 Milwaukee WI SCIP 2016 Upgrade HVAC V9, S1, S4 in Bldg 111 ................................................................................................ 7,260 6,600 6,600 12 Milwaukee WI BT Replace Refrigerant Units Various Locations ........................................................................................ 285 285 285 12 Milwaukee WI SCIP 2015 Correct FCA Sanitary Deficiencies Grounds Phase 1 ............................................................................ 3,300 3,000 3,000 12 Milwaukee WI BT Upgrade Elevators Buildings 5 and 6 A Wing ...................................................................................... 748 680 680 12 Milwaukee WI SCIP 2016 Replace Security Card Readers and Upgrade Security ......................................................................... 1,552 1,384 1,384 12 Milwaukee WI BT Repair Campus Steam Tunnel and Structural Supports ...................................................................... 500 450 450 12 Milwaukee WI BT Replacement of Structural Floor Slab for Building 43 Dining Room Mental Health ........................... 485 425 425 12 Tomah WI SCIP 2016 Renovate South End of Building 406, 2nd Floor .................................................................................. 2,783 2,530 2,530 12 Tomah WI CSI Construct Warehouse ............................................................................................................................. 4,600 4,250 4,250 15 Marion IL BT Install Ventilation Corrections for Sterile Processing ........................................................................... 150 130 130 15 Leavenworth KS SCIP 2018 Renovate Infrastructure of Laundry Building 153 ................................................................................ 5,000 500 500 15 Leavenworth KS SCIP 2018 Replace Steam/Condensate Lines throughout the facility .................................................................... 2,650 265 265 15 Topeka KS SCIP 2017 Renovate Bldg 6, Wing B of Existing CLC ............................................................................................ 4,990 4,456 4,456 15 Topeka KS OOC Renovate Space For VA Call Center At Fort Riley For VHA Member Services ...................................... 9,000 8,100 8,100 

47 

15 Topeka KS BT Upgrade Oncology For Pharmacy—Topeka ........................................................................................... 390 350 350 15 Topeka KS BT Relocate Gastrointestinal Laboratory ..................................................................................................... 899 800 800 15 Topeka KS BT Repair Boiler Plant Chimney ................................................................................................................. 360 320 320 15 Topeka KS BT Repair Surgery Ventilation System and Connect to Emergency Power ................................................. 625 550 550 15 Wichita KS CSI Construct Substance Abuse Residential Rehabilitation Treatment Building 59 .................................. 4,730 4,300 4,300 15 Wichita KS BT Correct Mechanical Deficiencies, Building 26 ...................................................................................... 500 450 450 15 Columbia MO BT Replace Air Handler (AC -S2) ................................................................................................................ 880 800 800 15 Columbia MO BT Renovate Vacated Surgery, Ward 6 ....................................................................................................... 890 800 800 15 Kansas City MO BT Replace Central Boiler Plant Control System ........................................................................................ 900 800 800 15 Kansas City MO BT Replace Building 26 Roof ...................................................................................................................... 500 475 475 15 Kansas City MO BT Extend Chilled Water Loop Building 15 and 26 ................................................................................... 900 800 800 15 Kansas City MO CSI Expand Outpatient Mental Health Clinic ............................................................................................... 2,200 2,000 2,000 15 Poplar Bluff MO OOC Replace Boilers, Building 7 ................................................................................................................... 3,000 2,700 2,700 15 Poplar Bluff MO SCIP 2017 Replace Station 518,000 Volt Amps Electrical Life Safety Generator .................................................. 1,315 1,206 1,206 15 Poplar Bluff MO BT Create Exterior Secure Storage Area ..................................................................................................... 250 200 200 15 Poplar Bluff MO BT Correct Legionella Deficiencies Phase 1 ............................................................................................... 900 810 810 15 St. Louis MO OOC Renovate Operating Rooms and Support Spaces ................................................................................. 6,120 5,943 5,943 15 St. Louis MO CSI Demolish Sextro Warehouse, John Cochran Division ............................................................................. 4,100 4,000 4,000 15 St. Louis MO BT Prepare Site for X-Ray Units ................................................................................................................. 640 640 640 16 Fayetteville AR SCIP 2018 Renovate B9 Laundry ............................................................................................................................. 1,925 193 193 16 Fayetteville AR SCIP 2018 Replace Eaves, Soffit, Integral Gutters and Fascia, Multiple Buildings .............................................. 1,855 186 186 16 Fayetteville AR BT Replace Primary Care Elevator Controls ............................................................................................... 80 80 80 16 Little Rock AR SCIP 2016 Provide 100% Emergency Power ........................................................................................................... 9,900 9,000 9,000 16 Little Rock AR SCIP 2018 Develop Private/Semi-Private Bed Spaces ............................................................................................ 8,360 836 836 16 Alexandria LA SCIP 2016 Emergency Generator Replacement ....................................................................................................... 4,950 600 600 16 Shreveport LA SCIP 2018 Correct Electrical Deficiencies, Building 1 ............................................................................................ 7,300 730 730 16 Shreveport LA SCIP 2018 Abate Central Chase/Replace Fire Main Risers .................................................................................... 1,320 132 132 16 Shreveport LA BT Renovate Morgue, Building 1 ................................................................................................................ 407 370 370 16 Shreveport LA SCIP 2017 Replace Primary Switch Gear ................................................................................................................ 1,557 1,410 1,410 16 Jackson MS OOC Renovate Ground Floor Community Living Center—Bldg. 7 ................................................................ 8,505 7,667 7,667 16 Jackson MS BT Continuous Monitoring of Potable Water Engineering Controls ............................................................ 200 200 200 16 Jackson MS BT Replace Cable TV System ...................................................................................................................... 150 150 150 16 Jackson MS BT Repair Employee Parking Lot Area I ...................................................................................................... 550 550 550 16 Jackson MS OOC Upgrade HVAC System 9B ..................................................................................................................... 5,335 4,850 4,850 16 Jackson MS BT Upgrade Auto Transfer Switches/Emergency Generator Control Units ................................................. 935 850 850 16 Oklahoma City OK SCIP 2018 Renovate Pharmacy for Chapter 797/800 Compliance ......................................................................... 1,760 176 176 16 Oklahoma City OK SCIP 2018 Correct Domestic Hot Water Distribution System Deficiencies ............................................................. 1,980 198 198 16 Oklahoma City OK SCIP 2018 Renovate to Separate OIT and Engineering Closets ............................................................................. 1,878 188 188 16 Oklahoma City OK SCIP 2018 Renovate 6 North for Patient Privacy .................................................................................................... 2,715 272 272 16 Houston TX SCIP 2018 Renovation of Pathology and Laboratory- Phase 1 ............................................................................... 6,000 600 600 

48 

Planned 2018 Non-Recurring Maintenance Projects—Continued 

VISN Location ST Project Type Project Name - Short Description 

Total 

Estimated 

Cost 

($000) 

Planned 

FY 2018 

Obs 

($000) 

′′First 

Bite′′ 

($000) 

′′Second 

Bite′′ 

($000) 

16 Houston TX Pending OOC Replace Elevators B-100 ....................................................................................................................... 6,000 5,250 5,250 16 Houston TX SCIP 2017 Renovate/Expand ER Building 100 ........................................................................................................ 6,500 1,800 1,800 17 Amarillo TX SCIP 2016 Replace HVAC Components for Energy Savings Building 28 ............................................................... 3,800 3,500 3,500 17 Amarillo TX SCIP 2016 Replace HVAC Components for Energy Savings Building 1 ................................................................. 2,750 2,000 2,000 17 Amarillo TX BT Repair Medical Air & Vacuum Systems ................................................................................................ 150 150 150 17 Amarillo TX OOC Renovate Building 28 Medical Ward for Privacy .................................................................................. 3,372 3,322 3,322 17 Big Spring TX BT Renovate fifth floor Nursing Station and Corridor ................................................................................ 825 700 700 17 Big Spring TX BT Relocate & Expand Audiology ................................................................................................................ 599 544 544 17 Big Spring TX BT Replace Deficient HVAC Fan Coil Units ................................................................................................ 975 850 850 17 Big Spring TX BT Renovate Street Entrance ...................................................................................................................... 455 400 400 17 Big Spring TX OOC Replace Roofs on Building 1 ................................................................................................................. 3,350 3,200 3,200 17 Big Spring TX BT Construct Restrooms for Education Training Center ............................................................................ 375 300 300 17 Big Spring TX BT Replace Flag Pole .................................................................................................................................. 410 350 350 17 Big Spring TX OOC Renovate Administration for Physical Therapy and Prosthetics ........................................................... 2,530 2,300 2,300 17 Big Spring TX BT Correct Facade Deficiencies .................................................................................................................. 95 50 50 17 Big Spring TX OOC Install Perimeter Fencing Around Campus ............................................................................................ 2,700 2,500 2,500 17 Big Spring TX OOC Upgrade Electrical Panels ..................................................................................................................... 2,250 2,000 2,000 17 Big Spring TX BT Replace HVAC in Bldg 4 & 7 ................................................................................................................ 800 725 725 17 Big Spring TX SCIP 2015 Remove Dead Leg Water Lines in the Facility ...................................................................................... 1,150 1,035 1,035 17 Bonham TX SCIP 2016 Replace HVAC Bldg 1 & 2 ..................................................................................................................... 2,170 2,000 2,000 17 Bonham TX OOC Replace Pipe Support Stands ................................................................................................................ 2,303 2,100 2,100 17 Bonham TX SCIP 2015 Replace Bonham Fire Alarm System ..................................................................................................... 3,200 3,000 3,000 17 Dallas TX BT Roof Top Chiller Pressurized System ..................................................................................................... 874 800 800 17 Dallas TX OOC Renovate Building #60 Bed & Bath Rooms B Wing ............................................................................. 3,600 3,500 3,500 17 Dallas TX BT Correct B.70 Deficiencies ...................................................................................................................... 990 900 900 17 Dallas TX BT Replacing Bldg. 6 & 8 AHU System ...................................................................................................... 550 500 500 17 Dallas TX BT Replace/Repair Roof Bldg.60 ................................................................................................................. 550 500 500 17 Dallas TX OOC Replace Patient Exterior and Interior Signage ...................................................................................... 3,000 3,000 3,000 17 El Paso TX OOC Repair FCA Deficiencies ......................................................................................................................... 1,650 1,500 1,500 17 Harlingen TX OOC Upgrade HVAC ........................................................................................................................................ 2,750 2,500 2,500 17 Harlingen TX OOC Repair Parking Lot Corpus Christi Outpatient Clinic ............................................................................ 550 500 500 17 San Antonio TX BT Activate Emergency Well Water @ ALMD .............................................................................................. 666 600 600 17 San Antonio TX BT Conduct Legionella Study ...................................................................................................................... 440 400 400 17 San Antonio TX SCIP 2016 Replace 1000kw Generator and Fuel Storage Tank .............................................................................. 2,200 2,000 2,000 

49 

17 San Antonio TX SCIP 2018 Replace main switch gear ..................................................................................................................... 2,200 220 220 17 Temple TX Pending OOC Reconfigure Specialty Clinics 4th Floor Teague Tower ......................................................................... 2,838 2,580 2,580 17 Temple TX SCIP 2018 Relocate Mental Health to Dom C-Wing ............................................................................................... 9,686 4,860 4,860 17 Temple TX SCIP 2018 Relocate Mental Health to Dom D-Wing ............................................................................................... 7,578 4,440 4,440 17 Temple TX BT Construct 2nd Cardiac Cath ................................................................................................................. 491 450 450 17 Temple TX OOC Replace Air Handler Units Bldg 163 Tower .......................................................................................... 4,075 3,705 3,705 17 Temple TX SCIP 2017 Convert Bldg 44W to Admin .................................................................................................................. 1,650 1,500 1,500 17 Temple TX OOC Prevention of Legionella—Temple ......................................................................................................... 3,377 3,070 3,070 17 Temple TX OOC Replace Medium Voltage Switchgear .................................................................................................... 3,232 3,000 3,000 17 Waco TX SCIP 2017 Relocate Canteen Bldg 202 ................................................................................................................... 2,299 2,090 2,090 17 Waco TX OOC Upgrade Electrical Secondary Distribution System ............................................................................... 2,200 2,000 2,000 17 Waco TX BT Replace Building 1 HVAC ...................................................................................................................... 817 777 777 17 Waco TX OOC Prevention of Legionella—Waco ............................................................................................................ 2,742 2,493 2,493 19 Denver CO OOC Replace CBS West AHU ......................................................................................................................... 2,321 2,121 2,121 19 Grand Junction CO Pending OOC Energy Audit Finding Corrections .......................................................................................................... 1,118 1,026 1,026 19 Grand Junction CO BT Correct Building 33 FCA Deficiencies ................................................................................................... 229 208 208 19 Grand Junction CO SCIP 2016 Replace AHU 9 AND 10 ......................................................................................................................... 1,680 1,500 1,500 19 Grand Junction CO Pending OOC Ventilate and Expand IT Closets ........................................................................................................... 1,090 1,000 1,000 19 Grand Junction CO SCIP 2017 Replace Boilers and Controls, Phase 2 ................................................................................................. 7,616 7,201 7,201 19 Grand Junction CO Pending OOC Renovate 4E/4W and Upgrade Mechanical AHU ................................................................................... 2,150 1,980 1,980 19 Grand Junction CO SCIP 2013 Elimination of Substandard Beds on 3rd Floor .................................................................................... 3,740 3,400 3,400 19 Grand Junction CO BT DR Site Prep .......................................................................................................................................... 175 160 160 19 Ft Harrison MT SCIP 2017 Replace Penthouse HVAC Systems ........................................................................................................ 2,420 2,150 2,150 19 Ft Harrison MT BT Digital Security Enhancements .............................................................................................................. 935 850 850 19 Ft Harrison MT OOC LED Lighting Phase I ............................................................................................................................. 1,100 990 990 19 Ft Harrison MT SCIP 2017 Building 141 Heating ............................................................................................................................ 1,452 1,280 1,280 19 Muskogee OK BT Replace & Upgrade DW1 Cart Elevator ................................................................................................. 375 375 375 19 Muskogee OK Pending OOC Replace Surveillance System ................................................................................................................. 2,050 1,900 1,900 19 Muskogee OK SCIP 2015 Install Energy Retrofits for Air Handling Units, Controls, and Lighting .............................................. 5,445 4,901 4,901 19 Muskogee OK BT Upgrade Roofing Systems Phase 2 ....................................................................................................... 800 800 800 19 Oklahoma City OK CSI Remodel Cath Labs ............................................................................................................................... 1,450 1,300 1,300 19 Oklahoma City OK SCIP 2016 Renovate 7 East for Patient Privacy ..................................................................................................... 3,215 2,700 2,700 19 Oklahoma City OK SCIP 2016 Renovate Canteen Food Court and Office Suite ................................................................................... 1,628 1,480 1,480 19 Oklahoma City OK SCIP 2016 Increase Electrical Capacity to 9th Floor Server Room ........................................................................ 1,540 1,400 1,400 19 Oklahoma City OK OOC Upgrade Interior Fixed Equipment ......................................................................................................... 2,075 1,850 1,850 19 Oklahoma City OK CSI Site Prep for New 80 Slice CT ............................................................................................................... 660 500 500 19 Salt Lake City UT SCIP 2017 Upgrade Public Address Mass Notification System (PAMNS) ............................................................... 4,750 4,300 4,300 19 Salt Lake City UT BT B.7, B.35, B.37 Research Renovation ................................................................................................... 880 800 800 19 Salt Lake City UT OOC Legionella—Mixing Valves, Schematics, Controls ................................................................................ 1,870 1,700 1,700 19 Salt Lake City UT SCIP 2017 Chilled Water Distribution Line Ph. 6 ................................................................................................... 1,980 1,800 1,800 

50 

Planned 2018 Non-Recurring Maintenance Projects—Continued 

VISN Location ST Project Type Project Name - Short Description 

Total 

Estimated 

Cost 

($000) 

Planned 

FY 2018 

Obs 

($000) 

′′First 

Bite′′ 

($000) 

′′Second 

Bite′′ 

($000) 

19 Salt Lake City UT SCIP 2017 Upgrade Fire Alarms .............................................................................................................................. 1,527 153 153 19 Salt Lake City UT SCIP 2016 Site Electrical Replacement ................................................................................................................... 1,000 100 100 19 Salt Lake City UT SCIP 2016 Solar PV Parking Garage ....................................................................................................................... 4,180 380 380 19 Cheyenne WY SCIP 2016 Improve Facility Security Phase 1 ......................................................................................................... 1,000 988 988 19 Cheyenne WY BT FCA Improve Wayfinding ........................................................................................................................ 135 135 135 19 Cheyenne WY BT Potable Water Improvements ................................................................................................................. 990 900 900 19 Cheyenne WY Pending OOC Renovate Pharmacy & SPS, Phase 2 .................................................................................................... 1,090 90 90 19 Sheridan WY BT Demo 30,34,39 & 83 ............................................................................................................................. 700 700 700 19 Sheridan WY BT Replace O2 Tanks .................................................................................................................................. 580 580 580 19 Sheridan WY Pending OOC Site Prep Sheridan MRI ......................................................................................................................... 1,700 1,700 1,700 19 Sheridan WY BT Porch and Roof Corrections ................................................................................................................... 682 592 592 19 Sheridan WY BT Boiler Upgrade Ph3 ................................................................................................................................ 960 850 850 19 Sheridan WY Pending OOC IT Comm Closet Upgrades Ph 1 ............................................................................................................ 2,080 1,900 1,900 19 Sheridan WY BT Replace B64 Parking Lots ..................................................................................................................... 958 860 860 19 Sheridan WY SCIP 2018 IT Communication Closets Upgrade Phase I ......................................................................................... 2,180 218 218 20 Anchorage AK BT Surgical Suite Steam Humidification System ....................................................................................... 600 520 520 20 Anchorage AK BT Building 100 Site Improvements ........................................................................................................... 440 400 400 20 Boise ID BT Replace Officer’s Row Road .................................................................................................................. 335 300 300 20 Portland OR SCIP 2017 Upgrade and Replace condensate and steam infrastructure (V) ......................................................... 2,750 2,500 2,500 20 Portland OR BT Upgrade Building 18 TLU HVAC ............................................................................................................ 880 800 800 20 Portland OR BT Simulation Lab Relocation ..................................................................................................................... 335 300 300 20 Roseburg OR SCIP 2016 Upgrade Campus Security ..................................................................................................................... 3,300 3,000 3,000 20 Roseburg OR SCIP 2017 Renovate Building 1 to Relocate Short Stay ......................................................................................... 1,936 1,760 1,760 20 Roseburg OR BT Replace Campus PA System .................................................................................................................. 715 650 650 20 Roseburg OR BT Update Wayfinding Signage campus wide ............................................................................................ 980 900 900 20 Roseburg OR BT Replace Nurse Call System Building 81 ............................................................................................... 275 250 250 20 Roseburg OR BT Replace Quonset Huts T6, T7, T8, T15 & T19 ...................................................................................... 832 772 772 20 White City OR SCIP 2016 Renovate Space, Building 210 Upper South for Clinical Areas ........................................................... 2,200 1,980 1,980 20 White City OR SCIP 2016 Retrofit Campus Wide Infrastructure Systems—Water, Sewer, & Storm ............................................. 7,900 7,200 7,200 20 American Lake WA BT Replace Building 148 Boiler .................................................................................................................. 550 500 500 20 American Lake WA BT VCS Coffee Shop in Building 2 ............................................................................................................. 198 143 143 20 American Lake WA OOC Expand Blind Rehabilitation Building 2 ................................................................................................ 1,485 1,376 1,376 20 American Lake WA SCIP 2016 Am Lake Replace Boilers for Energy Efficiency .................................................................................... 3,300 2,970 2,970 20 Seattle WA BT Replace Flooring in B100 First Floor Core/Lobby .................................................................................. 220 200 200 

51 

20 Seattle WA BT Renovate Main Entrance Canopy and Demo Smoking Shelter/Canopy ................................................. 275 250 250 20 Seattle WA BT Replace Ceiling and Flooring in Bldg 23 .............................................................................................. 165 150 150 20 Seattle WA BT Replace Flooring in Bldg 11 OR Rooms and Corridor .......................................................................... 115 100 100 20 Seattle WA BT Renovate Rooms in Bldg 34 for Veterinary Treatment ......................................................................... 286 260 260 20 Seattle WA BT Replace Flooring in Bldg 34 First Floor ................................................................................................ 65 50 50 20 Seattle WA BT Building 1 Sterilizer Installation ........................................................................................................... 385 350 350 20 Seattle WA BT Renovate SCI Bathrooms ....................................................................................................................... 660 600 600 20 Seattle WA BT OR Mechanical Upgrades ...................................................................................................................... 550 500 500 20 Seattle WA SCIP 2015 Renovate and Expand Seattle Sterile Processing Service ..................................................................... 7,797 7,019 7,019 20 Seattle WA BT Replace 2 West Corridor Flooring .......................................................................................................... 115 100 100 20 Seattle WA SCIP 2016 Renovate Seattle B37 First Floor for VA Police ..................................................................................... 1,654 1,489 1,489 20 Seattle WA SCIP 2017 4W Surgical Specialty Care Clinic Expansion ....................................................................................... 4,686 4,296 4,296 20 Seattle WA BT Install Wi-Fi in Patient Areas ................................................................................................................ 825 750 750 20 Seattle WA SCIP 2018 Replace Roofs—Seattle VA ................................................................................................................... 4,675 468 468 20 Spokane WA CSI Site Prep for Nuke Med SPECT/CT ......................................................................................................... 660 630 630 20 Spokane WA BT Demolish Building 32 ............................................................................................................................ 60 50 50 20 Spokane WA CSI Site Prep for MRI Replacement ............................................................................................................. 250 200 200 20 Spokane WA SCIP 2015 Correct Electrical and Communication Infrastructure Deficiencies ...................................................... 3,900 3,510 3,510 20 Spokane WA BT Install Hot Water Recirculation Loop for Acute Psychiatric Unit .......................................................... 495 450 450 20 Spokane WA BT CLC Remodel and Portico ...................................................................................................................... 714 650 650 20 Spokane WA BT Replace Elevators in Bldg 1 and 27 ..................................................................................................... 990 900 900 20 Spokane WA SCIP 2016 Replace Boiler Plant .............................................................................................................................. 11,000 9,900 9,900 20 Walla Walla WA BT Replace Steam Traps ............................................................................................................................. 440 400 400 21 Fresno CA BT Repair Mechanical Systems, Building 1 Sub-Basement ....................................................................... 755 700 700 21 Fresno CA BT Remodel ED for Observation Beds ........................................................................................................ 550 200 200 21 Fresno CA CSI Expand Mental Health Center, Building 27 .......................................................................................... 4,950 4,540 4,540 21 Fresno CA SCIP 2016 Expand Chilled Water Capacity ............................................................................................................. 9,600 8,800 8,800 21 Fresno CA BT Install Skytron Ceiling Mount Booms in Surgical Suite, 3rd Floor, Building 1 .................................... 375 300 300 21 Fresno CA BT Install USP800 Chemo Compounding Room, 3rd Floor, Building 24 ................................................... 410 360 360 21 Fresno CA BT Remodel Building 24, 1st Floor ............................................................................................................. 990 800 800 21 Fresno CA SCIP 2018 Renovate Outpatient Clinic Basement for Emergency Department Observation Bed Suite ................. 5,010 501 501 21 Livermore CA BT Repair Main Water Line, LVD ................................................................................................................ 65 65 65 21 Martinez CA BT Renovate Outpatient Clinic Office Space, Building 778, Fairfield ....................................................... 880 800 800 21 Martinez CA SCIP 2014 Correct Campus Security Deficiencies and Renovate for Sterile Storage Supply ................................ 2,000 1,800 1,800 21 Martinez CA Pending OOC Investigate Seismic Capacity Building 21 ............................................................................................ 3,100 100 100 21 Menlo Park CA BT Renovate Tele radiology, Bldg 334 ........................................................................................................ 870 800 800 21 Palo Alto CA OOC Create 60kV Substation and Infrastructure .......................................................................................... 30,000 30,000 30,000 21 Palo Alto CA BT Expand Emergency Preparedness Capabilities, PAD Campus .............................................................. 550 500 500 21 Palo Alto CA BT Construct Bump Out for Major Construction Team .............................................................................. 550 500 500 21 Palo Alto CA BT Create Surface Parking at Stockton ...................................................................................................... 800 750 750 

52 

Planned 2018 Non-Recurring Maintenance Projects—Continued 

VISN Location ST Project Type Project Name - Short Description 

Total 

Estimated 

Cost 

($000) 

Planned 

FY 2018 

Obs 

($000) 

′′First 

Bite′′ 

($000) 

′′Second 

Bite′′ 

($000) 

21 Palo Alto CA SCIP 2017 Construct Consolidated Fisher House Central Reception Building ....................................................... 3,575 2,300 2,300 21 Palo Alto CA SCIP 2015 Replace Chillers in Building 100 .......................................................................................................... 4,824 4,000 4,000 21 Palo Alto CA SCIP 2013 Improve Emergency Sustainment capabilities -South Campus Generator ........................................... 2,788 2,600 2,600 21 Palo Alto CA BT Create Additional Patient & Staff Parking at PAD ............................................................................... 950 850 850 21 Sacramento CA BT Renovate for Clean Room Expansion, Building 652 ............................................................................. 560 500 500 21 San Francisco CA BT Upgrade Sanitary System on East Side of Campus ............................................................................. 990 890 890 21 San Francisco CA Pending OOC Replace Building 3, 200 Chillers, insulate ductwork ........................................................................... 2,076 1,750 1,750 21 San Francisco CA OOC Replacement of Bldg. 200 Roof System ............................................................................................... 1,500 1,500 1,500 21 San Francisco CA SCIP 2015 Renovate and Consolidate Clinical Programs on the Ground Floor of the Main Hospital .................. 3,685 3,500 3,500 21 San Francisco CA OOC Renovate and Upgrade Patient Restrooms in Bldgs 200 and 203 ...................................................... 1,500 1,200 1,200 21 San Francisco CA BT Correct Non-structural Components of B. 200 and 203 ...................................................................... 700 700 700 21 San Francisco CA CSI Site Preparation for Bi-Plane ................................................................................................................ 1,000 1,000 1,000 21 Honolulu HI BT Renovate Pharmacy ............................................................................................................................... 700 600 600 21 Honolulu HI BT Finish Parking Structure Basement ....................................................................................................... 558 475 475 21 Honolulu HI BT Replace Fire Alarm Panels .................................................................................................................... 575 575 575 21 Honolulu HI BT Upgrade Center For Aging HVAC System .............................................................................................. 990 990 990 21 Honolulu HI BT Install Real-time Water Monitoring System—Legionella ...................................................................... 235 175 175 21 Las Vegas NV Pending OOC CLC Patient Lift Installation .................................................................................................................. 1,757 1,757 1,757 21 Las Vegas NV SCIP 2017 Modify Main Entrances in Building 1 ................................................................................................... 1,841 1,690 1,690 21 Las Vegas NV BT Back Up Cooling System for Critical Care Areas .................................................................................. 879 790 790 21 Las Vegas NV BT Environmental Controls and Monitoring ................................................................................................ 572 520 520 21 Las Vegas NV SCIP 2017 Water Line Improvement/Bypass ........................................................................................................... 1,950 960 960 21 Las Vegas NV OOC Radiology and Surgical UPS .................................................................................................................. 2,114 1,995 1,995 21 Las Vegas NV OOC Stairwell Safeguards .............................................................................................................................. 1,540 1,400 1,400 21 Reno NV BT MRI Upgrade Site Prep .......................................................................................................................... 400 400 400 21 Reno NV BT Upgrade Mental Health Interlocking Doors (Study) ............................................................................... 253 200 200 21 Reno NV BT Demolish Buildings 15, 138, F and K ................................................................................................... 646 600 600 21 Reno NV BT Convert Room for Blood Draw ............................................................................................................... 15 15 15 21 Reno NV SCIP 2017 Expand Emergency Power Capacity at the Boiler Plant ....................................................................... 1,390 1,300 1,300 21 Reno NV SCIP 2018 Replace damaged piping in clinical Building 1D. ................................................................................ 5,500 550 550 21 Reno NV SCIP 2018 Repair critical electrical deficiencies in Clinical Building 1D ............................................................. 3,850 385 385 22 Phoenix AZ CSI Renovate and Expand Women’s Health Clinic ...................................................................................... 4,400 4,000 4,000 22 Phoenix AZ SCIP 2018 Replace AHUs at CLC and Main Building ............................................................................................. 3,300 330 330 22 Phoenix AZ SCIP 2016 Renovate Inpatient Ward 2C ................................................................................................................. 4,504 4,104 4,104 

53 

22 Phoenix AZ OOC Renovate 6D for Inpatient Ward ............................................................................................................ 4,000 3,600 3,600 22 Phoenix AZ BT OI&T Electrical Upgrades ....................................................................................................................... 990 900 900 22 Phoenix AZ Pending OOC Remodel Dietetics Kitchen ..................................................................................................................... 3,411 3,029 3,029 22 Phoenix AZ SCIP 2016 Site Stormwater Correction .................................................................................................................... 1,760 1,600 1,600 22 Prescott AZ SCIP 2014 Perform Retro-commissioning and Repair of Building Control Systems .............................................. 825 750 750 22 Prescott AZ SCIP 2016 Repair/Resurface Roads, Ph 4 .............................................................................................................. 1,107 992 992 22 Prescott AZ Pending OOC Renovate Buildings 12-17 (Thermal Envelope) ..................................................................................... 1,400 1,300 1,300 22 Prescott AZ BT Replace Heating Systems for Outer Buildings, Phase 1 ...................................................................... 940 880 880 22 Prescott AZ OOC Repair/Replace Main Steam Riser from Boiler Plant ............................................................................ 1,050 900 900 22 Tucson AZ BT Replace Air Handlers (B60) ................................................................................................................... 990 900 900 22 Tucson AZ BT Correct Safety Deficiencies, B4 ............................................................................................................. 401 350 350 22 Tucson AZ SCIP 2017 Legionella DOM Water Loop Repairs, B-30 & B-67 .............................................................................. 1,200 950 950 22 Tucson AZ OOC Renovate for Pathology Morgue and IT, B-38 Basement ...................................................................... 2,420 2,200 2,200 22 Tucson AZ OOC Replace Air Handling Units for Critical Care and Sterile Processing .................................................. 3,300 3,000 3,000 22 Tucson AZ OOC Upgrade Information Technology Server Room ...................................................................................... 1,815 1,650 1,650 22 Tucson AZ OOC Replace Ancillary Boiler Plant Equipment & Controls .......................................................................... 1,430 1,345 1,345 22 Tucson AZ BT Replace SPS and Logistics Dumbwaiters (B-57) .................................................................................. 655 600 600 22 Loma Linda CA BT Renovate 4SW Bathrooms ...................................................................................................................... 880 800 800 22 Loma Linda CA BT Correct Steam Distribution Deficiencies ................................................................................................ 801 720 720 22 Loma Linda CA BT Renovate Stairwells ............................................................................................................................... 600 550 550 22 Loma Linda CA SCIP 2016 Replace Main Stormwater, Waste & Vent Piping .................................................................................. 3,000 2,700 2,700 22 Loma Linda CA SCIP 2018 Correct Environmental Controls & Security Deficiencies in IT rooms .................................................. 2,500 250 250 22 Long Beach CA SCIP 2015 Physical Security Access Control ........................................................................................................... 1,650 880 880 22 Long Beach CA OOC Correct Carpet-Wall Finish Deficiency B150 SCI .................................................................................. 3,960 3,600 3,600 22 Long Beach CA SCIP 2012 Install Emergency Management Generator, Phase 2 ............................................................................ 5,498 5,000 5,000 22 Long Beach CA OOC B126OP Basement-Correct FCA Deficiencies and Remodel .................................................................. 4,015 3,650 3,650 22 Long Beach CA SCIP 2016 B126 Renovate & Upgrade Hemodialysis Infrastructure ...................................................................... 4,950 4,455 4,455 22 Long Beach CA BT Metasys System ..................................................................................................................................... 800 720 720 22 Long Beach CA SCIP 2018 Correct Legionella Deficiencies—Bldg 1 .............................................................................................. 4,400 440 440 22 Long Beach CA SCIP 2018 Correct Electrical Site Security Deficiencies ......................................................................................... 5,203 520 520 22 Long Beach CA SCIP 2018 Renovate ICU Bldg 126 3rd Floor ......................................................................................................... 6,600 660 660 22 Long Beach CA SCIP 2018 Renovate Bldg 126 8th Floor North for Private/Semi Private Beds ..................................................... 9,200 920 920 22 Los Angeles CA BT Replace Fire Alarm System in LAACC ................................................................................................... 910 821 821 22 Los Angeles CA SCIP 2018 Replace Water Main and Valves ........................................................................................................... 3,795 380 380 22 San Diego CA SCIP 2016 Bldg 2 Remodel- Emergency Bus &Switchgear Modifications ............................................................. 9,020 8,200 8,200 22 San Diego CA SCIP 2017 Emergency Department Exterior Access & Signage .............................................................................. 2,310 2,100 2,100 22 Sepulveda CA SCIP 2016 Upgrade Information Technology Closets Sepulveda ............................................................................ 1,650 1,500 1,500 22 West Los Angeles CA BT Replace B158 Fire Alarm ....................................................................................................................... 770 700 700 22 West Los Angeles CA SCIP 2016 Upgrade Information Technology Closets WLA North Campus Six Buildings ....................................... 1,500 1,350 1,350 22 Albuquerque NM OOC Abate Asbestos B-41 ............................................................................................................................. 1,760 1,600 1,600 

54 

Planned 2018 Non-Recurring Maintenance Projects—Continued 

VISN Location ST Project Type Project Name - Short Description 

Total 

Estimated 

Cost 

($000) 

Planned 

FY 2018 

Obs 

($000) 

′′First 

Bite′′ 

($000) 

′′Second 

Bite′′ 

($000) 

22 Albuquerque NM OOC Install Legionella Corrections ................................................................................................................ 2,500 2,250 2,250 23 Des Moines IA SCIP 2015 Design/Construct Security Gates ........................................................................................................... 1,660 1,500 1,500 23 Des Moines IA BT Repair Roads/Walks for Safety .............................................................................................................. 820 672 672 23 Des Moines IA SCIP 2016 Upgrade OR Chilled Water Cooling System ........................................................................................... 1,756 800 800 23 Des Moines IA SCIP 2016 Install New Emergency Generator System ............................................................................................. 1,900 1,750 1,750 23 Des Moines IA CSI Site Prep to Replace Two CTs ............................................................................................................... 1,080 930 930 23 Des Moines IA SCIP 2015 Upgrade Existing and Construct New Elevators ................................................................................... 3,990 3,600 3,600 23 Des Moines IA SCIP 2018 Renovate and Expand Primary Care Infusion and Oncology Center ..................................................... 1,240 124 124 23 Iowa City IA Pending OOC Replace Deficient Mechanical Systems (AHU) ...................................................................................... 2,200 2,000 2,000 23 Iowa City IA SCIP 2017 Modernize Existing Chillers .................................................................................................................... 3,850 3,450 3,450 23 Iowa City IA SCIP 2015 Replace Defective Steam Traps and Correct Condensate Over pressurization .................................... 6,100 5,500 5,500 23 Iowa City IA OOC Upgrade and Expand Hospital Security Systems .................................................................................. 2,250 2,050 2,050 23 Iowa City IA OOC Correct Life Safety Deficiencies ............................................................................................................. 9,900 9,000 9,000 23 Minneapolis MN SCIP 2018 Renovate Outpatient Mental Health (1L) .............................................................................................. 4,300 430 430 23 Minneapolis MN SCIP 2018 Recommission of Main Hospital HVAC Systems ................................................................................... 1,000 100 100 23 Minneapolis MN CSI Site Prep—Multi-Site DR Rooms .......................................................................................................... 5,000 4,000 4,000 23 Minneapolis MN SCIP 2017 Construct Clinical Research Wings ....................................................................................................... 3,300 3,000 3,000 23 Minneapolis MN CSI Upgrade Cath Labs 2 and 3 ................................................................................................................. 2,200 2,000 2,000 23 Minneapolis MN SCIP 2016 Renovate Inpatient Mental Health ......................................................................................................... 2,600 2,300 2,300 23 St Cloud MN SCIP 2018 Renovate Primary Care Clinic Building 4 ............................................................................................. 8,203 820 820 23 St. Cloud MN SCIP 2016 Renovate Building 4 Basement for Sterile Processing Services and Sterile Processing and Distribution. 7,150 6,500 6,500 23 St. Cloud MN SCIP 2017 Relocate Rehab Functions ..................................................................................................................... 6,204 564 564 23 St. Cloud MN SCIP 2016 Upgrade Information Technology Closets for Security .......................................................................... 4,965 4,500 4,500 23 St. Cloud MN OOC Install Ground Source Heat Pump System for Building 28 .................................................................. 5,433 5,000 5,000 23 St. Cloud MN SCIP 2016 Renovate Building 4 East Side for Women’s Clinic .............................................................................. 2,900 2,636 2,636 23 St. Cloud MN SCIP 2015 Renovate Building 2, First Floor for Residential Rehabilitation Therapy Program .............................. 4,987 4,545 4,545 23 St. Cloud MN SCIP 2014 Replace Windows, Buildings 4, 8 & 9 .................................................................................................. 1,580 1,500 1,500 23 Fargo ND CSI Perform Site Prep for Urology Equipment in OR #4 ............................................................................. 316 287 287 23 Fargo ND BT Install Instrument Air and RO Water in SPS ........................................................................................ 202 182 182 23 Fargo ND BT Replace N&FS Ceiling System ............................................................................................................... 220 200 200 23 Fargo ND SCIP 2015 Renovate 2nd Floor Bldg 46 for Medical Specialties ........................................................................... 2,640 2,400 2,400 23 Fargo ND SCIP 2017 Replace Boiler Plant .............................................................................................................................. 8,250 7,500 7,500 23 Fargo ND SCIP 2017 Renovate Bldg 1 First Floor for PT/OT and Prosthetics ........................................................................ 4,840 4,400 4,400 

55 

23 Omaha NE BT Construct SPS Scope Processing Area .................................................................................................. 206 186 186 23 Omaha NE SCIP 2016 Construct Central Energy Plant ............................................................................................................. 36,027 35,640 35,640 23 Omaha NE BT Replace Overhead Paging Systems—Omaha and Grand Island .......................................................... 30 30 30 23 Fort Meade SD BT Upgrade Boiler Plant Automation Equipment ....................................................................................... 330 300 300 23 Fort Meade SD SCIP 2016 Renovate and Consolidate Inpatient Function Building 113 ................................................................ 7,490 6,590 6,590 23 Fort Meade SD SCIP 2016 Relocate Sterile Processing Service and Endoscopy ............................................................................. 5,265 4,778 4,778 23 Hot Springs SD BT Canteen Entry Upgrades Design ............................................................................................................ 175 150 150 23 Sioux Falls SD BT Electrical and Fire Suppression Upgrades ............................................................................................ 700 500 500 23 Sioux Falls SD SCIP 2015 Renovate 5th Floor Surgery ................................................................................................................... 3,909 3,519 3,519 23 Sioux Falls SD Pending Mechanical Upgrades ............................................................................................................................ 2,200 200 200 

Various Various Below Threshold/Urgent Projects ........................................................................................................... 121,374 121,374 

Total VHA Planned NRM Projects ............................................................................................. 2,549,939 1,870,000 600,000 1,270,000 

56 

Question 17. Please provide a list of the projects and their associated funding levels included in the $862 million for the activation of new and enhanced health care 

facilities. Specifically break out the additional projects included in the $364 million 

‘‘second bite’’ for 2018 advance appropriations. 

Response. See attached list of projects. 

Planned 2018 Non-Recurring Maintenance Projects 

VISN Project Name FY 2018 

New or Replacement? 

Actual or Esti- mated Construction 

Completion/ 

Lease Acceptance Date 

1 Boston, MA—Community-Based Outpatient Clinic Lease ........ $7,945,835 Replacement 7/31/2018 

2 Syracuse, NY—Spinal Cord Injury ............................................. $986,452 Replacement 6/1/2013 

2 Brick, NJ—Community-Based Outpatient Clinic ....................... $10,986,303 Replacement 6/1/2020 

2 Manhattan, NY—Hospital Restoration and Renovation ............ $1,819,563 Replacement 10/31/2019 

2 Canandaigua, NY—New Construction and Renovation 

Phase 1.

$3,890,735 Replacement 1/31/2023 

2 Rochester, NY—Health Care Center—Major Lease .................. $13,614,553 Replacement 9/30/2019 

4 Butler, PA—Health Care Center Lease ..................................... $1,398,248 New 6/12/2017 

5 Perry Point, MD—Replacement Long Term Care ...................... $1,200,000 Replacement 7/31/2021 

6 Fayetteville, NC—Health Care Center Lease ............................. $12,489,421 New 9/30/2016 

6 Charlotte, NC—Health Care Center Lease ................................ $27,008,337 New 2/28/2016 

6 Winston-Salem, NC—Health Care Center Lease ....................... $28,702,513 New 12/31/2015 

7 Expand Cobb City, AL—Community-Based Outpatient Clinic .. $7,599,157 New 6/1/2020 

7 Birmingham, AL—Clinical Annex/Outpatient Clinic Lease ....... $4,884,076 New 7/31/2015 

7 Huntsville, AL—Outpatient Clinic Lease ................................... $5,590,275 Replacement 12/15/2015 

7 Savannah, GA—Community-Based Outpatient Clinic Lease .... $9,058,563 Replacement 2/1/2017 

8 New Port Richey, FL—Lease Consolidation ............................... $2,311,438 Replacement 6/1/2020 

8 Bay Pines, FL—Mental Health/Inpatient-Outpatient Improvements.$8,329,187 Replacement 8/30/2020 

8 Tallahassee, FL—Outpatient Clinic Lease ................................ $21,491,622 Replacement 7/31/2016 

8 Brandon (South Hillsborough), FL—Outpatient Clinic (Tampa) 

Lease.

$20,946,907 New 10/1/2018 

8 Orlando, FL—New Medical Facility ........................................... $63,549,984 New 11/30/2015 

8 Tampa, FL—Polytrauma and New Bed Tower ........................... $36,230,637 New 1/31/2021 

9 Louisville, KY—Replacement Med Center/Regional Office ....... $1,195,634 Replacement 1/6/2023 

10 Terre Haute, IN—Health Care Center ........................................ $200,000 Replacement 2/1/2022 

10 St Joseph County VA Clinic, IN—Outpatient Clinic .................. $26,100,912 New 10/31/2017 

12 Green Bay, WI—Health Care Center ......................................... $37,326,024 Replacement 8/10/2015 

15 St. Louis, MO—Med Facility Improve & Expansion .................. $5,951,843 Replacement 11/15/2018 

15 St. Louis, MO—Clinic ................................................................ $773,726 Replacement 10/31/2017 

15 Cape Girardeau, MO—Clinic Expansion .................................... $773,726 Replacement 5/31/2019 

16 Mobile, AL—Outpatient Clinic Lease ........................................ $8,332,515 Replacement 12/1/2018 

16 Biloxi, MS—Building 1 & 2 Renovation .................................... $3,240,933 Replacement 5/31/2018 

16 New Orleans, LA—Restoration/Replacement Medical Facility .. $134,346,907 Replacement 2/28/2018 

16 Springfield, MO CBOC ................................................................ $23,256,953 New 6/30/2018 

16 Lafayette, LA—Outpatient Clinic Lease .................................... $4,864,834 New 9/30/2016 

17 San Antonio, TX—Polytrauma Renovation Project .................... $6,931,830 Replacement 12/31/2013 

17 McAllen, TX—Outpatient Clinic ................................................. $17,059,566 New 4/28/2014 

19 Missoula, MT—CBOC Lease ...................................................... $95,736 Replacement 1/31/2022 

19 Denver, CO—Replacement Medical Center Facility .................. $87,487,356 Replacement 7/1/2018 

20 American Lake, WA—Seismic Corrections of Building 81 ........ $240,000 Replacement 9/4/2023 

20 Seattle, WA—B101 Mental Health ............................................ $1,857,268 Replacement 3/22/2018 

20 Walla Walla, WA—New OPC and Renovation 86 ...................... $1,100,000 Replacement 1/6/2020 

20 East Portland, OR—Community Based Outpatient Clinic ........ $3,074,444 Replacement 8/1/2016 

20 Eugene, OR—Community-Based Outpatient Clinic Lease ........ $6,541,941 Replacement 12/31/2015 

20 Seattle, WA—Correct Seismic Deficiencies B100 ..................... $80,000 Replacement 5/19/2016 

20 Honolulu, HI—ALOHA (459) ....................................................... $6,500,000 New 5/1/2020 

21 Las Vegas, NV—New Medical Facility ...................................... $43,565,383 Replacement 3/7/2016 

21 Chico, CA—Replace Lease for Expiring CBOC .......................... $4,079,638 Replacement 4/1/2020 

21 Redding, CA—Replace Lease for Expiring CBOC ..................... $15,421,608 Replacement 6/1/2020 

21 Reno, NV—Building 1 Seismic .................................................. $200,000 Replacement 4/26/2021 

21 San Francisco, CA—Correct Seismic Deficiencies in Buildings 

1,6,8 & 12.

$14,823,000 Replacement 9/1/2022 

21 Livermore, CA—Livermore Realignment (Palo Alto) .................. $500,000 New 7/4/2023 

57 

Planned 2018 Non-Recurring Maintenance Projects—Continued 

VISN Project Name FY 2018 

New or 

Replacement? 

Actual or Estimated 

Construction 

Completion/ 

Lease Acceptance Date 

21 Palo Alto, CA—Polytrauma (Polytrauma-Ambulatory Care 

Center).

$2,000,000 New 6/30/2017 

21 Palo Alto, CA—Radiology (Polytrauma-Ambulatory Care 

Center).

$500,000 Replacement 7/2/2018 

21 Palo Alto, CA—Research (Polytrauma-Ambulatory Care 

Center).

$4,300,000 Replacement 4/1/2019 

21 Monterey, CA—Health Care Center Lease ................................. $1,500,000 New 2/28/2017 

21 San Jose, CA—Outpatient Clinic Lease .................................... $15,700,000 Replacement 12/31/2017 

21 Mission Valley, CA—Clinic ........................................................ $21,365,246 New 6/1/2020 

22 San Diego, CA—Spinal Cord Injury/Long Term Care ................ $31,959,139 Replacement 9/15/2025 

22 Chula Vista, CA—Clinic ............................................................ $7,483,329 Replacement 5/31/2019 

22 Loma Linda, CA—Health Care Center Lease ............................ $5,140,552 New 6/30/2016 

22 Long Beach, CA—Out Patient 126 ........................................... $7,104,443 Replacement 11/1/2019 

22 Long Beach, CA—Seismic Correction—Mental Health & Community Living Center.$1,871,545 Replacement 7/13/2021 

22 Los Angeles, CA—Seismic Corrections—12 Buildings ............ $6,571,450 Replacement 12/24/2024 

22 West Los Angeles, CA—New Bed Tower ................................... $1,581,592 Replacement 2/15/2030 

22 Bakersfield, CA—Community-Based Outpatient Clinic Lease .. $5,018,194 Replacement 5/1/2021 

Subtotal ............................................................................. $858,051,072 

VA Central Office Direct Field Support (PCAC/VACASE) ............ $4,115,722 

Grand Total ....................................................................... $862,166,794 

Note 2: Activation Funding (AF) covers multiple requirements to bring these projects into full operational status; i.e., furniture, fixtures, 

equipment, and support to plan and outfit each health care facility. Additionally, AF is utilized to cover additional clinical and administrative staff to provide new and expanded services, and supports other operating expenses; i.e., utilities, maintenance, etc. Based on the scope and 

complexity of the project, AF typically is allocated 2-3 years prior to the construction start date, and 2-3 years post construction completion 

date based on the activation phasing schedule. Within the VHA portfolio of activation projects, there are some projects that require activation 

support and funding beyond the typical period of activation funding allocation. These are activation funding estimates and may require adjustments based on changes in the construction and activation schedules. 

Question 18. Please provide the weights assigned to the criteria and sub-criteria 

in the Strategic Capital Investment Planning Process Decision Model contained on 

Page 10–3 of Volume IV of the Budget Justification. 

Response. Below are the definition and weights associated with the criteria and 

sub-criteria of the SCIP 2018 Decision model. 

STRATEGIC CAPITAL INVESTMENT PLANNING PROCESS DECISION CRITERIA

Improve Safety, Compliance, and Security: VA is dedicated to ensuring its Clients 

(Veterans) and Customers (VA Staff) are being served and/or work in a safe and secure environment. Mitigating the destruction and injury caused by natural or manmade disasters (including seismic, hurricane, flooding, blast, etc.); ensuring problems or injuries caused by the potential failure of critical building systems are 

avoided; improving compliance with safety and security laws, Federal Information 

Security Management Act (FISMA) standards, building codes, and regulations (including operating room, supply processing and distribution, inpatient privacy standards, PACT, and Research functional deficiencies for VHA; counselor offices, hearing 

rooms, and public/non-public separation for VBA and equipment rooms for OIT); 

mitigating threats to persons (physical security) on a VA facility (duress alarms for 

VBA); and ensuring VA mission critical buildings are able to provide service in the 

wake of a catastrophic event are of paramount importance. 

The three sub-criteria that projects are measured against with respect to Improving Safety and Security are: 

• Safety/Compliance (Excludes Seismic) 

• Physical and Building Security/Emergency Preparedness 

• Seismic 

Fixing What We Have (making the most of current infrastructure/extending useful 

life): VA is committed to managing its buildings in order minimize the extent to 

which deficiencies in infrastructure (including IT infrastructure) and other areas impact the delivery of benefits and services to Veterans, such as Central Office rent 

reduction efforts, depletion dates for National Cemeteries and VBA’s TransVerDate Mar 15 2010 16:16 Jul 12, 2018 Jkt 000000 PO 00000 Frm 00061 Fmt 6633 Sfmt 6621 Z:\ACTIVE\061417.TXT PAULIN
58 

formation Initiative. For infrastructure deficiencies, facility condition assessments 

(FCA) evaluate the condition of VA buildings using scores A through F and the criticality of building sub-systems. 

The three sub-criteria projects are measured against with respect to Fixing What 

We Have are: 

• Reduce Facility Condition Assessment Deficiencies (critical) 

• Reduce Facility Condition Assessment Deficiencies (non-critical) 

• Other Self-Identified Gaps (gaps not defined in existing criteria) 

Increasing Access: Serving Veterans is at the core of VA’s mission. We strive to 

increase access for Veterans (our Clients) by reducing the time and distance a Veteran must travel to receive the best quality services and benefits; ensuring Veterans 

have access to National Cemeteries, providing virtual access to benefits); providing 

adequate supporting structures at VA facilities, such as parking facilities and gravesite locators; by increasing our ability to handle workload; and by enabling VA staff 

(our Customers) to work more efficiently. 

The four sub-criteria that projects are measured against with respect to increasing access are: 

• Client (Veteran) Access to Services 

• Customer (Internal) Access to Services 

• Support Structures (includes parking deficiencies) 

• Utilization/Workload 

Right-Sizing Inventory: In order to provide the highest quality service to Veterans 

at the right time and in the right place, VA is managing its space inventory by removing excess VA-owned space via demolition, sale or transfer, building new space, 

collocating (VHA, VBA, NCA, and Staff Offices using the vacant or underutilized 

space of another office), leasing new space, converting underutilized space of one 

type to another type, to better suit its mission, and using space efficiency strategies 

such as but not limited to teleworking, cubicle reconfiguration, converting to new 

space standards, and expanded office hours to reduce the need for space. 

The four sub-criteria projects are measured against with respect to Right-Sizing 

Inventory are: 

• Space—New Construction/Renovation/Conversion/Lease 

• Space—Disposal (via demolition, sale, or transfer only) 

• Space—Collocation 

• Space—Space Efficiency Strategies 

Ensure Value of Investment: As a steward of the public’s trust VA is responsible 

for making capital investments in the most cost-effective way possible by ensuring 

new capital investments optimize operating and maintenance costs, in order to create the best value. 

The two sub-criteria that projects are measured against with respect to Ensure 

Value of Investment are: 

• Cost Saving Strategies—identification, quantification, and description any cost 

savings realized with the implementation of this project. 

• Best Value Solution—completion of a cost-effectiveness analysis (CEA) on the 

Status Quo and required alternatives is mandatory for Major Construction, Minor 

Construction, and Lease projects; if the chosen option does not have the best net 

present value (NPV) an explain for why the chosen option is the better value is also 

required 

Departmental Initiatives: For improved management and performance across the 

Department, capital projects should contribute to performance goals from the Department’s strategic plan, including DOD collaboration and complying with energy 

standards established in law and Executive Orders. 

The five sub-criteria that projects are measured against with respect to Strategic 

Requirements are: 

• Empower Veterans to Improve Their Well-being 

• Enhance and Develop Trusted Partnerships 

• Manage and Improve VA Operations to Deliver Seamless and Integrated Support 

• DOD Collaboration 

• Energy Standards 

59 

OFFICE OF TRANSITION, EMPLOYMENT AND ECONOMIC IMPACT

Question 19. Please provide the number of Direct and Management Direction and 

Support FTE for the Office of Transition, Employment, and Economic Impact 

(OTEEI) for fiscal year 2017 and the request for fiscal year 2018. 

Response. For FY 2017, OTEEI was allocated 40 full-time employees (FTE) with 

10 slots designated as supervisors or program managers. On November 1, 2016, 

OTEEI was realigned under VBA’s Benefits Assistance Service (BAS) and the Office 

of Economic Opportunities (OEO). Of this total, 23 FTE were realigned under BAS, 

7 FTE were realigned under OEO, and the remaining FTE were realigned to other 

mission essential functions. No FTE was allocated for FY 2018 as OTEEI no longer 

exists. 

Question 20. Please provide the total administrative costs for OTEEI for fiscal 

year 2017 and the request for fiscal year 2018. 

Response. OTEEI was provided $199,000 in operating budget for FY 2017. These 

funds were reallocated to BAS and OEO, to support mission functions. In FY 2018, 

there was not a separate budget submission for OTEEI as those duties have been 

dispersed between other business lines in VBA. 

Question 21. Please provide a list of the programs and other functions for which 

OTEEI is responsible, including the annual cost or expenditure per program, for fiscal year 2017 and the request for fiscal year 2018. 

Response. OTEEI is no longer an existing organization. BAS assumed responsibilities for the Transition Assistance Program while OEO continues to collaborate with 

Department of Labor (DOL), non-profits, and the private sector with the goal of 

helping Veterans reach their full economic potential. 

EDUCATION SERVICE

Question 22. The Budget Justification noted that Education Service has indefinitely delayed implementation of the Veterans Approval, Certification, Enrollment, 

Reporting, and Tracking System (VA-CERTS) due to funding constraints. 


614q1VAi_Investment_flow_chart.eps
60 

a. What functions would VA-CERTS provide to Education Service and to school 

certifying officials? 

Response. VA-CERTS would provide a modernized way for schools to send enrollment information to VA. Training institutions would be able to access VA data to 

include chapter 33 eligibility percentages, which is not currently available in the existing legacy system. With the completion of VA-CERTS, it would allow VA to consolidate two legacy systems into one agile and accessible system. 

b. How would VA-CERTS improve the administration of education benefits compared to the current system? 

Response. Improvements would allow for schools to have the ability to see VA 

data in order to verify that schools were paid the correct tuition and fees rates. VACERTS would also incorporate the ability to certify multiple enrollments for students at one time, as opposed to entering one enrollment at a time. In addition, a 

newer system would eliminate the need for duplication of work for VA employees 

by combining the Web Enabled Approval Management System and VA-ONCE. Currently, VA employees have to enter similar information into both systems. 

c. What is the cost to complete and fully implement VA-CERTS, and when will 

VA make a decision on completing it? 

Response. The cost to implement VA-CERTS is not known at this time. When initially conceived in 2014 its estimated cost of completion was $39M. Currently, the 

Office of Information and Technology is in the process of re-engineering education 

systems—eliminating the Business Delivery Network (BDN), a 51-year-old COBOLbased mainframe system and consolidating all education processing and payments 

into Long Term Solution (LTS) and VETSNET/FAS (Financial Accounting Services). 

This elimination of a critical legacy system and the resulting consolidation of capabilities, beginning now and running through 2018, will greatly facilitate VA’s ability 

to conduct system enhancements going forward. Due to the aggressive timeline for 

accomplishing this work, it is vitally important to not introduce additional changes 

or enhancements during this period to avoid additional complexity and risk. Implementation of VA-CERTS capabilities could begin once this initial effort is complete. 

VA will be in a better position to estimate costs, timing and how to best implement 

the capabilities conceived for VA-CERTS at the end of this calendar year once the 

engineering plan for the initial effort is solidified and implementation well underway. 

Question 23. The Budget Justification stated VA is working toward ‘‘a fully automated system for all education claims.’’ 

a. What is Education Service’s goal for automating original claims in the Long 

Term Solution? 

Response. The current average processing time for original claims is 22 days. By 

fully automating original claims, VA would be able to provide even faster service 

for some beneficiaries. VA’s long-term goal is for a beneficiary to be able to obtain 

an eligibility determination electronically, as opposed to waiting until VA manually 

adjudicates a claim and then mails a letter regarding the eligibility determination. 

By full automating the original claims process, there would be a savings to the government because it would eliminate the costs of paper, postage, envelopes, and mail 

handling. 

b. What is the cost to complete development of the Long Term Solution in order 

to fully automate all education claims? 

Response. The cost to complete development of LTS is not known at this time. 

We have, however, included projections of $37.5M in our budget planning for FY19– 

21. Currently, the Office of Information and Technology is in the process of re-engineering education systems—eliminating the BDN, a 51-year-old COBOL-based 

mainframe system and consolidating all education processing and payments into 

LTS and VETSNET/FAS. This elimination of a critical legacy system and the resulting consolidation of capabilities, which is beginning now and will run through 2018, 

will greatly facilitate VA’s ability to conduct system enhancements going forward. 

Due to the aggressive timeline for accomplishing this work, it is vitally important 

to not introduce additional changes or enhancements during this period to avoid additional complexity and risk. Implementation of LTS enhancements could begin once 

this initial effort is complete. VA will be in a better position to estimate costs, timing and how to best implement LTS enhancements at the end of this calendar year 

once the engineering plan for the initial effort is solidified and implementation well 

underway. 

c. How many man hours were spent processing original claims in fiscal year 2016 

and how many are expected to be spent in fiscal year 2017 and fiscal year 2018? 

What is the average cost of a man hour to process original claims? 

61 

Response. VA does not track the specific number of man hours that are spent 

processing various types of claims. However, we track the number of claims that are 

processed, and in 2016, we processed 356,756 ‘‘original’’ claims of all benefit types 

combined. Our current time to process an original claim is approximately 22 days. 

Prior to automating supplemental claims in September 2012, the average timeframe for processing a claim was 21 days for supplemental and 36 days for originals; 

presently we are operating at 8 days for supplemental and 22 days for original 

claims. We would expect a similar benefit to our timeliness if we automate original 

claims. 

Chairman ISAKSON. Thank you, Dr. Shulkin. We appreciate your 

attendance today. 

I want to start off with my questions on the appeals process. I 

have consistently said that any change in the process to improve 

it must include an acceleration in dealing with the 470,000 veterans whose claims are pending today at the VA. Would you agree 

with that? 

Secretary SHULKIN. I would like to see that happen. 

Chairman ISAKSON. Well, I am going to give you the same question, once we give you a chance to make a commitment on that. 

If both appeals reform and budget requests are adopted in this 

budget, would VA be able to begin accelerating decisions for those 

470,000 appeals that are pending? 

Secretary SHULKIN. The appeals that are in the Board of Appeals 

are the ones that we are most concerned about. If the Senate votes 

to move the appeals modernization forward, as I think you are saying, Mr. Chairman, we will have a process to expedite those from 

the time that the law passes moving forward. 

You are asking about the legacy claims—— 

Chairman ISAKSON. Right. 

Secretary SHULKIN [continuing]. And appeals. We do not have a 

plan to make significant progress on those. We are going to have 

to whittle away at them. The budget this year will add 142 more 

staff to the board. That will allow us to make incremental progress, 

but I think to deal with the backlog, we would be looking at 2026 

before we dealt with the backlog. 

The one hope that I have, Mr. Chairman, rather than adding a 

large number of staff to deal with the backlog, is that we will give 

current veterans who are in the appeals process the option of opting into the new process, and if they choose to opt in—but it is 

going to have to be their choice—they would be able to have their 

appeal dealt with in the expedited fashion, in the faster fashion. 

It is my hope to be able to accelerate the backlog, to encourage 

veterans, who unfortunately right now would have to wait years to 

get decisions, to opt into the new process. 

Chairman ISAKSON. Well, first of all, let me commend you because you just gave a patently honest answer to my question, not 

that I had expected anything else. 

Secretary SHULKIN. Mm-hmm. 

Chairman ISAKSON. But it is easy for a department head sometimes to talk department-ese—— 

Secretary SHULKIN. Mm-hmm. 

Chairman ISAKSON [continuing]. Where we think we heard one 

thing and we heard something else, but what I heard you say, in 

effect, as far as those legacy appeals are concerned, this really is 

62 

not going to do much, even if it is adopted, to take those legacy 

claims and move them forward. 

Secretary SHULKIN. Yes. 

Chairman ISAKSON. Which means we will still have 470,000 veterans claims out there that are old. One of them is 25 years old. 

I know that. 

Secretary SHULKIN. At least. At least. 

Chairman ISAKSON. That is the oldest legacy claim. 

Secretary SHULKIN. Yes. 

Chairman ISAKSON. Eventually, he will die, and we will get that 

one solved, but we have got 469,999 more we have got to. 

I hate to—I am going to quote now what I have heard secondhand, and I will say up front this is secondhand. I have been told 

that the VA recently told the Congressional Budget Office that 

VA’s plan is to, ‘‘very gradually,’’ address the 470,000 legacy appeals if appeals reform is passed. Is that the plan, and how long 

would that take? I heard your answer being yes, it is probably 

going to be very gradual, and yes, it would be 2026 before we got 

to it? 

Secretary SHULKIN. Yes, yes. Mr. Chairman, let me just add that 

we share that frustration. I find it really difficult to tell people who 

have submitted into the appeals process that they have 6 years to 

wait on average to get a response. 

So, I have asked the question: how much more would it take to 

get that backlog address? 

Chairman ISAKSON. And the answer is? 

Secretary SHULKIN. I am not sure you want to know because I 

was astounded by how much it was. 

Chairman ISAKSON. I want to know. 

Secretary SHULKIN. Around $800 million. 

Chairman ISAKSON. Senator Sanders, Senator Tester, Senator 

Heller, Senator Boozman, Senator Moran, everything we do as a 

Committee—Senator Manchin—will pale in comparison to the hell 

we are going to catch if it is going to cost $800 million to handle 

those claims before 2026. The appeals, we are going to clean up appeals prospectively in the future with what this budget proposes, 

but for the legacy appeals that sit out there, they are going to still 

be out there. 

Secretary SHULKIN. Yes. 

Chairman ISAKSON. The anger is going to get louder and the 

frustration deeper. So, we really need—you need to know the number—$800 million will do it—and we need to be prepared to try to 

find some way to do that because all that—all that is going to happen is there are a lot of people that are going to get worse, more 

and more anguish, less and less service, and it is going to cause 

us more and more problems with our new programs we try to bring 

in place. 

Thank you for being candid about that. I want all of us to be 

aware as Members of this Committee what we are dealing with, 

and we have got to make the hard decisions. One of them is going 

to be to get those legacy claims done and not let them build up in 

the future because when you do put your new program in that is 

going to solve all the problems prospectively—it sure as hell better!—because if we fix the ones that are back there and then we 

63 

have another buildup, we are going to be madder than a wet hornet. Is that not right, Jon? 

Senator TESTER. That is a fact. 

Secretary SHULKIN. Mm-hmm. 

Chairman ISAKSON. Now, very quickly—I took much time on 

that, but I thought that ought to be out on the table. 

When a veteran, when an American citizen signs up in the 

United States military and commits themselves to a period of service, carries out that service, and it meets the qualification necessary for them to go for VA health care in their retirement or 

when they leave the service, then we are obligated as a nation to 

pay for those benefits. Is that not correct? 

Secretary SHULKIN. That is correct. 

Chairman ISAKSON. Does anybody up here at the dais disagree 

with that? [No response.] 

This is not a trick, by the way. I am just trying to get everybody 

engaged. 

We did Choice, and Senator Sanders and Senator McCain did a 

great job of leadership 36 months ago on that. We did Choice to 

address the appointment backlog, the wait time periods, and things 

of that nature. We did some good things, which brought about some 

problems, which we have illuminated and have begun to solve. 

We are now in a situation—and you alluded to it in your remarks—where you need to find some money to finish out Choice in 

this current budget period by moving some money from one part 

of the VA budget to the other. 

I just want to make sure I am right on this. You have seven accounts that fund health care benefits; is that correct? 

Secretary SHULKIN. Community Care. 

Chairman ISAKSON. Community Care, but there are seven 

accounts? 

Secretary SHULKIN. Yeah, seven. Right. 

Chairman ISAKSON. One of those is Choice. One of those is Community Care, care in the community. So, you have enough money; 

you are not asking for new money to be given to you by appropriators or by the Congress. You are asking to move existing appropriated money for health care benefits under one stovepipe in the 

VA to another stovepipe to achieve balance, but there is no new appropriation. Am I correct? 

Secretary SHULKIN. That is correct. We have enough money to be 

able to make sure that all veterans will get the care that they 

need. 

We need your help to figure out the best solution about how to 

get more money into the Choice account. 

Chairman ISAKSON. I am raising this only as a good talking point 

for all of us on the Committee to have a discussion, which I am 

sure we will have on this, but I want to get that point also. We 

sometimes get bogged down in legi-speak, words like ‘‘mandatory’’ 

and ‘‘discretionary’’ and this acronym and that acronym, when it is 

all the same money in the case you are talking about. It is for veterans health care benefits. It is in your current appropriations. It 

is not any new money. We are not raising any expenditure to the 

taxpayer. We are just trying to meet our obligation to our veterans. 

64 

So, we need to find the way to do that on not just a stop-gap 

manner but permanently, and one of those ways might be to see 

to it that all the veterans benefits for health care are paid out of 

one account and is under the Secretary of the VA. Is that not 

correct? 

Secretary SHULKIN. That would make sense to me, Mr. 

Chairman. 

Chairman ISAKSON. Senator Tester. 

Senator TESTER. Thank you, Mr. Chairman. 

Once again, thank you for being here, Dr. Shulkin. 

You talked about—and I want to just follow up on the Chairman’s questions. You talked about in your opening statement 

Choice being down to $821 million and the fact that there was additional dollars in Community Care that you wanted to transfer 

over. 

You had put out a rule or edict. I do not know what you want 

to call it. What is it called? 

Secretary SHULKIN. A directive? 

Senator TESTER. A directive. That is better. A few days ago that 

directive said you wanted to go to the original intent on Choice, 

which would dry up a lot of how the dollars were spent. Then, a 

day or two later, you rescinded that. 

Thank you for the breakfast yesterday. We had a great breakfast, 

and we talked yesterday about potentially doing a fix legislatively. 

I was told today that another directive was put out today that 

reinstated that rule to go back to the initial. Is that correct? 

Secretary SHULKIN. Let me try to be accurate about what happened. We noticed that there was an imbalance in our two checking 

accounts. 

Senator TESTER. Yes. 

Secretary SHULKIN. On Friday, we sent out a directive saying—— 

Senator TESTER. Right. 

Secretary SHULKIN [continuing]. Stop spending from this account. 

Senator TESTER. Right. 

Secretary SHULKIN. OK. Start spending from this account. 

Senator TESTER. Correct. 

Secretary SHULKIN. We were afraid after seeing that directive 

that we were going to confuse the field—— 

Senator TESTER. Bingo. 

Secretary SHULKIN [continuing]. And so we rescinded that memo. 

Senator TESTER. That is correct. Right. 

Secretary SHULKIN. The field, once we rescinded the memo, said, 

‘‘OK. We get it. You are rescinding the memo, but will you give us 

some direction about how we should spend out of both of these accounts? because we still do have money in the Choice account. We 

have more money in Community Care.’’ 

So, we sent out four principles about the appropriate use of 

Choice and the appropriate use of Community Care funds, while 

we are working with you to figure out the best solution about how 

to get the appropriate money in each of those checking accounts. 

Senator TESTER. Did those four principles—I do not have a problem here. 

Secretary SHULKIN. Yeah. 

65 

Senator TESTER. All I want is predictability because I think it is 

important. 

Did those four principles tell the folks to go back to the original 

use of Choice? 

Secretary SHULKIN. It told them—it told them to use Choice for 

the appropriate use of Choice, which is clearly as you legislated, 

which is 40 miles, 30 days, and to use Community Care for the 

original use that they were using it for. 

Senator TESTER. OK. With all due respect, the directive was put 

back in place, and by the way, I do not have a problem with the 

first directive. I do not have a problem with staying the way it was. 

It has got to be driving your folks on the ground and it is going 

to be driving our veterans crazy if it is yes, no, yes. Then, in a 

week, when we fix this, it will be no again, so that is all I ask. 

That uncertainty, by the way—and I will not speak for everybody 

on this Committee, but I have a notion that it will be this way for 

everybody on the Committee—does not add confidence to the VA 

moving forward. I will just tell you. Do you get my drift? 

Secretary SHULKIN. Absolutely. Let me just say and—— 

Senator TESTER. Yes. 

Secretary SHULKIN. Listen, I would not disagree or argue with 

you. 

Senator TESTER. Yes. 

Secretary SHULKIN. The Choice Program has been difficult to administer—— 

Senator TESTER. Yeah, yeah. 

Secretary SHULKIN [continuing]. Difficult to understand—— 

Senator TESTER. Yep. 

Secretary SHULKIN [continuing]. And very complex. 

The first memo was rescinded—— 

Senator TESTER. Yeah. 

Secretary SHULKIN [continuing]. And remains rescinded because 

what it said is ‘‘Do not go to Choice.’’ We do not mean that. What 

we have tried to do is provide guidance to say, ‘‘You can use choice, 

and we want you to use Choice appropriately, but we have Community Care funds. We want you to use those.’’ 

We understand—— 

Senator TESTER. OK. 

Secretary SHULKIN [continuing]. But it is different than the first 

memo. 

Senator TESTER. OK. I would just say this, communication is a 

very good thing, we need to have communication. The breakfast we 

had yesterday was very, very important. 

Secretary SHULKIN. Mm-hmm. 

Senator TESTER. I think everybody who was at that breakfast 

will do it, and hopefully, we can have more of them. But, there was 

never an indication of this happening at the breakfast yesterday, 

or we could have talked about it some more. I do not want to 

micromanage the VA. 

Secretary SHULKIN. Mm-hmm. 

Senator TESTER. It is your baby. You would hang me out to dry 

if I tried to do that, and rightfully so. We just need predictability, 

that is all. 

66 

By the way—when I say we, I mean this Committee—but more 

importantly are the people sitting behind you who need that predictability. 

Secretary SHULKIN. Mm-hmm. Absolutely. 

Senator TESTER. Otherwise things are going to go upside-down 

pretty quick. 

I have got a bunch more questions, but I will refer to the next 

person in line. 

Secretary SHULKIN. OK. 

Chairman ISAKSON. Senator Moran. 

HON. JERRY MORAN, U.S. SENATOR FROM KANSAS 

Senator MORAN. Chairman, thank you. I want to be in the position agreeing with Senator Tester and disagreeing with Senator 

Tester. 

Senator TESTER. Uh-oh. 

Senator MORAN. The memos are different, and there is a significant consequence to the difference. 

Secretary SHULKIN. Yes. 

Senator MORAN. When we visited about the first memo, the consequence of that would be that the third-party administrators 

would have no role to play, and the networks potentially could go 

away. Lie dormant? 

Secretary SHULKIN. Exactly. 

Senator MORAN. The second memo says Choice is alive and 

well—— 

Secretary SHULKIN. Absolutely. 

Senator MORAN [continuing]. And it is to be used in these circumstances, which are the ones that were defined by the original 

Choice Act. 

Secretary SHULKIN. Right. 

Senator MORAN. I do not actually know what—why that is different than how it was being used. How is Choice being used different than 40 miles and 30 days? 

Secretary SHULKIN. Because we were also putting everything 

that we could through Choice, especially services that were not 

being offered at the VA. 

So, Senator Moran, you have it correct. That was exactly what 

we tried to do between the first and second memos. Senator Tester 

is pointing out that we have some work to do in getting our communications a little bit better. 

Senator MORAN. That is the part I was going to agree with Senator Tester. 

Secretary SHULKIN. Yes. I agree with him too. 

Senator MORAN. Because on that point—— 

Secretary SHULKIN. Yes. 

Senator MORAN [continuing]. I would make the case on behalf of 

Senator Tester that—— 

Secretary SHULKIN. Right. 

Senator MORAN [continuing]. We had a hearing on Wednesday on 

Choice. 

Secretary SHULKIN. Yes. 

Senator MORAN. Your first memo goes out on Thursday or Friday. 

67 

Secretary SHULKIN. Friday. 

Senator MORAN. This conversation never occurred with people 

who care a lot about Choice but care a lot about veterans. 

Secretary SHULKIN. I will say everything that both of you have 

said is accurate, and I will tell you—and I hope that you—— 

Senator SANDERS. You are quite the politician, I must confess. 

[Laughter.] 

Secretary SHULKIN. Yeah. 

I will tell you that, look, my integrity is very important. On 

Wednesday, Senator, I did not know this information. I learned 

about it on Thursday. 

Senator MORAN. I assumed that was the case. 

Secretary SHULKIN. Yes. Thank you. 

Senator MORAN. Let me then again try to highlight why keeping 

Choice in existence—and it is not just a matter of transferring. 

How we transfer the money or what pot of money it comes from 

is an important issue, and that revolves around whether or not 

Choice has a future today and again when we potentially reauthorize its existence into the future. 

When I say that it matters, because if Choice is not being used, 

then our intermediaries are not being paid, the network that has 

been established under Choice goes away, and you have Community Care but no Choice and no network, no third-party intermediary. It is not just a matter of transferring money back and 

forth. It is a matter of making sure that Choice is viable so that 

the network stays in place. Does that make sense? 

Secretary SHULKIN. Yes. We worked very hard to do that, and I 

agree with you. We want to keep that in place. 

Senator MORAN. A part of this that I still am confused about, because your response in regard to Chairman Isakson was that we 

just need transfer authority. I certainly have been in these hearings enough to know that you have said that more than once, and 

I think that is something that we are interested in. It makes no 

sense to have unneeded barriers. 

Secretary SHULKIN. Mm-hmm. 

Senator MORAN. We also need to make certain that this issue of 

mandatory is handled in a way that, again, Choice is mandatory, 

and that money has to stay available so that the program stays 

viable. 

Here is what I wonder, is that just—and, again, in response to 

the Chairman, I think you said, ‘‘We are not asking for any new 

money.’’ 

Secretary SHULKIN. Right. 

Senator MORAN. My understanding is that you have about $2 billion in the Community Care account. Is that an accurate number? 

Secretary SHULKIN. Unobligated, yes. 

Senator MORAN. Unobligated. So, at some point in time—and I 

do not know how soon that is, maybe the VA does—that money becomes scarce. The fix can only last so long before both the Choice 

account and the Community Care account are insufficient to meet 

the community, the health care needs through Community Care. Is 

that true? 

Secretary SHULKIN. We have enough money to get us through the 

end of the fiscal year in both—if we could balance the accounts corVerDate Mar 15 2010 16:16 Jul 12, 2018 Jkt 000000 PO 00000 Frm 00071 Fmt 6633 Sfmt 6601 Z:\ACTIVE\061417.TXT PAULIN
68 

rectly, we could make it through till the end of the year to get 

Community Care paid for in both Choice and internal Community 

Care. 

Senator MORAN. So, the $2.9 billion in the fiscal year 2018 Budget Request is not needed until fiscal year 2018? 

Secretary SHULKIN. I am going to defer to my CFO, but I would 

have said yes. 

Mr. YOW. Yes, sir. That is a requirement that is for next year. 

Now, the one caveat is in the budget, we assumed we were going 

to carry over $626 million of this year’s Choice money into next 

year. Our actual requirement for 2018 is $3.5 billion. We are going 

to consume that $626 million, we think now, before the end of this 

year, so we will have a hole next year of about $600 million. 

Senator MORAN. That hole exists in mandatory dollars, not discretionary dollars? 

Mr. YOW. Yes, sir. 

Senator MORAN. Which then means this Committee has to act to 

authorize additional mandatory spending for whatever the account 

is then called. 

Mr. YOW. Yes, sir. 

Senator MORAN. Is that true? 

Mr. YOW. Unless we were to find some other offset somewhere 

in our direct appropriated discretionary funds. 

Senator MORAN. I guess my takeaway is, assuming that your 

budget numbers are right, Mr. Yow and Mr. Secretary, that there 

is no emergency is what you are telling us? That Choice will continue between now and the end of the fiscal year without any additional input of money as long as there can be a transfer of, I suppose, discretionary spending into the mandatory account. 

Secretary SHULKIN. Yeah. 

Senator MORAN. Is that true? 

Secretary SHULKIN. The last part that you said is true, but if 

there is no action at all by Congress, then the Choice Program will 

dry up by mid-August. 

Senator MORAN. You have no ability, in your view, to fix the 

transfer issue, the discretionary and the mandatory, two components, to combine those into an account without legislative authorization? 

Secretary SHULKIN. That is correct. 

Senator MORAN. So, the emergency is not more money. 

Secretary SHULKIN. Right. 

Senator MORAN. The emergency is changing the law to allow you 

to spend money that you have, although it certainly sounds like it 

creates a likelihood of fiscal shortfall, dollar shortfall in fiscal year 

2018, even if we appropriate the $2.8 billion in the President’s 

request. 

Secretary SHULKIN. I think everything you said is correct, and as 

Mr. Yow said, we are not seeking, though, additional monies. If we 

needed to, we will identify the offset to the $600 million for 2018. 

Senator MORAN. The Chairman has his finger on the—— 

Chairman ISAKSON. No. 

Senator MORAN. I think I have had my fair shot. We may have 

another chance. Thank you. 

69 

Chairman ISAKSON. Well, that is very helpful, and I apologize, 

Senator Sanders. I am going to take 1 minute just to clarify a couple of points. 

Dr. Shulkin, I am a veteran. I served in the military in Afghanistan. I served my years to necessarily make me eligible for VA 

health care. I am a veteran. I am in VA health care. If I go to the 

VA hospital for a medical need related to my service or to just regular health care, you are obligated as head of the VA to pay for 

it and deliver that health care to me the best possible way possible. 

Is that not right? 

Secretary SHULKIN. Yes. 

Chairman ISAKSON. So, it is mandatory that you do that. You do 

not have the discretion as director of the VA to not provide me with 

health care because you did not get enough money? 

Secretary SHULKIN. Correct. 

Chairman ISAKSON. You have the obligation to manage the 

money you have, and if you need more come to get more money appropriated. Is that not correct? 

Secretary SHULKIN. Yes. 

Chairman ISAKSON. That is why when we talk about mandatory 

and discretionary; I do not think it is a matter of discretion if a 

veteran’s health care is at risk for not having enough money. We 

have got to find the money, and it is mandatory that we provide 

that money. 

Secretary SHULKIN. I would agree. 

Chairman ISAKSON. What you are talking about in transferability 

is after we decide to put X number of dollars in however many accounts that are in the VA, you want to be able to take money out 

of any of those accounts to pay for the benefit of that veteran without having to go to a secondary step within the VA to get money 

removed—moved by somebody else because something is named 

‘‘mandatory’’ or named ‘‘discretionary.’’ 

Secretary SHULKIN. Correct. 

Chairman ISAKSON. Is that correct? 

Secretary SHULKIN. Yes. 

Chairman ISAKSON. I just want to make sure I had that right. 

I am not sure I said it right, but—— 

Secretary SHULKIN. You said it perfectly. 

Chairman ISAKSON. It is clear to me now. Clear as mud, anyway. 

Secretary SHULKIN. OK. 

Chairman ISAKSON. Senator Sanders. 

HON. BERNIE SANDERS, U.S. SENATOR FROM VERMONT 

Senator SANDERS. Thank you very much, Mr. Chairman. 

Dr. Shulkin, great to see you. 

On page 3 of your testimony, you point out, I think, what most 

veterans organizations and veterans know, by and large, the VA 

has a pretty good health care system. You quote a study published 

by the Journal of the American Medical Association (JAMA), where 

researchers compared hospital-level quality care on 129 VA hospitals with over 4,000 non-VA hospitals, and you found that you 

have better outcomes in the VA on six of nine patient safety indicators, and the other three were about the same. That is pretty good. 

70 

I mean, that speaks pretty well for the system that you are running, despite all of the criticism we hear every day. True? 

Secretary SHULKIN. Yes. Yes, sir. 

Senator SANDERS. Let me ask you a question that has always 

fascinated me. Maybe you can give me an answer. I held a hearing 

a few years ago on the Health Committee talking about preventable deaths in American hospitals. According to—I am looking at 

an article right now in the New England Journal of Medicine, and 

they say that hospital medical errors are the third leading cause 

of death in the United States. 700 people every single day die in 

this country from hospital medical errors. How is the VA doing 

compared to non-VA hospitals on that issue? 

Secretary SHULKIN. Well, as the article in JAMA suggested, the 

VA is actually performing better on patient safety—and patient 

safety is defined by medical errors—than, on average, the private 

sector. Of course, every hospital in America, including VA, are always looking for ways to get better, but the VA has systems in 

place that help it perform better than many of the private-sector 

hospitals. 

Senator SANDERS. Well, congratulations for that. I know that the 

veterans appreciate that, which takes me to the point that Senator 

Tester made a moment ago, and that is what we hear every time 

there is a hearing with veterans, they like VA health care. 

Secretary SHULKIN. Mm-hmm. 

Senator SANDERS. What I do not want to see—and I think Senator Tester—many of us do not want to see the shifting of funds 

that go to traditional VA health care moved to the Choice Program. 

Regarding the Choice Program, we have had long discussions. We 

will continue to discuss that. 

I am a little bit distressed that a significant amount of money 

in President Trump’s budget is going to Choice, not quite so much 

going to traditional VA. 

Another question. You mention on page 9 what is obvious. You 

say that VHA is the largest health care system in the U.S. in an 

industry where there is a national shortage of health care providers. We have a major doctors crisis, especially in certain areas: 

primary health care relief, maybe psychiatry/psychology. 

Secretary SHULKIN. Those are the two biggest, yes. 

Senator SANDERS. OK. A couple of years ago when I helped work 

on the major veterans bill, we put—we expanded a program for 

medical education. It was the Section 302 of the Health Professionals Educational System Program. What that does, essentially, 

Mr. Chairman, is—what it does is help. As you know, medical 

school is now outrageously expensive, which is a very serious 

problem. I talk to young doctors who are $3–400,000 in debt. OK? They 

are probably not going to go to work at the VA. They are going to 

go work where the money is. I would like to see that program expanded. What it does is provides debt forgiveness. You want to 

work for the VA for X number of years; we will forgive the debt 

that you have incurred at medical school. Is that an idea that 

makes sense to you? 

Secretary SHULKIN. Senator Sanders, both of the ideas that you 

said and that the Ranking Member talked about make a great deal 

71 

of sense to me. I do not want to see VA care diluted because we 

are getting more veterans treated in the community. I want to see 

more veterans treated in the community because they need the 

care and VA cannot provide it right now. 

So, what we are proposing and hoping to work with you in this 

new Choice Program are the two things you have talked about. 

Right now, we are restricted to a 1 percent transfer from care in 

the community back into the VA or vice versa. We would like to 

see that aperture open so that we could actually take money that 

was in the budget for sending veterans out and reinvesting more 

of it into the VA. We think that is very important. It should be 

done at the local level when every local VISN makes its decision 

about what services the VA needs to strengthen in. 

On the GME issue, graduate medical education, I could not agree 

with you more. The program that you were helpful in crafting was 

a great success. 

Senator SANDERS. Is it working well? 

Secretary SHULKIN. It is. It is. We need to do more of it. We are 

proposing exactly what you are saying, which is creating more 

GME spots. The country needs them. VA would pay for them, and 

in exchange, it would be like the military or public health service. 

Senator SANDERS. Or the National Health Service Corps. 

Secretary SHULKIN. Or the National Health Service Corps. Afterwards, they would give 5 years back to the VA. 

Senator SANDERS. Right. 

So, Mr. Chairman, this is an issue where I think we can go a 

long way in attracting excellent physicians and nurses, 

perhaps—— 

Secretary SHULKIN. Yeah. 

Senator SANDERS [continuing]. Into the VA by doing a debt—expanding the debt forgiveness program, which I understand is already working well. I would look forward to working with you on 

that. 

Last question is—I am quoting from a publication called Families 

USA: ‘‘Cutting Medicaid would hurt veterans. Efforts in Congress 

to cut Medicaid jeopardize a critical source of health coverage for 

veterans. Approximately 1.75 million veterans, nearly 1 in 10, have 

Medicaid as a source of coverage.’’ 

If the Republican health care plan goes through—and I am going 

to do everything I can to see that it does not, but if it does go 

through and Medicaid is cut by over $800 billion in a 10-year period, I assume that means that a lot more veterans are going to 

be flocking into the VA. Am I correct on that? 

Secretary SHULKIN. I would think so. We are a safety-net organization, and we tend to have veterans without other health access 

come to the VA. I do not want to sound like a politician, but, you 

know, as the Chairman said, our role is to provide that care. We 

would need to do that. 

Senator SANDERS. So, if veterans lost their Medicaid, there is a 

reasonable possibility, many of them would turn to the VA for care. 

Secretary SHULKIN. I believe so. 

Senator SANDERS. And you need additional health to accommodate that large number of veterans? 

Secretary SHULKIN. Yes. 

72 

Senator SANDERS. Thank you very much. 

Chairman ISAKSON. Thank you, Senator Sanders. 

Senator Rounds. 

HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA 

Senator ROUNDS. Thank you, Mr. Chairman. 

Mr. Secretary, last week, we had a rather—I guess I would call 

it a spirited discussion about the Emergency Care Fairness Act, 

and under the VA’s Fiscal Year 2018 budget proposal, a budget line 

to pay for emergency care is still lacking. However, the VSOs’ Independent Budget has included a recommendation of $1 billion for 

2018. 

I guess my question, sir, would be, what is the status of the 

Staab appeal, which is the appeal on the Emergency Care Fairness 

Act, the way that it is being interpreted, and at what point will the 

VA formally request the necessary funds to pay for the emergency 

care for our veterans? 

Secretary SHULKIN. Well, first of all, Senator, I appreciated the 

interchange that you and I had. I think that you were making excellent points, and you were actually on the right side of this issue. 

We have done two things since we talked last. First, we have 

completed all of the regulations to be able to move forward with 

payment of the Staab claims, and we have now transmitted them 

to the Office of Management and Budget. That part is complete, so 

that is moving forward. 

Senator ROUNDS. That is good news. 

Secretary SHULKIN. The second thing is that after considering 

what you said and also I think Senator Blumenthal, I have decided 

to voluntarily withdraw the appeal to the Staab case. 

Senator ROUNDS. Oh, that is great news, Mr. Secretary. I think 

what that means is the last time we checked, there were 370,000 

claims outstanding that now can expect to receive payment for the 

emergency room care that they have expected since 2010? 

Secretary SHULKIN. Well, we still have to go through the rulemaking process. That is why we transmitted those rules to OMB, 

and they need to go through the process. I do not want to set time 

expectations, but yes, we are moving in that direction to adhere to 

the judge’s ruling on this. 

Senator ROUNDS. That is a very positive development. For those 

370,000 individuals, this is great news. Any possibility of expediting that rulemaking process? 

Secretary SHULKIN. We did. We got the rules over there very 

fast, and what happens now, we will certainly encourage the administration and be supportive of that. 

Senator ROUNDS. I cannot tell you how glad I am to hear that. 

I appreciate the fact that you have taken the time to get personally 

involved in this and to work through that issue. I think that is 

what veterans want to see coming from the VA, to be focused on 

what the veterans need, what the veterans care should be, and 

then when we make a promise, we honor that promise. I think that 

is what veterans are expecting from the VA, and I think this is a 

major first step in that. Thank you very, very much for your work 

on it, your attention to this, which I think will pay dividends for 

the entire organization for years to come, so thank you. 

73 

Mr. Chairman, I would yield back time. 

Thank you, sir. 

Secretary SHULKIN. Thank you. 

Senator ROUNDS. That is great news. 

Secretary SHULKIN. Good. 

Senator BOOZMAN [presiding]. Thank you, Senator. 

Senator Manchin. 

HON. JOE MANCHIN III, U.S. SENATOR FROM WEST VIRGINIA 

Senator MANCHIN. Thank you, Mr. Chairman. 

Secretary Shulkin, recently, you announced that you would be 

scrapping the current electronic health care record system (EMR) 

and adopting the same system that DOD uses from the Cerner Corporation based in St. Louis. While I am certainly in favor of making it easier on veterans transitioning from DOD to VA, my concern is that speed of this decision will have second- and third-order 

effects that could be detrimental. My questions to you are: are you 

concerned that there will be increased risk in having one company 

manage all these records? What if Cerner becomes the Health Net 

of electronic health records? 

Secretary SHULKIN. Wow. Well, first of all, I think in making a 

decision of this magnitude, there are absolutely risks involved with 

it. I have to tell you, I thought the risks were greater to do nothing. 

Senator MANCHIN. OK. 

Secretary SHULKIN. That considering the maintenance required 

on VistA, the expense that will be required, and our lack of ability 

to maintain qualified software developers within VA, the risk of 

doing nothing was worse. 

I think that DOD went through a strong due diligence process. 

I think that they selected a stable platform. We have benefited a 

lot from their due diligence and expertise, and that was one of the 

reasons why I went in that direction. There is always a risk, Senator, especially when you transfer systems, so—— 

Senator MANCHIN. Here is another part. 

Secretary SHULKIN. Yeah. 

Senator MANCHIN. I have got two more parts to this. 

Secretary SHULKIN. Yeah. 

Senator MANCHIN. By waiving the bidding process, which you 

just spoke about, how are you guaranteeing Cerner is not taking 

the VA for what we would consider a little bit of a ride? 

Secretary SHULKIN. Well, because all that I have done is start 

the process of negotiations. We have not committed to any funding. 

We have not committed to the contractual—— 

Senator MANCHIN. How will you know if the price is competitive 

if you have nothing to compare it to? 

Secretary SHULKIN. Well, we certainly know the price that DOD 

paid. We know the price that we are currently paying to maintain 

our systems, and we are going to be seeking the best way to do this 

for taxpayers. 

Now, most of the cost of a transfer of system is actually in internal change management, not in software licensing prices. 

Senator MANCHIN. I notice it is not in your budget right now. 

Secretary SHULKIN. Right. 

74 

Senator MANCHIN. I was going to ask, how are you going to absorb the cost? 

Secretary SHULKIN. We are going to have to go to the appropriators and lay out a plan so that they could decide whether they believe this is also a good decision. 

Senator MANCHIN. Well, we know this hearing is about care in 

the community. While ensuring the records transfer between DOD 

and VA, it is important we must also ensure that records transfer 

and their operability between VA and non-VA providers is just as 

seamless. Will Cerner be undertaking that as well? 

Secretary SHULKIN. Yes. What I said in the decision on the EMR 

is that while it is a decision to move forward with a common platform with DOD, this will not be the DOD system. VA’s needs are 

much different in that we have to be interoperable with our community partners, and many, many—in fact, 80 percent of our community partners are not necessarily on the Cerner platform. So, we 

are going to have to create a system that does several things that 

the DOD does not. We are not going to be scrapping VistA. We are 

going to have to connect into and maintain our 30-year database, 

and we are going to have to be interoperable with community partners. 

Senator MANCHIN. Very quickly, I have one more, and then I 

have a real quick question. There is no Assistant Secretary of IT, 

nor is there an Under Secretary for Health. So, how are you undertaking this without those positions filled? 

Secretary SHULKIN. Well, fortunately, we have very competent 

acting people in those roles, but we look forward to getting those 

roles permanent. 

Senator MANCHIN. You feel like you have the personnel to do it? 

Secretary SHULKIN. I feel like we are very lucky to have very 

competent acting people, but I need to have permanent people in 

those roles soon. 

Senator MANCHIN. My other question is concerning the opioid 

epidemic, which is the number 1 problem I have in my State—— 

Secretary SHULKIN. Yes. 

Senator MANCHIN [continuing]. Not just with the general population, but my veterans—— 

Secretary SHULKIN. Yeah. 

Senator MANCHIN [continuing]. With my veteran community. 

What I am concerned about, what the new non-VA care redesign 

looks like, I am looking for assurances that when we do new provider agreements on any contracts with non-VA care providers, we 

are going to be making sure that they understand that VA will not 

tolerate the over-prescription of opioids. More or less, we have a lot 

of pill mills; they get these people hooked, and they keep them 

hooked. How are you going to ensure or how—what is your oversight? Are you prepared for this? 

Secretary SHULKIN. Well, I have to say I do not think we are 

doing a good enough job in this. I think the country needs to do 

a lot better. 

Senator MANCHIN. We have challenges within the VA ourself. 

Secretary SHULKIN. Yes. 

Senator MANCHIN. We know that, and you all have been addressing that—— 

75 

Secretary SHULKIN. Right, right. 

Senator MANCHIN [continuing]. And I appreciate it. A lot more 

needs to be done. You have very little control when you go out into 

the private sector. 

Secretary SHULKIN. I think we have really made good progress 

in the VA on the oversight. We have seen the 33 percent reduction 

in opioid use since 2010. We monitor patterns of prescribing. I have 

the concern about going out into the community that you have. 

Senator MANCHIN. What I am saying is the contracts that you 

write, if I am a provider—— 

Secretary SHULKIN. Yeah. 

Senator MANCHIN [continuing]. If I am a non-VA provider, where 

the new act lets that person come to me, I contract with the VA 

to take care of these people. 

Secretary SHULKIN. Mm-hmm. 

Senator MANCHIN. Are there conditions on that if I prescribe? Do 

I have to follow prescription guidelines? Are you going to be monitoring that as far as opioid prescription guidelines? 

Secretary SHULKIN. Today, there are not those requirements. I 

think this is a really good area for us to come back to you with 

some thoughts on. 

Senator MANCHIN. Sir, we need your help on this—— 

Secretary SHULKIN. I know. Yep. 

Senator MANCHIN [continuing]. Because you are on the front 

lines. 

Secretary SHULKIN. Thank you. 

Senator MANCHIN. Thank you. 

Thank you, Mr. Chairman. 

Chairman ISAKSON [presiding]. Thank you, Senator Manchin. 

Senator Heller. 

HON. DEAN HELLER, U.S. SENATOR FROM NEVADA 

Senator HELLER. Mr. Chairman, thank you. 

Mr. Secretary, thanks for being here. 

Secretary SHULKIN. Thank you. Sure. 

Senator HELLER. Glad to have you here. 

I want to talk about the budget for just a minute, if I may; specifically, I want to talk about the individual unemployability (IU) 

cuts. 

Secretary SHULKIN. Yeah. 

Senator HELLER. Can you explain the rationale of the thought 

process that reduced this? 

Secretary SHULKIN. Yes, Senator Heller, my starting point on 

this is that we always have to do better for our veterans, and we 

have to deliver on our commitments that we have to our veterans. 

The President’s budget includes significant increases in both discretionary and mandatory funds and makes Choice a permanent part 

of funding. 

But, we have a responsibility to use our current funds in a way 

that makes the best sense for veterans and for taxpayers. So, we 

proposed a part of the process that would revise the individual 

unemployability benefit. 

The budget is a process, and this was part of a menu of opportunities that we had for thinking how we could make the budget 

76 

process better. As I began to listen to veterans and their concerns—VSOs in particular—it became clearer that this would be 

hurting some veterans and that this would be a takeaway from veterans who cannot afford to have those benefits taken away. I am 

really concerned about that. 

So, what I would like to say is that this is part of a process. We 

have to be looking at ways to do things better, but I am not going 

to support policies that hurt veterans. I would look forward to 

working you and all the Members of the Committee on figuring out 

how we can do this better. We have budget numbers and targets 

that we have to hit, but we should not be doing things that are 

going to be hurting veterans that cannot afford to lose these 

benefits. 

Senator HELLER. I appreciate hearing that. Do you know how 

many veterans would have been affected by this change? 

Secretary SHULKIN. Yes. We have 300,000, Jamie? 

Mr. MANKER. Yes. There are 300,000 that are in receipt of IU, 

about 330,000. About 210,000 of those are over the age of 60 and, 

therefore, would have been affected. 

Senator HELLER. Would have been. 

Secretary SHULKIN. Yeah. 

Mr. MANKER. Correct. 

Senator HELLER. It would not have been—it would have been 

retroactive? 

Mr. MANKER. It would have been point forward, but to include 

all veterans in receipt of IU. So, when you say retroactive, I do not 

believe we would pull any benefits that we have distributed back. 

However—— 

Senator HELLER. Right. No, no. I am just saying that if you had 

the benefit, you could lose the benefits—— 

Secretary SHULKIN. Yes. Yes. 

Mr. MANKER. Yes, sir. That is correct. 

Senator HELLER [continuing]. Even if you are currently receiving 

it? 

Mr. MANKER. That is correct. 

Secretary SHULKIN. Yes. That was the proposal, and—but we do 

look forward to working with you to figure out how we could do 

this better. 

Senator HELLER. I appreciate your concern for that. 

Do you know what the average is per veteran on this IU, what 

the average intake is? 

Mr. MANKER. The average payment? 

Senator HELLER. Yeah. 

Mr. MANKER. It is roughly $1,600. 

Senator HELLER. Roughly $1,600. 

Mr. MANKER. Yes, sir. That is on top of—you have to be rated 

between 60 percent to 100 percent, and it takes you to a temporary 

100 percent. Sixteen percent is—or beg your pardon—60 percent is 

roughly $1,600. 

Senator HELLER. All right. 

Mr. MANKER. It is about 13 or more. 

Senator HELLER. You can understand the financial burden that 

$1,600 may pose for an individual, and what I am more concerned 

about is, of course, their long-term retirement. They may have not 

77 

prepared or been prepared if in believing that that $1,600 might 

be there is I think the concern. 

Secretary SHULKIN. I think that is the issue, and this is why we 

had identified this as an opportunity. I think if we were designing 

this system from the beginning, we would not have used unemployment insurance to fund people’s retirement. I think that was the 

conflict. 

The end result is that is the benefit, and to withdraw this benefit 

from people who rely on that money is something that would be 

very difficult to do. 

Senator HELLER. Well, I appreciate your concern for this. 

Can I change topics for just minute—— 

Secretary SHULKIN. Mm-hmm. 

Senator HELLER [continuing]. And make sure I understood this 

correctly? Did you say that you had a decision-ready claim in 3 

days? 

Secretary SHULKIN. We have had 12 of them so far, I think. Yes. 

Senator HELLER. Twelve of them. 

Secretary SHULKIN. Yes. So, on September 1 we are going to be 

rolling that out across the country. 

Senator HELLER. I mean, that is big news. 

Secretary SHULKIN. That is big news. 

Senator HELLER. I am glad because I have been working with 

this issue for years; and to think that you could actually turn one 

around in 3 days is pretty incredible. 

Mr. MANKER. That is a big deal. We are piloting in St. Paul right 

now, again, with a couple of our VSOs. If the VSO brings in the 

claim ready to be decided, we know—— 

Senator HELLER. Right. It has got to be ready. I get it. 

Mr. MANKER. No further development and we decide the claim. 

Senator HELLER. We had a previous Secretary who said that he 

could get the claims down to zero by—I think it was 2015. What 

is the status now? If this works as well as—— 

Secretary SHULKIN. I can tell you I will not say that. [Laughter.] 

No. I mean, so—— 

Senator HELLER. No predictions. No predictions—— 

Secretary SHULKIN. Yeah. 

Senator HELLER [continuing]. On where the claims will be. 

Secretary SHULKIN. No. We right now—we are at about 90,000? 

Mr. MANKER. As of this morning, it was 94,000 that we had. 

Senator HELLER. Yeah. That is about what my notes say, too. 

Secretary SHULKIN. Yeah. 

Senator HELLER. There are about 1,200 of them in Nevada. 

Secretary SHULKIN. Yeah, yeah. I think our goal, Jamie, is by the 

end of the calendar year to about 70,000? 

Mr. MANKER. That is right. That is right. 

Secretary SHULKIN. These decision-ready claims, we think will 

take 10 to 15 percent of them off. So, we will not start rolling them 

out till September, but that will begin to whittle that down. We 

hope in 2 years to be down below around half of where we are now. 

Senator HELLER. OK, OK. 

Mr. Secretary, thank you, and, Mr. Chairman, thank you for the 

time. 

Chairman ISAKSON. Thank you, Senator Heller. 

78 

Senator Murray. 

HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Thank you, Mr. Chairman, and thank you all 

for being here. 

Secretary Shulkin, in last year’s budget request, the VA estimated that it would need $725 million in fiscal year 2017 and $840 

million in 2018 for the Veteran Caregiver Program, yet in the first 

budget of the Trump administration, you plan to only use $521 million in 2017 and $604 million in 2018. Those are cuts of about 30 

percent. Meanwhile, I am hearing from so many of my constituents, as I am sure everybody is, of caregivers being dropped from 

the program with no explanation and no justification. An investigation by NPR found the Charleston Medical Center actually dropped 

94 percent of its caregivers; 83 percent in Prescott, AZ; and 83 percent in Augusta, GA. 

It seems to me, watching this, that this is just another way the 

Administration is balancing its budget on the backs of veterans in 

need. How do you explain those numbers? 

Secretary SHULKIN. Well, let us just talk about the three things 

quickly that you said. What was reported on in Charleston is completely unacceptable; 95 percent of revocation of caregiver benefits, 

unacceptable. That is why we suspended the program, and today, 

there are no revocations across the country going on until we get 

the guidelines better understood and in better shape. 

Senator MURRAY. That is the freeze that you are talking about? 

Secretary SHULKIN. That is the—right, right. That is the freeze. 

Senator MURRAY. That is only a temporary measure—— 

Secretary SHULKIN. It is a temporary measure—— 

Senator MURRAY [continuing]. And I think you did the right 

thing. 

Secretary SHULKIN [continuing]. Until we revise policy, because 

I will not accept giving benefits and then taking 94 percent of them 

away. That is ridiculous. 

The second thing is, is that on the right amount of money to request? We only spent—even though $750 million was in the budget, 

we only spent $521 million. So, in budget planning for next year, 

they requested $600 million, which is a modest increase from 

where we are. 

Our hope, as you know—and you have been a tireless advocate 

for this—is to expand caregiver benefits, and we do plan on working with you with that. We hope by expanding caregiver benefits, 

particularly to older veterans, who today are not getting the benefit 

the way that they should, that we actually find that that is going 

to be cost effective, because remember we pay for long-term care. 

Senator MURRAY. Right. 

Secretary SHULKIN. My plan is to be responsible to taxpayers. I 

am going to seek to expand caregiver benefits to older veterans, but 

I am going to pay for it myself without asking the taxpayers to increase the bill. 

Senator MURRAY. OK. Well, the Ranking Member and I wrote to 

you a couple months ago suggesting a series of important reforms. 

Those issues have not been addressed, and I would just like to see 

79 

the freeze extended until all of those issues in that letter were discussed. Can you do that? 

Secretary SHULKIN. Yeah. Do you happen to have the date of the 

letter? If not, I will find it. 

Senator MURRAY. It was about 2 months ago. 

Secretary SHULKIN. Two months ago. Of course, absolutely. 

Senator MURRAY. OK. Let me go to the shortfall in the Choice 

Program. I know that you wrote to TriWest and Health Net telling 

them to return referrals for care, including for veterans that are 

currently waiting for care. How many veterans are going to be affected by that? 

Secretary SHULKIN. We ask—when they cannot appoint an appointment within a period of time in the contract, we ask them to 

return it. They are returning large numbers to us. 

Do you know, Mark? 

Mr. YOW. I do not. I am sorry. 

Secretary SHULKIN. This is an ongoing process. Before, they 

would just wait until—it took weeks and weeks to give an appointment. We have said, ‘‘If you cannot give an appointment within 5 

business days for a routine appointment, return them to the VA so 

we can take care of the veteran.’’ It is a big percent that we get 

back. 

Senator MURRAY. It is a big percent? 

Secretary SHULKIN. Yeah. 

Senator MURRAY. Do you know how long care is going to be delayed for veterans as a result of that? 

Secretary SHULKIN. Well, this is actually speeding up care. Rather than letting a veteran stay out there in the Choice Program, 

schedulers return them to the VA, and then the VA Community 

Care Program goes out and tries to find an appointment. 

Senator MURRAY. OK. Well, I am very concerned about where the 

money is going to come from, from this—— 

Secretary SHULKIN. Yeah. 

Senator MURRAY [continuing]. And how you are going to get the 

money to continue non-VA care. It seems to be two different stories 

here. Transfer authority is what I am hearing from this year? Correct? Well, if you transfer money from this year, then what you are 

doing is impacting what you thought—— 

Secretary SHULKIN. Yes. 

Senator MURRAY [continuing]. Was going to be a carryover for 

next year. So, will you not need additional money for next year? 

Secretary SHULKIN. Yeah. Look, the problem of having these two 

separate checking accounts and predicting where you need the 

money is, frankly, impossible. That is why we want to work to get 

the program into a single Community Care account. 

We are going to—these guys are going to help make the best predictions possible. Mr. Yow is going to help us understand the right 

amount of money to transfer over to predict it, but—— 

Senator MURRAY. But, it will impact 2018, so we need real numbers here. We cannot do our job if we do not know what the costs 

are. 

You know, I am already hearing from veterans in my State about 

the delays and burdens they are seeing as a result of this. I had 

veterans in Walla Walla who are being told they will have to drive 

80 

8 hours round-trip to Portland or Seattle just for some simple imaging tests as a result of this. I am hearing a lot more. We are 

happy to get those to you, but this is having an impact. I want you 

to know that and we want to know where this money is coming 

from. So, we will follow up with you on that, but I think this Committee needs to be aware of that. 

Secretary SHULKIN. OK. 

Senator MURRAY. OK. I am running out of time—or I am way 

over time. I have other questions, Mr. Chairman, which I will submit for the record. But, I am deeply concerned about that. 

Secretary SHULKIN. Yes. 

Chairman ISAKSON. Listening to all these questions about checking accounts and authorities reminds me of the question I was 

asked yesterday on my 49th wedding anniversary. Somebody asked 

my wife and I to what we would attribute 49 years together. I said 

we never had a joint checking account where both of us had to sign, 

so we never had those arguments. Let us not ever get in that situation with the VA either. 

Secretary SHULKIN. OK. 

Chairman ISAKSON. Senator Boozman. 

HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS 

Senator BOOZMAN. Thank you, Senator Isakson and Senator 

Tester. 

Thank you for being here, and we appreciate our veterans’ advocates who are going to testify shortly for being here also. 

Senator Sanders talked to you about the problem with the fact 

of providers, and so many people are at the age now where a big 

group of baby boomers that are aging out, they practice because 

they like, and medicine has gotten more complicated and stuff. I 

think we are going to see a bunch of those actually decide to do 

something else or not do anything. 

The idea of increasing—well, first of all, I agree that the fact that 

we can reward people for going in is a great idea, and I think it 

actually would work. I think we have good evidence of that. 

The problem is actually creating new slots versus taking slots 

away for veterans. If you could work with some of your counterparts—and the VA is a huge entity. 

Secretary SHULKIN. Mm-hmm. 

Senator BOOZMAN. This is a huge problem for the country, besides the VA, but if you could craft a situation where you could actually increase the medical school classes and then also the 

residencies, which are a huge problem too, that would be a great 

deal. 

Secretary SHULKIN. Yes. 

Senator BOOZMAN [continuing]. With your relationship with the 

teaching hospitals—— 

Secretary SHULKIN. Right. 

Senator BOOZMAN [continuing]. I think that could be done. It is 

going to take some work, but that truly could be a great legacy. 

Secretary SHULKIN. Right. We are focused on the residency spots. 

The medical schools have actually increased the number of medical 

school spots because they have tuition that pays for it, so it is to 

their benefit. 

81 

The residency spots, as you know, are capped by Medicare. 

Senator BOOZMAN. Right. 

Secretary SHULKIN. What you did in the Choice Program that 

Senator Sanders help lead was expand those graduate medical education spots. That is what we need desperately. 

Senator BOOZMAN. Yeah, very much so. 

Secretary SHULKIN. Yeah. 

Senator BOOZMAN. And, again, we need to do that—— 

Secretary SHULKIN. Yes. 

Senator BOOZMAN [continuing]. With whatever it takes in the future or we are going to get ourselves in trouble. $8.4 billion in mental health, 6 percent increase. That is great. 

Mental health has improved so much in the VA in the last years. 

We are not at the point where we are just writing prescriptions like 

so many providers, not just in the VA, but throughout the country 

giving a prescription. That simply does not work. 

On the other hand, we need to go farther. How are we going to 

prioritize that 6 percent as far as increasing our ability to provide 

good care? 

Secretary SHULKIN. Well, we have targeted to hire a thousand 

mental health professionals. This year to date we are seeing 58,000 

more mental health appointments than we did last year at this 

time. 

We are expanding our tele-mental health programs. We have 

just, as you know, this past year given full practice authority to our 

advanced practice nurses. Many of them will be putting their skills 

to work in behavioral health and expanding the training. As Senator Sanders said, psychiatry and psychology and nursing, all are 

areas of shortages that we can use more help in, not only in the 

VA, but the entire country, quite frankly. 

We need to do a lot more. I think you are right. We have 

prioritized mental health, but it is an area that needs a lot more 

help. 

Senator BOOZMAN. You talked about the core mission of the VA, 

the foundational services that make the VA unique. Can you walk 

us through those or what you feel those are? 

Secretary SHULKIN. Yes. These are the services that make me so 

strongly believe that a strong VA is essential for veterans and for 

the country, because I believe that without the types of services 

that the VA provides, you cannot find those in the private sector. 

If we just turned our veterans over to the private sector, they 

would really be lost. 

These are services that veterans have a high predilection for: 

post-traumatic stress, behavioral health issues, spinal cord injury, 

prostheses or orthotics, polytrauma. Comprehensive primary care 

and behavioral health care services are clearly foundational as 

well. Environmental exposures, blind rehab—I do not want to leave 

out a group because I know I will offend them, but these are things 

that the VA does extraordinarily well that you would not find easily, except in very specialized geographies where there are centers 

of excellence. So, it is important that we keep those strong. 

Senator BOOZMAN. In your testimony also, you talked about Community Care and how doctors will make decisions on providing care 

in VA facilities versus in the community due to clinical need and 

82 

what is best for the veteran. How do we—how do you do this? How 

do you make sure that with—we have an institution, somewhat 

of—well, we have a bureaucracy. How do you make sure that those 

decisions are based on what is best for the veterans as opposed to 

what is best for the facility? 

Secretary SHULKIN. Well, I think—I wish that there was an easy 

answer to that. 

What we have to do as an organization is get out of the way of 

the doctor and the provider making those decisions together, so we 

need to get rid of the administrative rules and the third parties in 

between. That is what we saw in the Choice Program. We were 

having veterans call Call Centers of people who did not know them, 

and that was frustrating the veteran. What we have learned is to 

de-layer the process, get it back into the exam room or now, in 

more modern terms, you know, the tele-monitors. Let the doctor, 

the patient, the provider of the patient make the decisions together 

in a partnership about what is best for them. That is the system 

we are trying to design now. 

Senator BOOZMAN. Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Boozman. 

Senator Tillis. 

HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA 

Senator TILLIS. Thank you, Mr. Chair. Mr. Chair, I am going to 

be married 30 years, 2 weeks from today. We have a slightly different approach to longevity. We do have a joint account; I just do 

not have access to it. [Laughter.] 

Chairman ISAKSON. That works also. 

Senator TILLIS. I am not even allowed to go out of network to get 

an ATM withdrawal. 

Thank you all for being here. I am actually running between 

committees. We have an Acting Committee going on right now, and 

we are talking about supporting caregivers, the Hidden Heroes 

Project that Senator Dole is heading up, and it is critically important. I will not spend time talking about it here, but one thing that 

was striking in Senator Dole’s opening testimony was the fact that 

there is about $14 billion a year in caregiving being donated by 

these husbands and wives and sons and daughters that we need to 

find a way to provide support over time. 

I understand that in order for us to do that, we have to talk 

about the resources and make sure that we are not shifting our attention away from so many other pressing things, but it is something I look forward to talking about in a future hearing. 

Dr. Shulkin, I want to know how we are doing. Some of the estimating, I have got to believe some of the uncertainty with respect 

to accounts, and how much we need in one or the other—one 

thing—— 

Secretary SHULKIN. Yeah. 

Senator TILLIS [continuing]. It is a fluid situation based on factors that are different across the country. Another one may have 

to do with having the right resources in place so that you can actually get to that information pretty quickly. How are we doing on 

getting your—I understand the CIO nominee, I think, has withdrawn their name from consideration. How are we doing on trying 

83 

to get that administration stacked up so that you have got a good 

organization, permanent organization under you? 

Secretary SHULKIN. Well, not only the CIO, but the CFO candidate. If we are attracting a good viewing audience, we need help. 

We need people to want to come and help serve. 

Senator TILLIS. A permanent CFO is going to be pretty important 

to get in some of your financial—— 

Secretary SHULKIN. It really will. 

Senator TILLIS [continuing]. Financial planning in order and getting your financial processes and planning processes in order, 

so—— 

Secretary SHULKIN. Yes. 

Senator TILLIS. I think you have touched on something important. Hopefully, somebody can step forward. 

Secretary SHULKIN. Yes. 

Senator TILLIS. I know it is a sacrifice and you need somebody 

that is highly skilled, but we have got to get those positions filled. 

I, for one, think it will be one of the ways we can get back on track 

for the transformation effort. 

I am not going to spend much more time because I am going to 

get back to the other Committee, but I am going to echo again 

what I said in the last Committee. I am sure that there are various 

factors that led to the shortfall in one account versus another. 

Secretary SHULKIN. Yes. 

Senator TILLIS. There are probably other things that we need to 

do to make sure that we are facilitating the process and not giving 

you additional distractions or uncertainty as you go through the financial planning. Please speak candidly to the Committee Members—— 

Secretary SHULKIN. Thank you. 

Senator TILLIS [continuing]. And make sure when there are 

things that we can do or should not do that are getting in the way 

of you giving us definitive answers, so we can count on it also. 

Secretary SHULKIN. Yeah. 

Senator TILLIS. I also want to reiterate what—Senator Murray 

made several very good points. I agree with all of them. I think 

that she is absolutely right. The sooner you articulate what your 

funding levels are, the better, so that we can go and be advocates 

for it. 

Secretary SHULKIN. Yeah. Thank you. 

Senator TILLIS. Thank you, Mr. Chair. 

Chairman ISAKSON. Thank you, Senator Tillis. 

Senator Boozman—Senator Blumenthal. I am sorry. 

HON. RICHARD BLUMENTHAL, 

U.S. SENATOR FROM CONNECTICUT 

Senator BLUMENTHAL. Thank you, Chairman. 

First of all, I want to express my appreciation on the Richard 

Staab v. McDonald case. 

Secretary SHULKIN. Thank you. 

Senator BLUMENTHAL. I join my colleague, Senator Rounds, 

in—— 

Secretary SHULKIN. Yes. 

84 

Senator BLUMENTHAL [continuing]. Expressing my appreciation 

for your decision to withdraw the appeal and also join with him in 

asking for a quick rulemaking, which I know you will do. 

On the VA’s Vocational Rehabilitation and Employment Program, as you know, it provides career counseling and rehabilitative 

services to veterans with service-connected disabilities to overcome 

employment barriers. It also assists with postsecondary training at 

educational institutions. 

I have been told by Connecticut University that there are delays 

in vocational rehab housing and education payments for servicedisabled veterans. The VA has previously attributed those delays 

to lack of vocational rehabilitation counselors at the Hartford Regional Benefit Office and nationwide staffing shortages. The VA’s 

purported goal ratio of vocational rehab counselor to client is one 

counselor per 125 veterans, but the average ratio in July 2015, I 

am told was one counselor to every 139 veterans, despite the payment delays and the VA’s inability to meet the ratio. 

The fiscal year 2018 budget makes cuts to this program; Voca- tional Rehabilitation is $13.8 million. You are probably more familiar with these numbers than I am, so I apologize for telling you 

something you already know. This decrease in requested funding 

seems unacceptable, particularly for those of us in Connecticut who 

see the results already of underfunding. I would like to know 

whether you plan to address the delays and your view of the apparent underfunding of this very valuable program. 

Secretary SHULKIN. Senator, first of all, thank you for your outspoken leadership on the Staab case. 

On terms of Vocational Rehab and Education, we may have different numbers, so I would like to go over it with you. We see a 

$1.5 million increase in the President’s budget for these programs, 

but there are some staffing issues and delays in the Hartford region that we do want to get improved and we do want to fix. We 

think this is an important program. We believe in it, and we believe the President’s budget adequately funds it. 

But if you have different numbers and we are wrong, we will 

want to address that. 

Senator BLUMENTHAL. Well, I would like my staff perhaps—— 

Secretary SHULKIN. Yes. 

Senator BLUMENTHAL [continuing]. To get together with you all, 

but I think the overriding issue here is not necessarily even the 

numbers, because even if there is a slight increase, this is—— 

Secretary SHULKIN. Small. 

Senator BLUMENTHAL. This program is so valuable, it ought to be 

a major increase and certainly not a reduction. 

Secretary SHULKIN. Right. 

Senator BLUMENTHAL. Again, this is not a criticism of the VA. In 

fact, on the contrary, it is saying you are doing great work. We do 

not want to see it diminished. We see these delays in Hartford and 

we would like your help in solving them. 

Secretary SHULKIN. Yes. OK. We will follow up with you. 

Senator BLUMENTHAL. I thank you. 

Secretary SHULKIN. Yes. 

Senator BLUMENTHAL. I do not know whether it has been asked, 

but I wonder if I could ask you again about the Veterans Benefit 

85 

Administration, whether you see real progress in reducing the 

claims backlog. I am guessing someone has asked about it already, 

and I apologize for bringing it—— 

Secretary SHULKIN. No. No, that is not a problem. 

Senator BLUMENTHAL. What is your prognosis? 

Secretary SHULKIN. Well, I will briefly just tell you we are at 

94,000 now. We hope by the end of the year to be at approximately 

70,000, and then a year following that or 2 years from now below 

about half the level, so 45,000. 

We just announced that we have done 12 claims so far in 3 days, 

called ‘‘decision-ready claims.’’ We are going to roll that process out 

nationally September 1. That will impact around 10 to 15 percent 

of our claims because they have to have all the information ready, 

they are presented, and we give a decision in 3 days. So, I think 

that we are making some progress. 

We are trying to actually look at some breakthrough ways to do 

better, but as of today, I have given you the most accurate information we have. 

Senator BLUMENTHAL. The progress that you are making is the 

result of a different—reforms in the process—— 

Secretary SHULKIN. Yeah. 

Senator BLUMENTHAL [continuing]. Or is it more resources or a 

combination? 

Secretary SHULKIN. The budget—the budget stays flat for next 

year, so it is not in VBA. It is not necessarily more resources, although they have added in the past couple of years. 

I would say the major changes are process improvements. There 

is something called the National Work Queue, which is really allowing productivity adjustments. Therefore, you can distribute the 

workload across the country evenly. They have just enhanced and 

increased their productivity standards for the people who work in 

VBA, and they are doing a terrific job. We have a great staff who 

work in VBA, who are up to the challenge, and we are seeing improvements. It is mostly process improvement, but over the past 

couple of years, they had added to their staff. 

Senator BLUMENTHAL. Well, I want to thank you for your focus. 

As you know, this is a problem that has continued to—— 

Secretary SHULKIN. Mm-hmm. 

Senator BLUMENTHAL [continuing]. Bedevil us over many years, 

so I am glad that you are making those process changes. And there 

may be some breakthrough—— 

Secretary SHULKIN. Yes. 

Senator BLUMENTHAL [continuing]. Changes in the foreseeable 

future? 

Secretary SHULKIN. Yes, yes. 

Senator BLUMENTHAL. Thank you. 

Secretary SHULKIN. Thank you. 

Senator BLUMENTHAL. Thank you, Mr. Chair. 

Chairman ISAKSON. Thank you, Mr. Blumenthal. 

I have been asked by Senator Sanders and Senator Tester to be 

able to make brief statements, so I am going to waive any time I 

might have and recognize Senator Tester and then Senator Sanders for their statement and/or question. 

Senator TESTER. Thank you, Mr. Chairman. 

86 

I have beaten this horse in the past. We have to beat it one more 

time. OK? 

Secretary SHULKIN. Sure. 

Senator TESTER. The VSOs we are going to hear from next want 

to have the VA as a primary care provider. I have heard it over 

and over again. Senator Sanders talked about it. Others have 

talked about it in this Committee. 

I have been in public life long enough to know that if you want 

to know where things are headed, you follow the money. 

Secretary SHULKIN. Mm-hmm. 

Senator TESTER. The fact that we have 1.2 percent increase for 

in-house medical care and 33 percent for outside medical care is 

disturbing. 

Moving forward, because you have said over and over again to 

me, ‘‘Do not worry about this, Jon. It is going to be fine. We are 

going to make the VA the best it can be, and the VA is going to 

fill in the gaps,’’ we just need to drive that point home because we 

are going to hear from a panel of VSO representatives. I have got 

a notion that they are going to talk about VA care, and they are 

going to be reasonably complimentary and talk about other ways 

we can fix it. 

Number 2, this is an authorization committee. Concerning 

electronical-IT funding, you have got $200 million in this budget. 

You should be asking this Committee to plus that budget up. You 

need to do it so it represents the money that you are going to be 

dumping out to Cerner for the DOD electronic platform that we all 

support you doing, by the way. 

Secretary SHULKIN. Mm-hmm. 

Senator TESTER. I think it is really important that we are honest 

with ourselves, and I will tell you why. I happen to be on both 

Committees, and I do not want to get nailed and say, ‘‘You know 

what? The Authorization Committee did not do that, and these 

spendthrift appropriators are just dumping money in.’’ I would just 

say we need to have a budget that accurately reflects what we need 

to do. In this case, we know this IT thing is going to cost some 

dough. 

Secretary SHULKIN. Mm-hmm. 

Senator TESTER. So, we need to act accordingly. 

The last thing is we are going to have Carl Blake from Paralyzed 

Veterans of American (PVA), LeRoy Acosta from Disabled American Veterans (DAV), Carlos Fuentes from Veterans of Foreign 

Wars (VFW), and John Rowen from Vietnam Veterans of America 

(VVA), up here in a second. I just want to thank those guys for 

their service. We had said earlier that we need to take our direction from the VSOs. I am not going to be able to be here, although 

I am going to try to get back before the end, and we do need to 

take the direction from the veterans. I think it is critically important, so thank you all. 

Secretary SHULKIN. Senator Tester, thank you, and, you know, 

the one thing is we are always clear on where you stand and appreciate that. 

I do want to try to work with you and your staff because we have 

different numbers than you have in terms of the Community Care 

87 

and internal care. You know, we have an interest in making sure 

the VA is the best system. 

The ability to transfer more—right now, we are limited at 1 percent—would help us a great deal, and that is something we will 

continue to work with you on. 

Senator TESTER. I would just say, we are going to work with you 

on that, too. Johnny and I both agreed to that. 

I think that, as I said to you at the breakfast yesterday, you can 

outsource care, but you cannot outsource responsibility. 

Secretary SHULKIN. No, that is right. 

Chairman ISAKSON. Senator Sanders. 

Senator SANDERS. Thanks very much. 

I want to touch on briefly what is a terrible, terrible national crisis, and that is the opioid epidemic. I think in the past, the DOD 

and the VA were criticized for an overdependence on opioids. 

Secretary SHULKIN. Sure. 

Senator SANDERS. I know that there has been some significant 

changes. I have been pleased to go to VA hospitals around the 

country and see very robust programs regarding alternative complementary medicine—yoga, nutrition, and so forth and so on. 

Secretary SHULKIN. Yes. 

Senator SANDERS. Can you say a word about how the VA can 

lead this country away from opioids, although obviously sometimes 

they are necessary, into less type of dependent drug approaches? 

Secretary SHULKIN. Yeah. I will try to do it briefly, but I will tell 

you I published an article on this 4 or 5 months ago in the Journal 

of the American Medical Association about the VA’s approach, because I think it is a national example that others can learn from. 

We started this work in 2010, where we identified problems before the rest of America did, as the VA often does, and we did this 

through a multifactorial approach. We essentially now monitor the 

patterns of all of our providers, and we give them feedback on how 

they perform compared to their peers. 

Senator SANDERS. If they are overprescribing. 

Secretary SHULKIN. If they are overprescribing. 

We do academic detailing, where pharmacists go out and actually 

teach our providers the ways to use opioids appropriately. 

We have our patients sign informed consent, so that they are 

part of the process when they get an opioid. 

We participate in the State prescription data monitoring programs. It is mandatory that our providers do that. 

We are providing alternatives such as you said, complementary 

care. In fact, the best practice for us in the country—I do not know 

if you know this—is actually White River Junction, where we have 

a 50 percent reduction in opioid use, using those exact techniques, 

complementary medicine. 

Senator SANDERS. Acupuncture. 

Secretary SHULKIN. Acupuncture, yoga, mindfulness, biofeedback. 

I mean, you know, mind-body type of techniques, and so we are trying to get others to be as good as we are doing in White River 

Junction. 

We are working in a number of these areas, and of course, we 

are trying to work on research with the FDA and NIH on non-addictive narcotics as well, because we think that is important. 

88 

Senator SANDERS. Good. Thank you very much. 

Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Sanders. 

Thanks to all of you. It has been very helpful and informative. 

I would ask you to be excused, and our second panel may come 

forward. 

Secretary SHULKIN. Thank you. 

[Pause.] 

Chairman ISAKSON. Let me thank Secretary Shulkin and his 

staff for their testimony and their support and the continued response to Committee. We are very grateful for that. 

Let me welcome our second panel, and I will begin with the introductions: Mr. Carl Blake, Associate Executive Director, Government Relations, Paralyzed Veterans of America; Mr. LeRoy Acosta, 

Assistant National Service Director, Disabled American Veterans; 

Mr. Carlos Fuentes, Director, National Legislative Service, Vietnam—Veterans of Foreign Wars; Mr. John Rowan, National President, Vietnam Veterans of America. 

Mr. Blake. 

You are each recognized for 5 minutes. 

STATEMENT OF CARL BLAKE, ASSOCIATE EXECUTIVE DIRECTOR, GOVERNMENT RELATIONS, PARALYZED VETERANS OF 

AMERICA 

Mr. BLAKE. Mr. Chairman, thank you for the opportunity to testify today. With your approval and the Committee’s approval, we 

would like to submit our fiscal year 2018 Independent Budget Report into the official hearing record. 

Chairman ISAKSON. Without objection. 

[The report can be found online at: http:// 

www.independentbudget.org/2018/FY18_IB_BudgetBook_6.6.17.pdf] 

Mr. BLAKE. Thank you. 

I think I would like to spend my time talking a little bit about 

what we have heard today rather than just specifically the recommendations that are included in our budget report. 

Let us recap. I appreciate Senator Heller bringing up the question about IU. Although I would say it is not readily apparent, the 

VA has said for sure that it is going to drop that proposal altogether, it sounds like the Secretary is willing to discuss it further 

and see where this goes from here. 

I appreciate Senator Manchin and also Senator Tester for bringing up the question about the electronic health record (EHR) modernization and Cerner. 

Senator Rounds continues to beat the drum about the Staab 

ruling. 

Senator Moran really started to probe at the question about 

holes that seemed to be appearing in the VA’s budget. 

I appreciate that the Secretary has made the commitment he has 

as it relates to the EHR modernization, doing the right thing on 

the Staab ruling, and trying to address issues like the caregiver expansion. It is not an easy job. I do not envy the position he is 

placed in. 

Let us forget for minute, let us just set aside the fact that it 

sounded like to me, we may be staring a budget shortfall right in 

89 

the face just for this current fiscal year based on this transferability problem and moving money between Community Care and 

Choice. All those things historically have added up to a shortfall 

somewhere. 

Let us look at fiscal year 2018. I think that is a good way to sort 

of snapshot the bigger hole that VA has to deal with. 

Senator Heller mentioned IU. IU and its proposal was presumably going to fund a large majority of Choice going forward, in perpetuity as it were, at least $3.2 billion. If we assume that that is 

not going to happen, that is $3 billion in Community Care under 

Choice that has to be addressed somehow. It is not addressed in 

the discretionary part of the VA’s budget. 

It is all well and good to say we have enough money; $3 billion 

is a lot of money to say that we have enough. 

Senator Manchin and Senator Tester mentioned the Cerner decision. I think on policy, that is probably the right decision to make 

for VA and for DOD, but I read an article recently that said the 

Department of Defense’s obligation under Cerner is something on 

the order of $9 billion, I think, in the life cycle of that program. 

It also said that VA’s obligation will be at least three to four times 

that great. How does the VA’s budget rationalize that point? I am 

sure it does not. 

Senator Rounds mentioned Staab. It is the right thing to do, 

what the Secretary said. I think he knows it, and he is acting upon 

that. I was actually sort of amused that he said they expedited the 

rulemaking process. I think he said it went to OMB. That is where 

the expedited process goes to die. He said last week it might take 

9 months. OMB will be on the clock for the next 9 months, I am 

sure, knowing their track record. 

That aside, the Staab ruling has already left VA with an obligation in previous years of at least $2 billion. Where is that money 

which is going to pay for that issue? 

The average in subsequent years is a billion dollars, 1.1, 1.08, 

something in that range. Where is that money? It is not in the VA 

budget either. 

Now we are keeping score. We have a $3.2 billion IU hole for 

Choice. We have an approximately $1 billion hole for Staab, and 

then we have the Cerner issue. We do not even know what that 

hole looks like. 

I could also make the argument that looking out into fiscal year 

2019 that budget is certainly short because the Community Care 

account in that budget alone is less than the projection for 2018, 

and the Choice plan has it at exactly the same dollar figure, approximately $3.5 billion. Are we going to decrease Community Care 

usage in 2019? I think we all at this table know that is not going 

to happen. 

Right now, the VA could be staring at a huge hole in its budget 

for 2018, and we have expressed this to the appropriators. Unfortunately, because of the timing and everything, the appropriators 

have already moved forward on the House side. They are going to 

mark up their MILCON/VA bill tomorrow, and none of these questions are answered, yet the VA is left with billions of dollars in unanswered questions. It is not enough to simply say, ‘‘We have 

90 

enough money. We can move it around.’’ That is not true. That is 

just simply not true. 

Mr. Chairman, I appreciate the opportunity to testify. I would be 

happy to answer any questions you may have. 

[The prepared statement of Mr. Blake follows:] 

PREPARED STATEMENT OF CARL BLAKE, ASSOCIATE EXECUTIVE DIRECTOR OF

GOVERNMENT RELATIONS, PARALYZED VETERANS OF AMERICA

CHAIRMAN ISAKSON, RANKING MEMBER TESTER, AND MEMBERS OF THE COMMITTEE, 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. 

VA Accounts for FY 2018 and FY 2019 Advance Appropriations 

FY 2017 

Appropriation 

FY 2018 

Advance 

Approps 

FY 2018 

Admin 

Revised FY 2018 IB 

FY 2018 

Advance 

Approps 

FY 2018 IB 

Advance 

Approps 

Veterans Health Administration (VHA) 

Medical Services ............................................................ 45,505,812 44,886,554 45,918,362 64,493,555 49,161,165 69,450,838 

Medical Community Care .............................................. 7,246,181 9,409,118 9,663,118 8,384,704 

Subtotal Medical Services ........................................ 52,751,993 54,295,672 55,581,480 64,493,555 57,545,869 69,450,838 

Medical Support and Compliance ................................. 6,524,000 6,654,480 6,938,877 6,657,955 7,239,156 6,793,408 

Medical Facilities .......................................................... 5,321,668 5,434,880 6,514,675 5,796,343 5,914,288 6,562,579 

Subtotal Medical Care, Discretionary ....................... 64,597,661 66,385,032 69,035,032 76,947,853 70,699,313 82,806,825 

Medical Care Collections ............................................... 3,558,307 3,627,255 3,271,000 3,277,000 

Choice Program** ......................................................... 2,900,000 3,500,000 3,500,000 

Total, Medical Care Budget Authority (including 

Collections) ........................................................... 68,155,968 70,012,287 75,806,032 76,947,853 77,476,313 82,806,825 

Medical and Prosthetic Research ................................. 675,366 640,000 713,200 

Millions Veterans Program ............................................ 65,000 

Total, Veterans Health Administration ..................... 68,831,334 70,012,287 76,446,032 77,726,053 

General Operating Expenses (GOE) 

Veterans Benefits Administration ................................. 2,856,160 2,844,000 3,134,540 

General Administration .................................................. 345,391 346,891 406,454 

Board of Veterans Appeals ........................................... 156,096 155,596 158,196 

Total, GOE ................................................................. 3,357,647 3,346,487 3,699,190 

Departmental Admin/Misc. Programs 

Information Technology ................................................. 4,278,259 4,055,500 4,361,502 

National Cemetery Administration ................................ 286,193 306,193 291,085 

Office of Inspector General ........................................... 160,106 159,606 162,545 

Total, Dept. Admin/Misc. Programs .......................... 4,724,558 4,521,299 4,815,132 

Construction Programs 

Construction, Major ....................................................... 528,110 512,430 1,500,000 

Construction, Minor ....................................................... 372,069 342,570 700,000 

Grants for State Extended Care Facilities .................... 90,000 90,000 300,000 

Grants for State Vets Cemeteries ................................. 45,000 45,000 46,000 

Total, Construction Programs ................................... 1,035,179 990,000 2,546,000 

Other Discretionary ........................................................ 201,000 180,214 203,000 

Total, Discretionary Budget Authority (including 

Medical Collections) ............................................. 78,149,718 85,484,032 88,989,375 

**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 

91 

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 

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-insignifiVerDate Mar 15 2010 16:16 Jul 12, 2018 Jkt 000000 PO 00000 Frm 00095 Fmt 6633 Sfmt 6621 Z:\ACTIVE\061417.TXT PAULIN
92 

cant 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 Veterans 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. 

93 

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 

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. 

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. 

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MEDICAL SUPPORT AND COMPLIANCE

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. 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 Committee may have. 

Chairman ISAKSON. Thank you very much for your testimony. 

Mr. Acosta. 

STATEMENT OF LEROY ACOSTA, ASSISTANT NATIONAL 

SERVICE DIRECTOR, DISABLED AMERICAN VETERANS 

Mr. ACOSTA. Mr. Chairman, Members of the Committee, as coauthor of the Independent Budget (IB), along with VFW and PVA, 

DAV is pleased to present our views regarding fiscal year 2018 

funding requirements for veterans’ benefits programs. 

Today, I will focus on critical funding needs for VBA’s Compensation Service, Vocational Rehabilitation and Employment, and the 

Board of Veterans Appeals. I will also cover our strong opposition 

to a couple of ill-conceived and unacceptable administration proposals to scale back veterans’ disability compensation. 

Mr. Chairman, the IB recognizes that VBA has made significant 

progress in reducing the disability claims backlog. VBA is processing more claims than ever before, yet workload continues to rise. 

To manage current and future workload, the IB recommends an additional 1,750 FTEE for VBA’s Compensation Service, which would 

require an increase of approximately $183 million. 

VA’s Voc Rehab Service also needs additional funding. Over the 

past few years, program participation has increased by 15 percent 

overall, and based on historical trends, it would increase by another 5 percent in fiscal year 2018. To meet rising demand and to 

achieve and sustain the 1–to–125 counselor-to-client ratio estabVerDate Mar 15 2010 16:16 Jul 12, 2018 Jkt 000000 PO 00000 Frm 00098 Fmt 6633 Sfmt 6601 Z:\ACTIVE\061417.TXT PAULIN
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lished for Voc Rehab by law, the IB recommends an additional 266 

FTEE, which would require a $32 million increase. 

Overall, the IB recommends total funding for VBA be increased by $278 million, a 10 percent increase in order to fund these two 

staffing increases and maintain current service levels for the rest 

of VBA. 

Unfortunately, the administration has recommended an outright cut in funding for VBA of $12 million. For overall funding, that is 

$300 million less than that recommended by the IB. We urge the Committee to support our recommended funding 

levels to continue VBA’s progress in delivering earned benefits to 

veterans, their families, and survivors. 

Mr. Chairman, VBA has made significant progress on its claims 

backlog. One consequence has been an alarming increase in a backlog of appeals for denied claims. Today, there are over 450,000 appeals pending either at VBA or the board, and it takes almost 6 

years on average for a decision by the board. 

Fortunately, the IBVSOs have been part of a stakeholder work 

group with VA to develop and enact comprehensive reform of the 

appeals process. S. 1024, the Veterans Appeals Improvement and 

Modernization Act of 2017, is built upon the stakeholder framework and has received broad bipartisan support. 

We urge you to move forward expeditiously and pass this legislation. The House has passed similar legislation earlier this year. Enactment of this legislation would lead to a more modern, responsive, and flexible appeals system, one that will provide veterans 

with quicker decisions on appeals while fully protecting veteran’s 

due process rights. Even with passage of appeals reform, however, 

the board will continue to require resources commensurate with 

workload. 

Last year, Congress authorized the board to increase this FTEE 

by 242 to an authorized staffing level of 922 FTEE. The board has 

not yet filled all those positions. For fiscal year 2018, the IB expects the board to continue hiring, to fill all authorized positions, 

and we do not recommend further staffing increases while this new 

legislation is being approved and implemented. 

Moving forward, the board and Congress must carefully monitor 

implementation of a new appeal system to ensure that staffing remains adequate to meet future workload demands. 

Finally, Mr. Chairman, DAV and the IB enthusiastically oppose 

two legislative proposals in the administration’s budget. First, we 

strongly oppose the proposal to round-down COLAs for 10 years, 

which would hurt our Nation’s injured and ill veterans, their families and survivors. The cumulative effect of this proposed tax would 

cost beneficiaries nearly $2.7 billion over 10 years. We urge this 

Committee and the entire Congress to soundly reject it. 

Furthermore, we adamantly object to the proposal that will cut 

off eligibility for VA’s individual unemployability, or IU, simply because disabled veterans reach an age in which they might qualify 

for Social Security retirement benefits. 

Mr. Chairman, total compensation for IU is not a retirement benefit. It is provided for as compensation for veterans who suffer lifelong service-connected disabilities and are determined unable to 

work. Furthermore, this would also lead to veterans losing ancilVerDate Mar 15 2010 16:16 Jul 12, 2018 Jkt 000000 PO 00000 Frm 00099 Fmt 6633 Sfmt 6601 Z:\ACTIVE\061417.TXT PAULIN
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lary benefits that result from a total disability rating, such as dependents educational assistance, CHAMPVA, commissary and exchange privileges, and in many cases, State benefits such as property tax exemptions. 

We call on Members of this Committee and the entire Congress 

to soundly reject these dangerous proposals that would be harmful 

to disabled veterans. 

That concludes my testimony. I would be happy to respond to 

any questions that you or Members of the Committee may have. 

[The prepared statement of Mr. Acosta follows:] 

PREPARED STATEMENT OF LEROY ACOSTA, ASSISTANT NATIONAL LEGISLATIVE

DIRECTOR, DISABLED AMERICAN VETERANS

MR. CHAIRMAN AND MEMBERS OF THE COMMITTEE: As one of the co-authors of The 

Independent Budget (IB), along with Veterans of Foreign Wars (VFW) and Paralyzed 

Veterans of America (PVA), DAV is pleased to present our views regarding fiscal 

year (FY) 2018 funding requirements to support the Department of Veterans Affairs 

(VA) ability to process and deliver timely, accurate benefits to veterans, their families and survivors. 

GENERAL OPERATING EXPENSES (GOE)

Veterans Benefits Administration $3.135 billion 

The Veterans Benefits Administration (VBA) account is comprised of six primary 

divisions. These include Compensation; Pension; Education; Vocational Rehabilitation and Employment (VR&E); Housing; and Insurance. The increases recommended 

for these accounts primarily reflect current services estimates with the impact of inflation accounting for most of the increase. However, the IB recommendations for 

Compensation and VR&E also reflect a significant increase in requested staffing to 

meet the rising demand for those benefits. The IB recommends approximately 

$3.135 billion overall for VBA for FY 2018, an increase of approximately $279 million over the enacted FY 2017 appropriations level. The IB recommendation includes 

an increase of $183 million above current services in the Compensation account, and 

approximately $32 million above current services in the VR&E account to provide 

for approximately 2,000 new full-time equivalent employees (FTEE) to address rising workload. 

Compensation Service Personnel 1750 New FTEEs $183 million 

VBA continues to produce record numbers of claims while maintaining an emphasis on quality. Over the past few years, VBA has made significant progress in reducing the disability compensation backlog, which at its peak, stood at over 600,000 

claims in March 2013. Today, the claims backlog stands at just over 90,000 claims, 

a decrease of more than 85 percent from its peak. However, there has recently been 

a rise in the overall disability claims inventory and the amount of time it takes to 

process both claims and appeals. These increases can be attributed to multiple factors, including an increase in the number of claims and appeals being filed, the lack 

of adequate resources to keep pace with demand and the curtailing of mandatory 

overtime to reduce the claims backlog. 

In 2009, VBA issued claims decisions on 2.74 million medical issues; that number 

more than doubled to 5.76 million in FY 2016, but was less than FY 2015 when 

it issued 6.35 million decisions on medical issues. In March 2013, VBA required 

roughly 282 days to process a claim. At the close of FY 2016, VBA reported that 

on average, it took 123 days to process a claim; however, in FY 2015, VBA reported 

that it took, on average, 92 days to complete a claim. In FY 2015, total inventory 

stood at about 352,000 claims; today VBA has a total inventory close to 400,000 

claims. Furthermore, VBA has an inventory of nearly 584,000 non-disability rating 

claims, such as, claims for changes in dependent or marital status. 

It will require a combined focus on technology and staffing levels for VBA to provide veterans and their dependents with more timely and accurate claims decisions. 

For FY 2018, the Independent Budget veterans service organizations (IBVSOs) recommend an additional 1,750 FTEE to manage VBA’s overall rising workload. Furthermore, since VBA stopped utilizing mandatory overtime for claims processing, 

the true need for additional personnel has become more evident. Of the overall increase in personnel, we recommend 1,000 FTEE be dedicated to processing appeals 

pending at VBA in an effort to eliminate the backlog of 380,000 appeals in VBA over 

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the next three years. Depending on progress this year, further personnel increases 

may be necessary to reduce the appeals backlog at VBA. In addition, we recommend 

350 FTEE be dedicated to addressing the growing backlog of non-rating related 

work, such as dependency claims. An additional 300 FTEE should be dedicated for 

claims processing to address the incremental rise in the claims inventory and backlog and 100 FTEE dedicated to staffing the Fiduciary program to meet the growing 

needs of veterans participating in VA’s Caregiver Support programs. This recommendation is based on a July 2015 VA Inspector General report on the Fiduciary 

program that found, ‘‘...Field Examiner staffing did not keep pace with the growth 

in the beneficiary population, [and] VBA did not staff the hubs according to their 

staffing plan... .’’ 

VR&E Service Personnel 266 New FTEEs $32 million 

The Vocational Rehabilitation and Employment Service (VR&E), also known as 

the VetSuccess program, provides critical counseling and other adjunct services necessary to enable service-disabled veterans to overcome barriers as they prepare for, 

find, and maintain gainful employment. VetSuccess offers services on five tracks: reemployment; rapid access to employment; self-employment; employment through 

long-term services; and independent living. 

VR&E also operates its VetSuccess on Campus (VSOC) program at 94 college 

campuses. 

Over the past few years, program participation has increased by 15 percent overall: increasing by 7.3 percent in FY 2015, 3.8 percent in FY 2016, and an estimated 

4 percent in FY 2017. As VBA continues to expand VR&E eligibility to more veterans, due to increased claims processing and the award of new service-connected 

disabilities due to new presumptive disabilities, we project that total program participation for FY 2018 will grow by at least 5 percent for total caseload of close to 

155,000. 

Last year, Congress enacted Public Law 114—223, which authorizes the Secretary 

to use appropriated funds to ensure the ratio of veterans to full-time employment 

equivalents does not exceed 125 veterans to one full-time employment equivalent, 

a goal that VA has not met for many years. In July 2015, VR&E reported that its 

average Vocational Rehabilitation Counselor (VRC)-to-client ratio had risen to 1:139. 

However, in both FY 2016 and FY 2017, the Administration flat-lined the VR&E 

request for direct personnel at 1,442. In order to achieve and sustain a 1:125 counselor-to-client ratio in FY 2018, we estimate that VR&E would need 266 new FTEE, 

for a total workforce of 1,550 FTEE, to manage an active caseload and provide support services to 155,000 VR&E participants. At a minimum, three-quarters, of the 

new hires should be VRCs dedicated to providing direct services to veterans. This 

increase in personnel would address expected growth in VR&E claim filings and 

program participation, as well as collateral duties performed by VRCs outside of 

general case management. It is also essential that these increases be properly distributed throughout all of the VR&E program to ensure that VRC caseloads are equitably balanced among VA Regional Offices. 

GENERAL ADMINISTRATION

Board of Veterans’ Appeals $158 million 

Faced with a rising appeals backlog that could no longer be ignored, last year 

Congress authorized the Board of Veterans’ Appeals (Board) to increase its FTEE 

by 242 over FY 2016 levels, bringing their total authorized staffing to 922 FTEE 

for FY 2017; however, the Board has not yet hired to their full authorized level. For 

FY 2018, the IBVSOs recommend no additional increases in FTEE; but note, the 

Board must be permitted to hire its full complement of 922 FTEE. Further, as the 

number of claims processed annually continues to rise as a result of the increased 

capacity of VBA, the number of appeals filed annually will grow commensurately. 

In order for the Board to keep pace with this new incoming workload alone, not including those appeals already in the system, FTEE levels will have to be adjusted 

accordingly, though appeals reform legislation could alleviate some of that need in 

the future. 

The IBVSOs thank Chairman Isakson, Senators Blumenthal, Tester and the other 

cosponsors for introducing the Veterans Appeals Improvement and Modernization 

Act of 2017 (S. 1024), legislation that would fundamentally reform and streamline 

the overall appeals process. Similar legislation, H.R. 2288, was introduced and 

passed in the House. These measures include provisions that reflect significant efforts and the consensus of a working group formed in March 2016 that consisted of 

the IBVSOs, other VSO stakeholders, and leaders within VBA and the Board. Regardless of potential passage of this legislation the Board will continue to require 

98 

resources commensurate with workload, especially to process legacy appeals remaining at the time of enactment of new appeals reform legislation. Further, the Board 

must be funded and empowered to continue pursuing information technology (IT) 

modernization solutions that best meet the specific workflow needs of the Board, 

while ensuring it also supports seamless integration with the Veterans Benefits 

Management System and other IT systems used by VBA and the Court of Appeals 

for Veterans Claims. Given the potential for significant and positive impact this 

would have on veterans’ ability to receive more timely decisions, we look forward 

to the Committee passing appeals modernization, followed swiftly by enactment. 

COST OF LIVING ROUND DOWN

The Administration’s budget proposal released on May 23, 2017, contains a provision that would round down cost-of-living adjustments (COLAs) for our Nation’s injured and ill veterans and their families and survivors for a period of 10 years. DAV 

and our IB partners are strongly opposed to this rounding down provision. Veterans 

and their survivors rely on their compensation for essential purchases such as food, 

transportation, rent, and utilities. It also enables them to maintain a marginally 

higher quality of life. 

Rounding down veterans’ COLAs unfairly targets disabled veterans, their dependents and survivors to save the government money or offset the cost of other Federal 

programs. The cumulative effect of this provision of law would, in essence, levy a 

10-year tax on disabled veterans and their survivors, reducing their income each 

year. When multiplied by the number of disabled veterans and recipients of Dependency and Indemnity Compensation or DIC, hundreds of millions of dollars would be 

siphoned from these deserving individuals annually. All totaled, VA estimates, this 

proposed COLA round down would cost beneficiaries close to $2.7 billion over 10 

years. Congress must reject this ill-conceived proposal. 

INDIVIDUAL UNEMPLOYABILITY AND SOCIAL SECURITY OFFSET

We also note there is, unfortunately, a new proposal included in the President’s 

budget that would impact the VA’s Individual Unemployability or IU program which 

allows VA to pay certain veterans disability compensation at the 100 percent rate, 

even though VA has not rated their service-connected disabilities at the total level. 

Specifically, the proposal would terminate existing IU ratings for veterans when 

they reach the minimum retirement age for Social Security purposes (62), or upon 

enactment of the proposal if the veteran is already in receipt of Social Security retirement benefits. The IBVSOs vehemently oppose this proposal. 

As the Members of this Committee know, Congress delegated to the Secretary of 

Veterans Affairs the authority to adopt and apply a schedule of rating disabilities 

pursuant to section 1155 of title 38, United States Code. In accordance with VA regulation promulgated by the Secretary, total disability exists when any veteran is determined by VA to be unable to secure and maintain substantially gainful employment by reason of service-connected disability, regardless of age. (See 38 CFR, section 4.16(b).) IU is based on the impact of the individual’s own circumstances and 

it is an exception to the ‘‘average person standard’’ of the rating schedule. As a prerequisite for an IU rating, a veteran generally must have a disability rated 60 percent or higher under the rating schedule. 

Total compensation for IU is not a retirement benefit. Properly applied, the rules 

require a factual showing that the service-connected disability is such as to be incompatible with substantially gainful employment, regardless of age. Today, many 

people, including the President, members of the Cabinet and members of Congress, 

work well beyond the minimum or ‘‘normal’’ retirement age. Some continue to work 

because they love their job, while others may be forced by financial requirements 

to continue to work. 

This proposal is especially detrimental to the well-being of ill and injured veterans 

and their families because it forces a totally disabled veteran to take their social 

security benefits at the minimum age of 62, when the benefit is a small fraction of 

what he or she would receive at normal retirement age (65 to 67) or at age 70. Further, since the level of social security benefits is based on what an individual has 

paid into the fund, a veteran who was severely or totally disabled at a young age 

may not have paid sufficient funds to receive a level of benefits at the minimum 

age, or any age for that matter, to live a comfortable life because of reduced earnings due to service-related disabilities. 

We also remind the Committee that the loss of IU for many veterans would also 

have a negative impact on a veteran’s family due to the concurrent loss of ancillary 

benefits. Once the total disability rating for IU is reduced at age 62, the veteran 

and his or her family will lose Chapter 35 benefits for Dependents Education AssistVerDate Mar 15 2010 16:16 Jul 12, 2018 Jkt 000000 PO 00000 Frm 00102 Fmt 6633 Sfmt 6621 Z:\ACTIVE\061417.TXT PAULIN
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ance program, essential health care benefits from the Civilian Health and Medical 

Program of the VA (CHAMPVA) for dependents, Commissary and Exchange privileges and, in many cases, state benefits such as property tax exemptions. This damaging proposal should be rejected by Congress as it lacks compassion for the men 

and women who served our country and were severely disabled as a result of that 

honorable service. 

In summary, a final point I would like to make is that benefits received from the 

VA, or based on military retirement pay and other Federal programs have differing 

eligibility criteria as compared with the earned payments of Social Security. Reducing a benefit provided to a disabled veteran in receipt of IU due to receipt of a different benefit offered through separate Federal benefit program is simply an unjust 

forfeit of an earned, necessary benefit. 

Mr. Chairman, thank you for the opportunity to submit testimony and to present 

the views of the IBVSOs regarding FY 2018 funding requirements to support the 

VA’s ability to process and deliver benefits to veterans, their families and survivors. 

I would be happy to respond to any questions that you or Members of the Committee may have regarding this statement or our recommendations. 

Chairman ISAKSON. Thank you very much, Mr. Acosta. 

Mr. Fuentes. 

STATEMENT OF CARLOS FUENTES, DIRECTOR OF THE NATIONAL LEGISLATIVE SERVICE, VETERANS OF FOREIGN 

WARS OF THE UNITED STATES 

Mr. FUENTES. Chairman Isakson and Members of the Committee, 

on behalf of the men and women of the VFW and its Auxiliary, I 

would like to thank you for the opportunity to present our views 

on VA’s budget. 

The VFW is glad the administration has proposed a 6 percent increase in VA’s discretionary budget. We certainly support the continued focus on expanding access to health care; expediting decisions on benefits, claims, and appeals, increased focus on combating veteran suicide and addressing the stigma associated with 

mental health; ensuring VA is ready and able to care for women 

veterans who are the fastest-growing cohort of the veteran population. However, I would like to make it clear the VFW strongly opposes efforts to claw back benefits from our most severely disabled 

veterans to pay for such improvements. 

In the past week, nearly 40,000 letters and e-mails 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-connected disabilities. The VFW opposes the 

IU proposal and the COLA round-down proposal and other measures to balance the budget on the backs of our Nation’s veterans. 

We are also concerned with the administration’s request to make 

the Veterans Choice Program a permanent mandatory program, 

which could possibly lead to the gradual erosion of the VA health 

care system. 

The continued failure by Congress to eliminate sequestration has 

forced the administration’s proposed cuts to veterans programs in 

order to expand the Choice Program under mandatory spending instead of including it in discretionary Community Care accounts. 

Sequestration and draconian 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 Committee to join our campaign and finally end sequestration and do 

100 

away with Federal budget processes based on arbitrary budget 

caps. 

In partnership with our Independent Budget co-authors, DAV 

and PVA, I would like to focus some of my remarks on VA’s construction and National Cemetery administration budget request. 

For more than a decade, the 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 121 percent in 2012. We continue to believe that this need 

for space and chronic underfunding of major construction projects 

could force VA to ration care. 

VA’s budget request says that improving the condition of VA’s facilities through major construction projects accounts for the largest 

resource need to keep pace with the growing demand for VA outpatient care, yet the administration’s major construction request 

only funds one VHA major construction project. 

The IBVSOs believe that VA has requested an adequate amount 

for its fiscal year 2018 major medical leases needs; however, Congress must find a way to quickly authorize leasing projects. There 

are now 27 major medical facility leases awaiting congressional authorization, 18 of which have been waiting since 2015. Delays in 

authorization of these leases has a direct impact on VA’s ability to 

provide timely care to veterans. 

The National Cemetery Administration has a sacred duty to provide our Nation’s veterans a final resting place that honors their 

service. In 2016, NCA entered more than 130,000 veterans and eligible family members. The number of interments is expected to increase until 2022. Other factors have placed additional demands on 

NCA, and the IBVSOs are glad to see the administration’s request 

for NCA as higher than our recommendation, which I believe may 

be one of the only ones. We commend VA for continued commitment to NCA’s mission. 

Mr. Chairman, this concludes my testimony. I am happy to answer any questions that you and the Members of the Committee 

may have. 

[The prepared statement of Mr. Fuentes follows:] 

PREPARED STATEMENT OF CARLOS FUENTES, DIRECTOR, NATIONAL LEGISLATIVE

SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED STATES

CHAIRMAN ISAKSON, RANKING MEMBER TESTER AND MEMBERS OF THE COMMITTEE, 

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’ (VA) Fiscal Year (FY) 2018 appropriations and FY 2019 advance appropriations. 

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 and 

benefits. 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 certain severely disabled veterans who are unable to 

work due to their service-connected disabilities and round down cost of living disability pay increases, a proposal which the VFW has opposed in the past and continues to strongly oppose. 

101 

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. 

The Administration has also proposed a cap on the amount of tuition and fees 

that may be paid under the Post-9/11 GI Bill for programs of education in which 

a public institution of higher learning enters into an agreement with another entity 

to provide such education. Currently, third party training programs that contract 

with public schools are able to charge unlimited fees since public schools have no 

set dollar amount cap. 

A couple of years ago, it came to light that some contracted flight training programs were charging exorbitant fees, which far exceeded the cost of an average instate education. The VFW supports the Administration’s proposal to place a reasonable cap on these sorts of training programs. 

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 

David J. Shulkin has indicated that VA would like all 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 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 servicemembers, veterans, and their families the care and benefits they have 

earned and deserve. The VFW calls on the Committee 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. 

The VFW, in partnership with our Independent Budget (IB) co-authors—Disabled 

American Veterans (DAV) and Paralyzed Veterans of America (PVA)—produces annual budget recommendations for each of VA’s discretionary appropriation accounts 

and compares them to the Administration’s request. PVA has submitted testimony 

covering Veterans Health Administration (VHA) appropriation accounts and DAV 

has covered the IB’s recommendations for the Veterans Benefits Administration accounts. I will focus my remarks on VA’s construction and National Cemetery Administration (NCA) appropriations. 

Major Construction: 

FY 2018 IB Recommendation—$1.50 billion 

FY 2018 Administration Request—$512 million 

FY 2017 Appropriations—$528 million 

For more than a decade, the IB 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 

projects (96) accounted for the largest resource need.’’ 1 Yet the Administration’s 

major construction request for 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 

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allow VA’s inability to invest in its VHA’s major construction to limit veterans’ access to the health care they have earned and deserve by forcing veterans onto VA’s 

community care programs and eliminating the choice to receive care at VA medical 

facilities. 

Currently, VA has 24 major construction projects that are partially funded—some 

of which were originally funded in FY 2004—that need a clear path to completion. 

An additional three projects are in the design phase. Outside of the partially funded 

major projects list are major construction projects at the top of the FY 2017 priority 

list that are seismic in nature. 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 24 partially funded projects. 

Of the top five projects on the priority list, two are seismic deficiencies, two support 

the core mission of VA—a mental health clinic and a spinal cord injury center—and 

one is an addition to an existing facility. The total cost of these five projects is $1.2 

billion. 

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: 

FY 2018 IB Recommendation—$700 million 

FY 2018 Administration Request—$343 million 

FY 2017 Appropriations—$372 million 

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 Account- ability Act of 2014 (Public Law 133–146). 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 precludes the full cost of the lease being accounted for in the 

first year. There are now 27 major medical leases awaiting congressional authorization, 18 of which have been waiting since FY 2016 and six from FY 2017 that Congress must still authorize. Delays in authorization of these leases have a direct impact on VA’s ability to provide timely care to veterans in their communities. Congress must authorize these leases. 

National Cemetery Administration: 

FY 2018 IB Recommendation—$291 million 

FY 2018 Administration Request—$306.2 million 

FY 2017 Appropriations—$286 million 

The NCA, which receives funding from eight appropriation accounts, has the sacred duty to provide the brave men and women who have worn our Nation’s uniform 

a final resting place that honors their service. 

In a strategic effort to meet the burial and access needs of our veterans and eligible family members, the NCA continues to expand and improve the national cemetery system, by adding new and/or expanded national cemeteries. Not surprising, 

due to the opening of additional national cemeteries, the NCA is expecting an increase in the number of annual veteran interments through 2016 to more than 

136,000, up from 125,180 in 2014; this number is expected to slowly decrease after 

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an expected peak of 138,000 in 2022. This much needed expansion of the national 

cemetery system will help to facilitate the projected increase in annual veteran interments and will simultaneously increase the overall number of graves being maintained by the NCA to 3.7 million in 2018 and 4 million by 2021. 

Even as the NCA continues to add veteran burial space to its expanding system, 

many existing cemeteries are exhausting their capacity and will no longer be able 

to inter casketed or cremated remains. That is why the VFW is glad the see the 

Administration’s FY 2018 budget request for the National Cemetery Administration 

is higher than what the IBVSOs have recommended and includes a seven percent 

increase from FY 2017 appropriations. 

Factors that have placed additional demand on the NCA include an increase in 

the issuance of Presidential Memorial Certificates, which is expected to increase 

from approximately 654,000 in 2013 to more than 870,000 in 2017; the expected increase in the burial of Native American, Alaska Native, and Pacific Islander veterans; and the possible increase, thanks to local historians and other interested 

stakeholders, in requests for headstones or markers for previously unidentified veterans. That is why the IBVSOs are glad to see the Administration has requested 

$256 million in FY 2018 to fund six national cemetery expansion projects which 

would provide more than 161,000 new burial spaces for veterans. 

With the above considerations in mind, The Independent Budget recommends 

$291 million for FY 2018 for the Operations & Maintenance of the NCA. The 

IBVSOs believe that this should include a minimum of $20 million for the National 

Shrine Initiative. The IBVSOs laud the Administration for providing NCA the first 

increase in this important initiative since FY 2013. 

Mr. Chairman, this concludes my testimony. I will be happy to answer any questions you or the Committee members may have. 

Chairman ISAKSON. Thank you, Mr. Fuentes. We appreciate it. 

Mr. Rowan. 

STATEMENT OF JOHN ROWAN, NATIONAL PRESIDENT, 

VIETNAM VETERANS OF AMERICA 

Mr. ROWAN. Thank you, Mr. Chairman. Senator Sanders, nice to 

see you. Nice to see you, Senator. It is good to see you back. I 

missed you when I had my annual testimony this year. 

Chairman ISAKSON. I missed you more than you might think. 

[Laughter.] 

I am glad to be vertical again. 

Mr. ROWAN. Yeah. Well, me too. I was coming out of the hospital 

when you were going in, I think. 

Anyway, I would like to, first of all, thank you for the Accountability Act. It is an issue we have been dealing with since we started VVA, frankly, 35 years ago, calling upon Congress to take full 

accountability of all the VA operations, and hopefully, this will 

work. We support that bill. 

IU, as was noticed, has got to be rescinded. That whole proposal 

is a classic budget-tier proposal that has no idea how it impacts on 

people. It is just a dollar amount to somebody in OMB, with effects 

beyond even what everybody understood the first time with this 

whole nonsense that Social Security was going to pick up the 

amount of money lost on IU, not even talking about the effects on 

the family members—the loss of dental care, the loss of 

CHAMPVA, loss of local benefits. As was mentioned earlier, tax 

abatements in New York City—we just got the expansion of our tax 

abatement for real estate, which would be cut significantly by that. 

So, that this has just got to be—one of the things we are calling 

upon, we would like—since the Secretary has alluded to the fact 

that they may agree with the idea that this should be shelved, we 

would love to see a joint effort between the VA and the leadership 

in both the Senate and the House Veterans’ Affairs Committee 

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publicly denouncing this idea and saying we are not going to pass 

it, so that we can tell all those scared people out there, who have 

been sending me e-mails and letters about all of the horrors that 

they are concerned about. Let them know they have nothing to 

worry about. We have got to bring these people down about ten 

notches because they are climbing the walls right now. I mean, 

that is something I hope that the Committees, both in the Senate 

and the House, and the VA would take into consideration so they 

could publicly acknowledge that this was one bad idea. 

The Choice Program is not a choice. It is a false choice, and I 

think we need to understand how it is done. I just came back from 

Idaho, where I met with my State council up in Sandpoint in 

northern Idaho. Almost everybody there utilizes the Choice Program because they are hundreds of miles from any VA facility, but 

they also can tell me all the problems they have with Choice in 

finding doctors who will take Choice, who will take the VA’s 

money, who will even sign on because of problems. Now, we know 

they are trying to resolve those problems, but it is going to be a 

big issue for that. 

The other thing is doctors. Where are they coming from? I can 

tell you, I live in New York City. My dermatologist that I had in 

my private medical program for 25 years just retired on me. I managed to outlive him and that was great. He is retired. I am still 

sick, and I have to go see the doctor. I called up my 

EmblemHealth, which is one of the largest health care providers in 

the country, and they could not find me a dermatologist that I 

could talk to—at the earliest in August, and really they were talking about October. That is a false choice. That is dermatology, 

which I think I could throw a stick out of my window and hit a 

dermatologist in New York City, but they are not there because 

they do not sign up with the VA. They will not take the VA’s payments, just like we have seen in Medicare and Medicaid with problems with doctors not signing on. We are concerned about that. It 

really needs to be rethought significantly because the private sector 

is not ready whatsoever to take on the VA patients, no way. 

The last thing—a couple of things I would—my other point also, 

the R&D budget has been cut. It should not be cut. It should be 

increased. We need more R&D for all of the programs that we 

have. We need to get more evidence-based programs testing on 

PTSD and how do we really handle it. 

I cannot tell you all the different programs where folks tell me 

what a great panacea they have for PTSD; it sounds great. You 

know, I love my dogs, and yeah, they are helpful. Yes, they help 

some veterans, but without counseling, that does not end their 

problem. We need to get more evidence-based actions, research into 

these programs. 

I am also concerned—we passed a bill last year that would look 

into the effects of toxic exposure on the children of Vietnam veterans and veterans that came after us. Where is that money going 

to come from if the R&D budget is cut? We got a nice bill passed 

after we fought for years. Where is the money? We need the money, 

and if the VA’s budget is not there, how are we going to get that 

done? 

105 

Last, let me just say one quick thing about the Board of Veterans 

Appeals and the whole appeals process. It would go a lot quicker 

if the VA took outside doctors’ opinions and did not have to redo 

everything that somebody came in with, with an outside doctor’s 

opinion. That would be nice. 

The other thing is we need to blow up the Board of Veterans Appeals. It just does not function. Nobody should lose 70 percent of 

the time, which the VA does every year. I have been in this position 12 years, and in 12 years, every year, our VSOs, 70 percent 

of the time, either get a remand or a direct payment from the 

Board of Veterans Appeals on cases we bring in—70 percent. We 

win; VA loses. Year after year after year, and I guarantee you, that 

is the same percentage with the rest of the gentlemen at this table. 

I will bet all of their VBA cases are around the same percentage. 

That is ridiculous. 

The other problem is no precedence. Carl can put in a claim. I 

can put in a claim for the exact same thing. He gets Judge A. I 

get Judge B. We get two different opinions. They both go down. He 

wins; I lose. Too bad. His opinion does not account for anybody that 

follows after them if they have been approved, and neither does 

mine, for that matter. The denial does not either. It just keeps regurgitating the same programs over and over and over again, the 

same problems over and over and over again. We need to get the 

issue of precedence, like in any other court. Frankly, now that we 

understand the Court of Veterans Appeals, we are going to be very 

happy to look at them, the idea of doing class-action lawsuits at the 

Court of Veterans Appeals. 

I would be happy to answer any and all questions that anybody 

may have. Thank you. 

[The prepared statement of Mr. Rowan follows:] 

PREPARED STATEMENT OF JOHN ROWAN, NATIONAL PRESIDENT, 

VIETNAM VETERANS OF AMERICA

GOOD AFTERNOON, CHAIRMAN ISAKSON, RANKING MEMBER TESTER, AND OTHER EXEMPLARY MEMBERS OF THE SENATE VETERANS’ AFFAIRS COMMITTEE. Vietnam Veterans of America is pleased to have the opportunity to present our views on the 

President’s Fiscal Year 2018 Budget and 2019 Advanced Appropriations Request for 

the Department of Veterans Affairs. 

First off, VVA is pleased that the VA warrants increased funding to help meet 

the needs of the department and the veterans it assists in an array of areas designed to restore, as much as possible, those who have given of themselves—often 

at great cost to their health, to their sense of well-being, to their families. We know 

that you, the members and staff of this most important and hard-working committee, recognize this, and that you will be true to the sacrifices these men and 

women have made so that we all may live in a free society. 

We do, however, want to commence our remarks with the one issue in the budget 

proposal that has been the source of great consternation not only to VVA but to the 

multitude of VSOs and MSOs. This is a proposal that has unleashed a firestorm of 

protest, of questions, concerns, and fears, by veterans and their spouses who have 

come to depend on this income. 

INDIVIDUAL UNEMPLOYABILITY TERMINATION AND ELDERLY VETERANS

First and foremost, the Administration’s proposal that would cap IU benefits for 

veterans rated 60–100 percent disabled at age 62 and terminate this benefit for 

those veterans currently receiving Social Security must be a non-starter. It is unfair 

and simply wrong to characterize IU and Social Security as duplicative. Veterans 

have earned both benefits, IU by virtue of their service in uniform and Social Security through working and contributing into the system. 

106 

The logic behind this proposition, which seems to arise from the depths of the Office of Management & Budget (OMB) every eight years or so, often at the beginning 

of a new administration, is that, at age 62, veterans can avail themselves of their 

Social Security benefits. This does not take into account, however, that if a veteran 

has been receiving IU for several years, there’s a pretty good chance, if indeed not 

a likelihood, that s/he does not qualify for any serious Social Security income because s/he has not had a significant work history. 

This piece of the Administration’s budget proposal, if approved, would impact 

nearly every Vietnam-era veteran and their family whose survival depends on the 

income received from this earned benefit. This proposed change would cut the compensation of a married disabled veteran receiving 100% by dint of IU compensation 

to about $1,300 a month from just over $3,000 per month. Should any Member of 

Congress exhibit political naivete and vote to eliminate IU at age 62, tens of thousands of Vietnam veterans in their late sixties and seventies would be in jeopardy 

of not being able to meet their basic needs, which would lead, for many, to impoverishment, homelessness, even suicide. 

According to the budget proposal, this provision would ‘‘save’’ the Compensation 

and Pensions account in the Veterans Benefits Administration an estimated $3.2 

billion in 2018; $17.9 billion over five years; and $40.8 billion over ten. The savings 

would go toward funding the Veterans Choice program, which at present is confusing endeavor in many areas, which many veterans neither understand nor 

embrace. 

Furthermore, there are 238,000 veterans 62 and older currently receiving 100% 

by dint of IU, and of those 178,000 are 67 and older. The plain fact is that the VA 

disability rating schedule for mental health, and particularly for Post Traumatic 

Stress Disorder (PTSD) has for many years been grossly unfair. In order to be rated 

at 100% for PTSD a veteran would need to be exhibiting symptomology of full blown 

dementia (which has nothing to do with PTSD!). Since these veterans should have 

been rated at 100% for PTSD, but were not because the rating schedule was faulty, 

they have continued to draw service-connected compensation at the 100% level. 

They have been unable to work, so have not paid much, if any,into Social Security. 

Social Security is NOT akin to service-connected compensation, but rather it is analogous to an annuity. The more you pay in to Social Security, the more you get out 

of it in monthly increments. The less you pay into the Social Security Trust fund, 

the less your monthly payments. VVA has talked to numerous Vietnam veterans 

who have not been able to work since they were blown up in the Vietnam War, but 

paid into Social Security before Vietnam, so that their monthly payments are as little as $25 per month. 

The so-called ‘‘savings’’ achieved by means of this ruse would be illusory, because 

nearly every veteran in this situation would immediately re-apply seeking 100% 

service-connected disability without IU. This would result in a flood of claims at VA, 

and would once again create backlogs in processing of claims. 

We strongly urge the Committees on Veterans Affairs to issue a bi-partisan declaration that his ill-advised move will not happen on your watch. 

VA HEALTH CARE

The President’s budget request for medical care is $4.6 billion greater than the 

FY’17 budget, representing a 7% increase in discretionary spending; also, $2.9 billion in new mandatory budget authority to continue, and to enhance, the so-called 

Choice Program. Undergirding this increase is the need to continue to improve access to care for the 6.8 million of the 9.2 million veterans enrolled in the VA 

healthcare system. 

Now, we understand that Secretary Shulkin embraces funding for Choice which, 

if you’ll recall, was never meant to be a solution to the long-standing problem of 

access to quality care for veterans who seek services from the VA. His goal is to 

integrate Choice into a local/regional program of Community Care, with significantly greater funding for the FY’19 budget. 

We want to focus attention on two issues: collections from third party payers, and 

privatization. 

In the recent past, the VA put forth overly optimistic assessments of the number 

of dollars it could recoup via third party collections (along with all the million$ that 

would be saved through ‘‘management efficiencies’’). We hope this is not the case 

again. 

The persistent call by some for privatization of VA health care should be quelled 

by a successful initiation and operation of the Community Care program. We know 

there is an unfortunate number of vacancies for clinicians—not only in the VA 

healthcare system but in private and public venues as well. It makes eminent good 

107 

sense to bring in qualified, credentialed professionals to fill voids caused by, in no 

particular order: retirement and/or resignation of VA clinicians; increased demand 

in certain VA medical centers; delayed delivery of care, and other problems. 

CHOICE 2.0

VVA is concerned that the proposed budget does not provide enough funding for 

the new Choice currently in development. The Secretary is redesigning the program, 

altering it from an administrative system to a clinical one. We have some concerns, 

too, over the impact of proposed organizational changes in care delivery to veterans; 

how the high performing networks will function; and how this will then ease health 

care access. We understand that under the new proposal, providers will bring their 

networks with them, modeled after the Defense Department’s Tri Care system. 

Additionally, VVA has concerns about the consolidation of care authorities, a legislative ask that has been a priority for the agency. This authorization is needed, 

according to the VA, to move Choice forward, and yet this step has yet to be accomplished. The gist behind consolidating the care authorities was to make it simpler 

for veterans, employees, and providers to determine eligibility, and pay to providers 

more promptly, with less paperwork. The establishment of a mandatory pot of 

money for the Choice Program, with more than $2 billion in funding, seems to defeat the purpose of the care consolidation legislation. 

CAREGIVERS EXPANSION

The budget for FY’18 shows the Caregivers program cost estimate decreased by 

$235.9 million due to a revision in the projected number of caregivers receiving stipend payments. VA dis-enrolled 7,000 caregivers earlier this year. VVA was stunned 

to hear that these dis-enrollments were seemingly haphazard and conducted in an 

effort to bring down the cost of the program. While the Secretary committed to do 

a look-back on some 300 cases to evaluate the accuracy of the actions of those in 

the field, the review has been extended for six weeks as he juggles priorities. There 

still has been no commitment to do a ‘‘look back’’ on all 7,000 cases, which VVA believes is demanded by simple justice. We, and you, must continue to monitor the 

progress of review and its outcome. 

As we testified on March 9, 2017, we will work with legislators to enact a bill that 

encompasses qualified caregivers of veterans who served before 9/11. We are aware 

that this is a relatively expensive program. However, it is a bargain when compared 

to the cost of caring for many of these same veterans in an institutional setting. 

NATIONAL CENTER FOR PTSD

VVA strongly supports the Center (NCPTSD), which leads the Nation (and indeed 

the world!) in research focused on war-induced PTSD and related mental health illnesses, and serves as the Nation’s front-line resource center for information and 

education about PTSD research, not only for the VA and other mental health professionals, but for affected families and the general public. A strong and independent 

NCPTSD is essential. 

MENTAL HEALTH

VVA also supports additional funding for the development and implementation of 

scientific, evidence-based, integrated psychosocial mental health programs, substance abuse recovery treatment programs, and suicide-risk assessment programs 

for all veterans, especially since Secretary Shulkin has publicly stated that veteran 

suicide is the VA’s top clinical priority. 

MEDICAL AND PROSTHETIC RESEARCH

VVA notes that the funding for Medical and Prosthetic Research for the 2018 

budget request suffered a decrease of over $30 million. VVA has strong reservations 

concerning this decrease and recommends instead a significant increase instead. 

VA’s research program is distinct from that of the National Institutes of Health in 

that it was created to respond to the unique medical needs of veterans. In this regard, it should seek to fund veterans’ pressing needs for breakthroughs in addressing hazardous environmental exposures, post-deployment mental health issues, TBI, 

long-term care service delivery, and prosthetics to meet the multiple needs of the 

latest generation of combat-wounded veterans. 

We respectfully thank you for the opportunity to present our views, and will be 

pleased to respond to any questions you might want to put to us. 

Chairman ISAKSON. Thank you for your testimony. 

108 

I do not have a question. I have a proposition for you, though. 

I would like to find a time—and I would like my staff to listen to 

this—find time you and I could have lunch 1 day in the next 3 

weeks or month because you piqued an interest in my mind. Your 

comments about the IU earlier, unemployment compensation recommendation, which is a nonstarter with you, and I think anybody 

else would tell you that is pretty much a nonstarter too. It is not 

hard to pass benefits. It is hell to take them back, and once you 

pace past them, you are not going to take them back, or if you do, 

you lose a lot more than what you get. 

I also heard the comment, I think Mr. Acosta may have referred 

to his organization. Somebody did. Mr. Fuentes may have, about 

the COLA round-down. There are lots of things out there that over 

the period of years of the Veterans Administration and its existence and benefit existence and health care, where times have 

changed, things have changed. We probably ought to look at everything that we have out there, because there may be some pearls 

of wisdom. There may be some benefits in the scheme of things 

that are going to help us a lot more, applied a different way today 

than they were when they were passed. We need some folks who 

do not have any agenda except to help our veterans and solve our 

problems rather than going to court, to sit down and talk. 

I will call you, and we will have that lunch. 

Mr. ROWAN. I would love to. 

Chairman ISAKSON. I am not avoiding you, Mr. Acosta or Mr. 

Fuentes. Bigger than everybody, I am not going to avoid him or 

Mr. Blake either. You made the comment that piqued the interest, 

so we will do that, because I think if we open a little one-on-one 

dialog, there may be in some of these things that we bring up, because staff brings them to us or the OMB brings it up or your organization. You are looking out for the best interest to your organization and its members, and I appreciate that. I serve them as a master, but I also serve the taxpayers as a master and other people. 

We ought to start having some meetings and talk some of this stuff 

through. We may end up finding no common ground anywhere; yet, 

we might find some pearls of wisdom. If we do, I would love to 

work with you and anybody else on doing that. We will try to set 

that up, Mr. Rowan. 

Senator Sanders. 

Senator SANDERS. Thanks, Mr. Chairman. 

I should have known, but I had thought that we got rid of this 

round-down thing finally. I have been hearing about it probably 

from my first day in Congress. I was Chairman. We got rid of it. 

The idea of nickel-and-diming veterans did not seem a lot—so what 

you are telling me, Mr. Acosta or Mr. Fuentes, it is back again? 

Mr. FUENTES. Yes, sir. Thank you very much for your leadership 

while you were Chairman of this Committee by really eliminating 

that COLA round-down or that practice. 

Now the President’s proposal, as Carl laid out, proposed to reinstate the COLA round-down as a way to pay for expansion of the 

Choice Program as a mandatory program. 

Senator SANDERS. So, this is actually taking money away from 

VA benefits and using it in another purpose. How much would 

109 

this—if this were implemented, how much would it cost veterans? 

Anyone know? 

I think, Mr. Acosta, you mentioned. 

Mr. ACOSTA. Yes. The cumulative effect of this proposed tax would cost beneficiaries close to $2.7 billion. 

Senator SANDERS. Over what? A 10-year period? 

Mr. ACOSTA. Over 10 years. 

Senator SANDERS. Wow. All right. 

Mr. Chairman, I do not think we should be nickel-and-diming 

veterans. I mean, we have been through this for years. I thought 

we got rid of it, and it is sad to see that it is coming back. 

Let me ask what I think is the elephant in the room, and that 

is the concern—and I know the numbers seem to be disputed and 

not quite the clarity we would like; but, the increase in appropriations for the Choice Program and the very, very modest increase 

for traditional VA care. Who wants to comment? Is that a concern 

of you guys? Mr. Blake, is that a concern? We will start with you. 

Mr. BLAKE. Well, I think one of the concerns is—and the Secretary sort of addressed this in his comments. There were a lot of 

talks about our marriages and checkbooks. I think the bottom line 

is we believe that all of the Community Care should be streamlined 

under one authority, one account, and manage it that way. 

I think I understand why they put Choice over here on the mandatory side. There are a number of reasons, things like discretionary caps that are holding down discretionary spending that 

place that at risk, but from the Independent Budget perspective, we 

believe they are still shorting even the larger discretionary pot. The 

differences for construction, in particular, which are tremendous, 

and when you take into account that outside of the health care accounts, virtually every other line item in the VA’s budget takes a 

reduction of some type—— 

Senator SANDERS. Right, right. Let me get other comments, if I 

could. 

Anybody else want to comment? 

Mr. ACOSTA. Well, I concur with Mr. Blake. 

Senator SANDERS. OK. 

Mr. FUENTES. I would also just like to add, this whole notion of 

having a mandatory program and discretionary issues and not 

being able to transfer, I think it is more about, as Carl said, having 

one checkbook instead of requiring VA to have to balance both. 

Ultimately, you are absolutely right, Senator. We cannot forget 

the need to invest in VA’s ability to provide direct care, hire more 

physicians, expand facilities, because, ultimately, that is the preferred choice of veterans, and we need to continue that. 

Senator SANDERS. John? 

Mr. ROWAN. Yeah, I would just like to add, look, I have studied 

privatization. I worked for the city of New York as a manager for 

26 years and the last 2 in the City Council in the Controller’s office 

looking at all of those kinds of programs. I watched them privatize 

all kinds of things that never worked, because once you go outside 

and privatize, you are adding layers of bureaucracy and cost. You 

are not going to give it—you are not going to a doctor. You are 

going to a plan. The plan is going to be administrated by somebody 

who is making $2 million a year, and thank God our VA people are 

110 

not paid that much. They maybe should be, as I will tell you in my 

hospital care that I got at the VA Manhattan Hospital. But, that 

is not what we should be doing. 

Senator SANDERS. OK. Let me ask you for your very brief 

thoughts on a crisis that is impacting Vermont, NH, and the whole 

bloody country, which is this opioid epidemic. My impression is 

that the VA is trying to do the right thing. What are your thoughts 

on that? Who wants to jump in there? Mr. Fuentes? 

Mr. FUENTES. It is certainly an epidemic that must be addressed. 

We hear about anecdotes where veterans are being overmedicated. 

One of our concerns, though, I think would be the reverse as well 

because what we have heard is cutting off veterans without proper 

alternatives, and we certainly do not want that either. We do not 

want an overcorrection, but we do want to eliminate overmedication. 

Senator SANDERS. Other thoughts? 

Mr. ACOSTA. I agree. 

Senator SANDERS. OK. Mr. Chairman, thanks very much. 

Chairman ISAKSON. Thank you, Senator Sanders. I want to again 

thank all our VSO members for coming. I know when you go after 

the big guy and he testifies and we take 2 hours grilling him and 

then everybody is gone and you are stuck with me and the Secretary, which I want to commend the Secretary for staying through 

both panels. We really appreciate it. Your words are heard. We appreciate your input. We look forward to working with you toward 

providing the benefits that are earned and deserved for our veterans and doing it in the most efficient way possible for the taxpayer. That is our ultimate goal as a Committee. 

We thank you very much for your attendance today. The record 

will stay open for 7 days for any additional information you may 

want us to have. Now this Committee meeting stands adjourned. 

[Whereupon, at 4:39 p.m., the Committee was adjourned.] 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOHNNY ISAKSON TO

HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

INFORMATION TECHNOLOGY

Question 1. One of the Department of Veterans Affairs’ (VA) motivations in moving to Cerner for the VA Electronic Health Record was the speed with which VA 

will be able to implement this solution. Please provide the Committee a broad 

timeline of VA’s expectations in implementing the new system. 

a. How is VA planning to utilize the Department of Defense to learn from their 

experience implementing a large information technology (IT) acquisition? 

Response. VA is judiciously balancing the speed of implementation with risks to 

cost, schedule and performance objectives, and of course the care of our Veterans 

and other beneficiaries. VA has been working closely with DOD and ensuring alignment with commercial implementation best practices to optimize our prospective 

schedule. VA will be looking to go faster as our learning increases, and change management, training, and governance strategies take hold in support of greater deployment/implementation efficiencies. As an additional barometer of how aggressive VA 

is in their plan, DOD is deploying over a 7-year period under its 10-year contract 

with less than one-third of the size and substantially less complex than VA. VA will 

assess our full deployment (FD) strategy upon completion of Initial Operating Capabilities (IOC) roll-out over the first 18 months, and incorporate schedule efficiencies 

as warranted. 

b. How much additional funding does VA anticipate requesting for the transition 

of Electronic Health Records? 

Response. The VA requested to transfer $782 million in FY 2018 to implement 

the EHRM contract, PMO efforts and support infrastructure. 

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c. Given the large number of ongoing IT contracts that VA has, how does VA plan 

to evaluate the current projects to determine if they are necessary after the transition to Cerner? 

Response. As part of the overarching EHRM effort, the Veterans Health Administration (VHA) and the Office of Information and Technology (OI&T) are evaluating 

health IT and related area projects and contracts currently underway to determine 

which efforts should continue, be paused, modified or canceled. 

d. From an acquisition standpoint, does VA have the ability to modify contracts 

post-award, based on internal preferences, to change out solution components or 

team members that were selected under specific Request for Proposal criteria? 

Response. Yes. This is a firm-fixed price contract with clearly delineated and discrete deployment schedules, timelines, and milestones. Though there are no ‘‘builtin’’ penalties, the VA Contracting Officer and Program Management Office (PMO) 

are authorized to withhold payments for failure to perform contracted services or 

deliver contracted capabilities in accordance with the terms and conditions of the 

contract. The issuance of task orders will be judiciously managed to ensure excessive risk to the achievement of cost, schedule and performance objectives is not injected into the EHR modernization portfolio. 

e. If so, how does that affect liability and the burden of risk in the underlying 

contract? Do changes post-award shift the burden of risk from the prime contractor 

and team that was selected over to VA since the modification was made after the 

contract and terms were already awarded? 

Response. Post-award contractual changes may shift the burden of risk; however, 

since task orders are intended to stay within the general scope of the basic contract, 

VA should be protected against liability claims. Moreover, and as detailed above, 

since VA does not intend to mandate the use of a specific product, partner or methodology in order to meet contractual requirements, it will be further protected 

against liability claims. If the use or incorporation of a particular product or methodology is required, then the parties will work toward a bilateral agreement whereby the prime contractor will maintain the burden of risk and the adherence to the 

requisite performance parameters. 

f. How does VA plan to address elements such as time or cost overruns and increased protests due to requirements changes post-award, thus impacting the ability 

to provide timely solutions to our veterans for improving healthcare services? 

Response. VA is already operating on the Veterans Health Information Systems 

and Technology Architecture (VistA) platform delivering the requisite capabilities. 

In the event of a protest, VA will continue to utilize the VistA platform to support 

Veterans until a protest is formally adjudicated. The indefinite delivery and indefinite quantity (IDIQ) type contract and site surveys in advance of deployment will 

support the identification of issues that could cause scope creep or negatively impact 

schedule in advance of committing resources. 

CONSTRUCTION

Question 2. VA’s testimony submitted for the hearing highlights VA’s participation 

in the White House Infrastructure Initiative to explore ways to modernize and obtain upgrades to VA’s real property portfolio. Please provide additional details on 

VA’s participation in this initiative and the process VA is using to examine its real 

property portfolio. 

Response. VA is participating in the White House Infrastructure initiative, and 

is working with the Office of Management and Budget (OMB) to explore methods 

to enhance the delivery of high quality care and services for Veterans in VA facilities. The Department will continue to keep Congress informed as the Infrastructure 

Initiative evolves. 

Question 3. The fiscal year 2018 budget request includes $255 million for construction of six cemetery projects. 

a. In terms of locations across the country and types of interments, please describe some the most immediate priorities for increasing veterans’ access to National 

and State veterans cemetery options. 

b. What would those needs be over the next decade if this funding request for expansion in fiscal year 2018 is provided? 

Response. The National Cemetery Administration (NCA) administers burial and 

memorial benefits to Veterans and eligible family members worldwide. Currently, 

VA operates and maintains 135 national cemeteries in 40 states, and Puerto Rico, 

and is in the process of establishing new cemeteries. VA has also funded the establishment, expansion, or improvement of 105 state and tribal Veterans cemeteries in 

47 states, Guam, and the Northern Mariana Islands (Saipan), through the Veterans 

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Cemetery Grant Program (VCGP). Combined, these cemeteries provide burial options to approximately 91.7 percent of the total Veteran population in all 50 states, 

Puerto Rico, and the U.S. Island Areas. 

NCA’s near term focus is establishing congressionally approved and planned 

cemeteries, increasing availability of state and tribal Veterans cemeteries, and keeping existing national cemeteries open through expansion. 

New burial policies approved by the Congress in 2011 and 2013 support NCA’s 

Long Range Plan for 18 new national cemeteries—including in urban and rural locations. Additionally, VA is establishing five new columbarium-only cemeteries to enhance burial access for approximately 2.4 million Veterans residing in densely populated areas. Moreover, NCA is improving burial access for Veterans residing in 

sparsely populated rural areas not meeting the criteria for new national cemeteries, 

and which are unlikely to receive a grant for a state Veterans cemetery. Eight such 

identified locations will serve an additional 133,000 Veterans. 

Four of the 18 new cemeteries have already opened at Yellowstone County, MT 

(2014); Cape Canaveral, FL (2015); Tallahassee, FL (2015); and Omaha, NE (2016). 

NCA plans to open the remaining 14 (listed below) by 2021 at which point over 3 

million Veterans and their families will have new access to burial options. 

City State 

Uniquely Served 

Veterans within 75 Miles* Type Interments 

Cities with at least 80,000 Unserved Veterans within a 75 Mile Service Area 

Colorado Springs ................................... Colorado ................................ 278,137 All Burial Options 

Western New York (Buffalo) .................. New York ............................... 87,538 All Burial Options 

Cities Targeted for Rural Initiative 

Twin Falls .............................................. Idaho ..................................... 12,789 All Burial Options 

Machias ................................................. Maine .................................... 3,381 All Burial Options 

Elko ........................................................ Nevada .................................. 4,964 All Burial Options 

Fargo ...................................................... North Dakota ........................ 24,855 All Burial Options 

Cedar City .............................................. Utah ...................................... 15,904 All Burial Options 

Rhinelander ............................................ Wisconsin .............................. 19,109 All Burial Options 

Cheyenne ................................................ Wyoming ............................... 17,103 All Burial Options 

Cities Targeted for Enhanced Service (Urban Initiative) 

Los Angeles ............................................ California .............................. 539,163 Columbarium only 

San Francisco ........................................ California .............................. 444,434 Columbarium only 

Chicago .................................................. Illinois ................................... 557,861 Columbarium only 

Indianapolis ........................................... Indianapolis .......................... 250,245 Columbarium only 

New York ................................................ New York ............................... 782,139 Columbarium only 

* The Veteran populations cited above are based on the Vet Pop 2016 model. 

VA also helps fund new or expanded state and tribal Veterans cemeteries through 

the VCGP. NCA currently has no plans to establish more national cemeteries beyond the planned 18, but is committed to providing reasonable access to burial options through VCGP grants for state and tribal Veterans cemeteries. In total, we 

anticipate that by the end of 2018, 92.3 percent of the total Veteran population (over 

20 million Veterans) will have access to burial options in national, state or tribal 

Veterans cemeteries, within 75 miles of their home. Shown below is a list of planned 

expansion and establishment VCGP projects funded through FY 2018. 

2017 Grants for Construction of State Veterans Cemeteries 

Cemetery State Type of Grant 

Rocky Gap ................. Maryland ................ Expansion 

Knoxville-2 ................ Tennessee .............. Expansion 

Higginsville ............... Missouri ................. Expansion 

King .......................... Wisconsin .............. Expansion 

Springfield ................ Montana ................ Expansion 

Middletown ............... Connecticut ........... Expansion 

Hopkinsville .............. Kentucky ................ Expansion 

Milledgeville .............. Georgia .................. Expansion 

Radcliff ..................... Kentucky ................ Expansion 

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2017 Grants for Construction of State Veterans 

Cemeteries—Continued 

Cemetery State Type of Grant 

Gallup ....................... New Mexico ............ Establishment 

Cass Lake ................. Minnesota .............. Establishment 

Fort Yates ................. North Dakota ......... Establishment 

Middle town .............. Connecticut ........... Operations and Maintenance 

Maui .......................... Hawaii ................... Improvement 

Lanai ......................... Hawaii ................... Improvement 

Killeen ....................... Texas ..................... Improvement 

Mission ..................... Texas ..................... Improvement 

Hilo II ........................ Hawaii ................... Improvement 

2018 Grants for Construction of State Veterans Cemeteries 

Cemetery State Type of Grant 

West Hawaii .............. Hawaii ................................... Expansion 

Spanish Fort ............. Alabama ................................ Expansion 

Garrison Forest ......... Maryland ................................ Expansion 

Spring Lake .............. North Carolina ....................... Expansion 

Black Mountain ........ North Carolina ....................... Expansion 

Killeen ....................... Texas ...................................... Expansion 

Suffolk ...................... Virginia .................................. Expansion 

North Little Rock ...... Arkansas ................................ Expansion 

Boscawen .................. New Hampshire ..................... Expansion 

Saipan ...................... Northern Mariana Islands ..... Expansion 

Jennings .................... Louisiana ............................... Establishment 

Angel Fire ................. New Mexico ............................ Establishment 

Existing Cemeteries: 

In addition to increasing access through new national and grant-funded cemeteries, NCA maintains access at existing cemeteries through major and minor construction projects to develop additional gravesites and columbaria, or by acquiring 

more land. Requested funding for these initiatives varies based on projected burial 

workload and gravesite depletion forecasts. The FY 2018 budget includes $255.9 

million in Major Construction funding for gravesite expansion at six national cemeteries, and advance planning and design activities. Gravesite expansion projects at 

National Cemetery of the Alleghenies, PA; Florida National Cemetery, FL; Abraham 

Lincoln National Cemetery, IL; National Memorial Cemetery of Arizona, AZ; Sacramento Valley National Cemetery, CA; and Calverton National Cemetery, NY will 

enable these cemeteries to remain open. Together, these cemeteries provide over two 

million Veterans with access to burial options. FY 2018 funding will be used to complete master planning, design, and construction in time for necessary modifications 

prior to the anticipated depletion of burial options, and to avoid a temporary closure 

at one or more cemeteries. 

The FY 2018 request includes $98 million for minor construction projects to develop additional gravesites at existing cemeteries, support the urban and rural initiatives, acquire land, and make infrastructure improvements. NCA relies heavily 

on minor construction funding to develop additional gravesites for smaller scale 

projects to keep existing cemeteries open. 

The enclosure provides information related to depletion of gravesites for national 

cemeteries projected to deplete gravesites within the next 10 years. Projects in 

italics represent those with an immediate need to prevent a burial option from closing. This list does not include gravesite expansion projects that are funded, currently underway, or not projected to deplete within 10 years. 


614q3iq2_1.eps

NCA Depletion Rates: Cemeteries Projected to Deplete Within 10 Years and with Expansion Projects 

Last full year of interments with already-in progress expansion 

projects incorporated 

District Operating Full Casket Pre-placed Cemetery In-Ground Columba ria • Planned Action (Traditional) Crypts Status 

Leavenworth National Cemetery MW OPEN 2093 2045 2033 2024 Planned future year gravesite expansion project to mitigate depletion 

Marion National Cemetery MW OPEN 2066 2023 2023 2028 Planned future year gravesite expansion project to mitigate depletion 

Ohio Western Reserve National MW OPEN 2223 2024 2020 2023 Planned future yeargravesite expansion project to mitigate depletion 

Cemetery 

Rock Island National Cemetery MW OPEN 2045 2025 2032 2025 Planned future year gravesite expansion project to mitigate depletion 

Biloxi National Cemetery CN OPEN 2028 2022 2027 2027 NCA currently evaluating whether to acquire remote annex land or close 

Dallas - Ft. Worth National CN OPEN 2034 2024 2026 2024 Planned future year gravesite expansion project to mitigate depletion 

Cemetery 

Fayetteville National Cemetery CN OPEN 2060 2026 2024 2024 Planned FY18 Minor Construction gravesite expansion project 

Ft. Bliss National Cemetery CN OPEN 2078 2023 2020 2047 Planned future year gravesite expansion project to mitigate depletion Ft. Gibson National Cemetery CN OPEN 2065 2022 2025 2030 Planned future year gravesite expansion project to mitigate depletion 

Ft. Sam Houston National CN OPEN 2030 2025 2029 2023 Planned future year gravesite expansion project to mitigate depletion 

Cemetery 

Ft. Sill Nationa l Cemetery CN OPEN 2441 2027 2022 2040 Planned future year gravesite expansion project to mitigate depletion 

Ft. Smith National Cemetery CN OPEN 2148 2025 2023 N/A Planned future year gravesite expansion project to mitigate depletion Houston National Cemetery CN OPEN 2040 2027 2020 2024 Planned future year gravesite expansion project to mitigate depletion, FY 17 Minor for 

Cremains 

Louisiana Notional Cemetery CN OPEN 2276 2024 2030 2034 Planned future year gravesite expansion project to mitigate depletion 

Yellowstone National Cemetery CN OPEN 2029 2036 202S 2023 Planned future year gravesite expansion project to mitigate depletion 

Ft. Richardson Notional Cemete PC OPEN 2064 2023 2023 N/A Planned future year gravesite expansion project to mitigate depletion 

Notional Memorial Cemetery of PC OPEN 2054 2022 2023 2022 FY18 Major Construction Funding Requested 

Arizona 

Roseburg National Cemetery PC OPEN 2097 2059 2024 2026 Planned future year gravesite expansion project to mitigate depletion 

Sacramento Volley Notional PC OPEN 2075 2025 2024 2022 FY18 Major Construction Funding Requested 

Cemetery 

Santa Fe National Cemetery PC OPEN 2032 2023 2022 2023 Land acquisition in progress to construct a replacement cemetery near Albuquerque 

• Planned Act ion: remarks in this column reflect NCA operating plans and future projections that are subject to change. 

Bold font indicates FY18 Major Construct ion funding requested. Italic font represents immediate priority to prevent closure of a burial option. 

614q3iq2_2.eps

NCA Depletion Rates: Cemeteries Projected to Deplete Within 10 Years and with Expansion Projects 

Last full year of interments with already-in progress expansion 

projects incorporated 

District Operating Full Casket Pre-placed Cemetery In-Ground Columba ria • Planned Action (Traditional) Crypts Status 

Leavenworth National Cemetery MW OPEN 2093 2045 2033 2024 Planned future year gravesite expansion project to mitigate depletion 

Marion National Cemetery MW OPEN 2066 2023 2023 2028 Planned future year gravesite expansion project to mitigate depletion 

Ohio Western Reserve National MW OPEN 2223 2024 2020 2023 Planned future yeargravesite expansion project to mitigate depletion 

Cemetery 

Rock Island National Cemetery MW OPEN 2045 2025 2032 2025 Planned future year gravesite expansion project to mitigate depletion 

Biloxi National Cemetery CN OPEN 2028 2022 2027 2027 NCA currently evaluating whether to acquire remote annex land or close 

Dallas - Ft. Worth National CN OPEN 2034 2024 2026 2024 Planned future year gravesite expansion project to mitigate depletion 

Cemetery 

Fayetteville National Cemetery CN OPEN 2060 2026 2024 2024 Planned FY18 Minor Construction gravesite expansion project 

Ft. Bliss National Cemetery CN OPEN 2078 2023 2020 2047 Planned future year gravesite expansion project to mitigate depletion Ft. Gibson National Cemetery CN OPEN 2065 2022 2025 2030 Planned future year gravesite expansion project to mitigate depletion 

Ft. Sam Houston National CN OPEN 2030 2025 2029 2023 Planned future year gravesite expansion project to mitigate depletion 

Cemetery 

Ft. Sill Nationa l Cemetery CN OPEN 2441 2027 2022 2040 Planned future year gravesite expansion project to mitigate depletion 

Ft. Smith National Cemetery CN OPEN 2148 2025 2023 N/A Planned future year gravesite expansion project to mitigate depletion Houston National Cemetery CN OPEN 2040 2027 2020 2024 Planned future year gravesite expansion project to mitigate depletion, FY 17 Minor for 

Cremains 

Louisiana Notional Cemetery CN OPEN 2276 2024 2030 2034 Planned future year gravesite expansion project to mitigate depletion 

Yellowstone National Cemetery CN OPEN 2029 2036 202S 2023 Planned future year gravesite expansion project to mitigate depletion 

Ft. Richardson Notional Cemete PC OPEN 2064 2023 2023 N/A Planned future year gravesite expansion project to mitigate depletion 

Notional Memorial Cemetery of PC OPEN 2054 2022 2023 2022 FY18 Major Construction Funding Requested 

Arizona 

Roseburg National Cemetery PC OPEN 2097 2059 2024 2026 Planned future year gravesite expansion project to mitigate depletion 

Sacramento Volley Notional PC OPEN 2075 2025 2024 2022 FY18 Major Construction Funding Requested 

Cemetery 

Santa Fe National Cemetery PC OPEN 2032 2023 2022 2023 Land acquisition in progress to construct a replacement cemetery near Albuquerque 

• Planned Act ion: remarks in this column reflect NCA operating plans and future projections that are subject to change. 

Bold font indicates FY18 Major Construct ion funding requested. Italic font represents immediate priority to prevent closure of a burial option. 
116 

c. What would those needs be over the next decade if this funding request for expansion in fiscal year 2018 is provided? 

Response. The enclosure provides information related to depletion of gravesites for 

those national cemeteries projected to deplete gravesites within the next 10 years. 

This information includes cemetery names, current operating status, and years in 

which specific burial options are projected to deplete. The projected depletion dates 

account for, and assume the completion of current, in-progress gravesite expansion 

construction projects on schedule. The depletion dates do not account for any potential future gravesite expansion construction projects. Bold highlights are the six 

cemetery expansion projects included in the 2018 Major Construction request of 

$255.9 million. 

MEDICAL CARE

Question 4. VA’s testimony submitted for the hearing indicates that, after becoming the Under Secretary for Health, Secretary Shulkin ‘‘discovered that years of ineffective systems and deficiencies in workplace culture led to [the access] problem.’’ 

While VA has made strides in improving care to veterans, more work is needed. 

a. What were some of the ineffective systems and deficiencies that contributed to 

the access issue? 

Response. VA identified several factors that contributed to extended appointment 

wait times, including: 

1. Increased patient requirements for care coupled with inadequate staffing levels 

of providers, nurses, and schedulers led to inability to keep up with the demand for 

care; 

2. Inefficient clinic practices, lack of adequate training, and complicated legacy 

software led to high rates of scheduling errors; and 

3. Lack of national oversight and local monitoring systems meant access red flags 

were not responded to in time and proactive strategies were not set in place. 

b. What specific changes have been made to improve the system? 

Response. Since 2015, VA embarked on its largest access transformation, a major 

part of which was the MyVA Access improvement endeavor. Subject matter experts 

across VA were sequestered for 4 weeks to identify ineffective systems and deficiencies contributing to VA access shortfalls, standardize national guidance, and implement strong practices. Through MyVA Access, VA developed a comprehensive approach toward systemic access improvements. Specific changes related to the aforementioned reasons are as follows: 

1. Increased patient requirement for care coupled with inadequate staffing levels of 

providers, nurses, and schedulers led to inability to keep up with the demand 

for care. 

Provider Recruitment and Productivity: VA prioritized active recruitment of 

healthcare providers and clinic staff—supported by the Veterans Access, Choice and 

Accountability Act of 2014. This resulted in increasing provider and nursing staff 

by approximately 12 percent over the past 2 FYs. Additionally, on January 13, 2017, 

VA full practice authority went into effect for all Advance Practice Registered 

Nurses (APRNs). This rule is expected to continue to grow and fill gaps with access 

coverage. VA also focused on improving productivity for existing providers. By assessing clinical workload by the community standard of work RVUs (work relative 

value units), VA marked a 13 percent increase in total clinical productivity (wRVUs) 

produced and an increase in physician productivity, wRVU per clinical full-time 

equivalents (FTE), of 9 percent from FY 2014 to April 15, 2017. 

Utilizing internal resources: VA focused on increasing the use of telehealth for Primary Care and Mental Health. As a result, 12 percent of Veterans (727,000) receiving VA care from obtained 2.18 million telehealth appointments. VA has also expanding telehealth ‘‘hubs’’—medical centers that easily hire providers to deliver telehealth to another part of the country where a provider shortage exists. As of the 

end of 2017, VA has nine fully operational hubs in Primary Care and 11 in Mental 

Health. Additionally, some Veterans Integrated Service Networks (VISNs) have 

been setting up their own hubs. 

VA is also working to implement VA Video Connect, a simplified mobile and webbased application connecting Veterans with providers using encrypted video. It allows Veterans to see and talk to their health care team from anywhere using their 

smart phone, iPad or desktop computer, making appointments more convenient and 

reducing travel and wait times. VA is in the process of implementing this across 

VA. 

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2. Inefficient clinic practices, lack of adequate training, and complicated legacy software led to high rate of scheduling errors. 

Clinic Practice Management: Beginning in early 2016, VA implemented a Clinic 

Practice Management program at each VA Health Care System based upon private 

sector and DOD best practices to optimize administrative activities. This program 

monitors data and oversees timeliness and accuracy of Veteran appointments. Each 

VA system has at least one Group Practice Manager as well as a Clinic Practice 

Management team. A user-friendly Clinic Practice Management dashboard allows 

the Group Practice Managers as well as facility leadership to monitor clinic activities. This dashboard includes scheduling performance data down to each individual 

scheduler. 

Scheduler Training: VA recognized its scheduler training in the past was ineffective. To reduce scheduling errors, VA enhanced its training and identification of 

scheduling error warning signs. In December 2016, VA commenced system-wide 

mandatory face-to-face scheduler training, including hands-on supervised practice 

scheduling sessions. All newly hired schedulers must successfully complete this 

training. Over 30,000 schedulers have completed the training. 

Scheduling Directive: Revisions and clarifications on national guidelines were included in VHA Directive 1230, Outpatient Scheduling Processes and Procedures, 

published on July 15, 2016. VA completed over 70,000 episodes of directive-related 

training for over 50,000 staff who schedule appointments. Using Lean methodology, 

VA is also in the process of simplifying the scheduling process, which was initiated 

based upon input from front-line staff including schedulers. This is expected to result in a simplified update to scheduling and consult directives. 

VistA Scheduling Enhancement: Using 1980’s technology, VA’s current scheduling 

system is inefficient, results in scheduling errors, and creates barriers to optimize 

clinician productivity. Until the time a comprehensive resource-based scheduling 

system can be deployed VA is implementing VistA Scheduling Enhancement (VSE) 

as an interim solution. This improved user interface makes it easier to view available appointment times and reduces entry errors. The VistA Scheduling Enhancement has been implemented in 97% of facilities within VA. 

3. Lack of national oversight and local monitoring systems meant that red flags were 

not responded to in time. 

New National Establishments: The Office of Veteran Access to Care, a national 

level program office, was created in 2016. The office provides oversight and direction 

for policy and operations for optimization of Veteran access to health care. This office is led by an executive-level Assistant Deputy Under Secretary for Health for Access to Care who directly reports to the Deputy Under Secretary for Health for Operations and Management, and also has a platform for interaction and feedback 

with the Secretary, Deputy Secretary, Under Secretary for Health and Principal 

Deputy Under Secretary for Health. 

VA established a Health Improvement Center to track trends in quality, safety, 

access, and Veteran experience across multiple indicators. Sites that display anomalies or unfavorable trends are contacted and, where it is determined sub-par performance exists, the new Office of Reporting, Analytics, Performance Improvement, 

and Deployment, within the VHA Office of Organizational Excellence, mobilizes a 

team of experts to visit the site and provide on-site training and consultation, with 

follow-up to assure that progress is made. 

Scheduling Triggers and Audits: Using advanced statistical techniques, Scheduling Triggers were implemented as an early warning sign to alert leadership about 

inconsistencies with scheduling procedures and timeliness of care. Additionally, a 

mandatory standardized Supervisory Audit Tool was implemented June 1, 2017 to 

ensure every scheduler is audited at least twice annually. Audit results lead to direct feedback and coaching of individual schedulers, and is used by Facility, VISN 

and National leadership to ensure compliance, and assist with identifying opportunities for improvement. 

4. Additional Improvements to improve access. 

Timely Care: VA has made it a priority to focus on ensuring that the urgent care 

needs of Veterans are met in a timely manner. VA held two stand downs in November 2015 and February 2016 to reduce backlogs and ensure Veterans with urgent 

needs received timely care. Additionally VA worked to deliver same-day services for 

Primary Care and Mental Health. As of December 31, 2016, same-day services were 

achieved at all VA medical centers and as of November 2017, same day services is 

now available at the more than 1000 outpatient clinics across VA. 

VA also standardized processes to ensure new referrals to specialists are screened 

for urgent needs. In FY 2014, the average time it took to complete the most urgent 

118 

referrals to a specialist was 31.3 days. As of December 2017, the average time was 

2.6 days. In support of the focus on urgent consults, VA instituted a weekly national 

consult management call whereby scheduling experts provide technical assistance to 

the field to ensure the timeliness of scheduling. The calls commenced in 2015 and 

have become a driving force supporting timely scheduling and completion of urgent 

consults. 

To ensure the timely follow-up care for Veterans with urgent needs, in December 2016 VA implemented a process for providers to indicate priority level for followup appointments to ensure that Veterans’ timely follow-up needs are met. Providers 

flag these time-sensitive appointments in the return to clinic order to signal the 

scheduler to arrange for the follow up appointment no later than the provider recommended date. Since implementation through the end of FY 2017, 128,000 timesensitive appointments were completed across VA and of those about 90 percent 

have been completed by the provider recommended date. Over the first 3.5 months 

of FY 2018, almost 80,000 such appointments have been completed and of those, 

94.8% have been completed by the provider recommended date. 

Veteran Control: VA is working to empower Veterans to schedule the care they 

need. The Veterans Appointment Request App enables Veterans to schedule or cancel Primary Care appointments, and has been deployed to 1 14 sites since January 2017. VA also instituted Direct Scheduling allowing Veterans to request routine 

audiology, optometry, and nutrition appointments without having to obtain a referral from a Primary Care Provider. This not only decreased the wait time for services, it freed up primary care capacity. VA is working to expand Direct Scheduling 

options to podiatry, prosthetics, wheelchair, screening mammography, smoking cessation, and weight management appointments as well. 

Access and Quality in VA Healthcare website: In April, VA launched the ‘‘Access 

and Quality in VA Healthcare’’ website at www.accesstocare.va.gov to promote 

transparency. Through this tool, Veterans, their families, and caregivers can view 

data related to: 

• Patient wait times at VA facilities in their area; 

• Veterans experiences scheduling primary and specialty care; 

• Available options for same day services; and, 

• Quality of healthcare delivered at every medical center. 

Question 5. The fiscal year 2018 budget request estimates a reduction in medical 

care collections for fiscal year 2017 and fiscal year 2018. Please explain in detail 

what factors contributed to this estimated decrease in collections. 

Response. There are several key factors that contribute to the stable/declining collections estimate for 2017 and 2018: 

1. Tiered Medication Copayments: Effective February 27, 2017, VA amended its 

regulations governing copayments for certain Veterans for medication required on 

an outpatient basis to treat non-service-connected conditions. Prior to this change, 

the medication copayment was $8 per fill for Veterans in Priority Groups 2—6 with 

an annual out of pocket cost cap of $960. For Veterans in Priority Groups 7 & 8, 

the medication copayment was $9 per fill and there was no out of pocket cost cap. 

Under current policy, per fill copayments are $5 for Tier 1 medications, $8 for Tier 

2 medications, and $11 for Tier 3 medications; with an annual out of pocket cost 

cap of $700 applicable to Priority Groups 2—8. Under the revised regulations, the 

average copayment per prescription is less than in the past. Thus, VA estimates collections for these pharmacy copayments will be lower in 2017 and into the future. 

2. Third Party Collection or Recovery: Changes in the healthcare landscape have 

caused payers to adjust rates and/or reimbursement methodologies to minimize expenditures. 38 CFR 17.101 permits health plan contracts to pay billed charges or 

the amount they would pay for care or services furnished by providers in the same 

geographic area. Historically, many health plan contracts paid VA 100 percent of 

billed charges or above market rates. During the last six months of 2016, five large 

payers reduced reimbursement rates, or requested a decrease to align VA with what 

they are paying other providers in their respective markets. Additionally, VA has 

been tracking six payers identified as being at ‘‘high risk’’ for reducing payments 

based upon high reimbursement rates. These payers may request reductions in reimbursement rates with 30 to 120 days’ notice. 

Additional factors: VA’s Third Party reasonable charges are projected to decrease 

in CY 2017 by an average of 3 percent, which translates to a negative impact on 

collections; in particular for payers reimbursing on a percent of charge basis. Pursuant to 38 CFR 17.101, outpatient charges are calculated at the 80th percentile of 

various data sources such as Fair Health, MarketScan and Medpar for the Centers 

for Medicare & Medicaid Services (CMS)/Medicare data. In 2017, VA experienced a 

decrease in outpatient charges as a result of decreased charges in the Fair Health 

119 

data as well as decreased charges for Durable Medical Equipment (DME) in the 

CMS data. 

EDUCATION

Question 6. One of VA’s priorities is to improve timeliness of service, and VA has 

made it a goal to fully automate claims for veterans’ education benefits and consolidate outdated enrollment certification systems. This would produce faster decisions, 

reduce labor and administrative costs, and improve accuracy of claims. Is the decision to postpone this development due to a lack of IT resources or are there other 

practical considerations for waiting? 

Response. VA is prioritizing the retirement and replacement (when warranted) of 

its legacy information technology systems due to the increased cost, risks with maintaining these systems, and the need to modernize our business processes to improve 

service delivery. For example, the Benefits Delivery Network (BDN) is the claims 

processing, payment, tracking, and disposition system used for education programs 

but consists of antiquated mainframe systems and is in need of replacement. VA is 

currently working on a solution to address its enterprise IT challenges, and is 

prioritizing accordingly to ensure that replacement systems meet the needs of all 

users and Veterans. Once these systems are replaced VA can redirect its focus on 

newer systems. For example, enhancing the Long Term Solution to provide 

functionality such as automated certificates of eligibility for original claims; electronically generated letters; expanded automation of supplemental claims; issuance 

of advance payments; monthly certification of attendance; and improved business 

analytics for reporting purposes. 

APPEALS

Question 7. At the hearing, Secretary Shulkin testified that VA would need an ad- ditional $800 million in order to address the 470,000 legacy appeals. 

a. Please provide copies of the modeling data and assumptions used in reaching 

that conclusion. 

Response. VA is committed to addressing the pending inventory of legacy appeals. 

Since the Secretary’s testimony, several enhancements to VA’s appeals process have 

influenced the assumptions VA uses to inform resource decisions. Following enactment of the Veterans Appeals Improvement and Modernization Act on August 23, 

2017 VA immediately began implementation. By February 2019, all requests for review of VA decisions will be processed under the new, multi-lane process. VA is also 

continuing work to address the pending inventory of legacy appeals through an approach that focuses resources on legacy appeals processing while also allowing Veterans to enter the new appeals system. 

VA established a new program on November 1, 2017, the Rapid Appeals Modernization Program (RAMP), to provide those Veterans who are waiting on the legacy appeals process, an opportunity for early participation in the new system. The 

administration of RAMP allows VA the opportunity to quickly resolve legacy appeals 

and to test certain facets of the new appeals system. VA will refine the new system 

based upon actual data prior to full implementation. VBA will direct appeals resources to maintain RAMP claims processing within prescribed timeliness goals as 

well as continue to process legacy appeals. 

VA will also utilize the legal authority for Veterans who receive Statements of the 

Case or Supplemental Statements of the Case after the effective date of the legislative change to elect to participate in the new system and transition from the old 

process. 

Once the new system is implemented, VA intends to allocate resources in an efficient manner that will establish timely processing, and utilize all remaining appeals 

resources to address legacy appeals. The Board will focus its resources on its core 

mission and will work to maximize efficiencies in appeals processing, to include 

technological and process improvements. This will enable the Board to also meet 

timeliness goals in the new system and devote all remaining resources to processing 

legacy appeals. 

The rate at which the legacy appeals inventory can be resolved is dependent on 

a number of factors, including the rate of election into the new framework process 

of claimants with appeals pending in the legacy system. As VA gathers data, and 

creates a forecasting model based upon actual Veteran behavior and employee productivity, this will inform resource needs and help establish achievable goals and 

milestones for reducing the number of pending legacy appeals, including the expected number of appeals, remands, and hearing requests at VBA and the Board. 

b. Please explain what steps VA has taken or will take to identify or secure any 

resources necessary to address the backlog of legacy appeals. 

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Response. VA remains committed to reducing the pending inventory of legacy appeals as quickly and efficiently as possible. In January 2017, the Veterans Benefits 

Administration (VBA) realigned its appeals policy and oversight of its national appeals operations under a single office, the Appeals Management Office (AMO). This 

realignment allows VBA to focus on internal people, process and technology appeals 

initiatives, and implementation of the appeals reform legislation. Under this realignment, VBA’s appeals productivity through May 31, 2017, has increased by 32 

percent over FY 2016 production during the same period. 

Question 8. According to the fiscal year 2018 budget request, the Board of Veterans’ Appeals (Board) had 660 employees in fiscal year 2016, expects 886 employees in fiscal year 2017, and requests 1,050 employees for fiscal year 2018. The budget request also reflects that the Board issued 52,000 decisions in fiscal year 2016, 

expects to issue nearly 66,000 decisions in fiscal year 2017, and expects to issue over 

80,000 decisions in fiscal year 2018. 

a. As of March 2017 (half way through the fiscal year), the Board had issued 

about 19,000 decisions. Is the Board still expecting to issue over 66,000 decisions 

in fiscal year 2017? If not, please outline the factors that have contributed to not 

meeting that target and how many decisions the Board now expects to issue during 

fiscal year 2017. 

Response. The Board is committed to its mission to hold hearings and decide appeals for Veterans and their families. Unfortunately, due to a variety of reasons, the 

Board did not meet its FY 2017 goal. There were a number of contributing factors, 

to include, hiring falling short of goals; the impact of revised attorney performance 

standards; time spent training and mentoring new attorneys; time attorneys spend 

on FMLA/leave and on official time; outdated technology; complexity of cases; and 

Veterans Benefits Management System user difficulties. As of June 25, 2017, the 

Board issued 32,598 decisions. compared to the 37,490 that it had issued during the 

same time period in the prior fiscal year. As more Board attorneys complete training 

and become fully productive, the Board projects increased productivity in the remaining weeks of FY 2017. We anticipate that the Board will decide at least 50,000 

appeals by the end of FY 2017. 

b. In a June 8, 2016, memorandum to stakeholders about appeals reform, VA 

noted as a risk factor that ‘‘staffing ramp at the Board is steep and challenging.’’ 

What challenges has the Board faced since 2016 in hiring additional employees; 

what steps is the Board taking to address those challenges; and what impact has 

that hiring had on overall productivity at the Board? Response. In FY 2017, Congress provided an additional $45.7 million to the Board 

to facilitate hiring additional personnel. To support the Board’s aggressive hiring in 

FY 2017, the Center of Excellence Pilot Program for hiring legal professionals was 

established with VA’s Office of Human Resources and Administration (HRA). The 

Board made great progress in hiring early in FY 2017, consistent with the budget, 

but was slowed by the hiring freeze. On March 13, 2017, the Secretary approved exemptions for eight occupations directly involved in appeals processing. Since that 

time, the Board resumed its aggressive hiring plan and, as of June 29, 2017, the 

Board had 882 FTEs employees on board, compared to 667 FTEs at the start of FY 

2017. Additionally, the Board is in the process of filling approximately 100 additional attorney positions, as well as other key vacancies. As more Board attorneys 

completed training and became fully productive, the Board projected an increased 

productivity in the remaining weeks of FY 2017. At the end of FY 2017, the Board 

issued 52,661 appeals decisions. 

c. Would the Board expect to encounter similar difficulties in hiring an additional 

164 employees during fiscal year 2018? If so, please outline what steps would be 

taken to mitigate those risks. 

Response. The Board does not anticipate difficulties in hiring additional employees during FY 2018. The Board has worked successfully with the Center of Excellence to on board over 200 new attorneys in FY 2017 to date. Based on this proven 

ability to hire and on board a large number of new employees, the Board does not 

anticipate difficulties in hiring additional employees in FY 2018. We plan to continue to work closely with HRA to accomplish our hiring objective. 

d. When would the Board expect to realize an overall increase in productivity as 

a result of employees hired during fiscal years 2017 and 2018? 

Response. The Board has a 6-month period during which new attorneys receive 

training and develop the necessary skills to effectively produce quality decisions in 

a timely manner. Therefore, new Board attorneys are not fully productive until after 

they have completed their 6-month training period. The Board anticipates that we 

will see incremental increases in productivity as new employees complete this training period. We would project all employees to be fully productive 6 months after we 

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complete our FY 2018 hiring plan. Notably, while Board attorneys are on production 

after 6 months, most cannot handle and are not given the most challenging cases 

until their 2-year point. 

e. What steps—other than hiring new employees—is the Board taking to improve 

overall productivity; what is the cost of each such initiative; and what impact is 

each such initiative expected to have on productivity? 

Response. The Board is committed to improving productivity. The Board is modernizing appeals processing technology to optimize efficiency to best serve Veterans 

and their families, and to ensure the seamless transfer of appeals between jurisdictions by leveraging industry best practices and Human Centered Design principles. 

The Board is fortunate to have Digital Service at VA (DSVA) leading the technical 

approach to this effort. Specifically, DSVA is developing several attorney-specific 

tools, including a document review tool for claims file review; a Decision Builder; 

and eFolder Express, providing a one-click download of the eFolder. These tools are 

intended to assist decision-writing attorneys in reviewing the record and drafting 

decisions more efficiently. The Board revised its attorney performance standards in 

October 2016. After using these standards for one quarter and evaluating their effectiveness in enabling the Board to meet its mission, the standards were revised 

again, effective January 15, 2017. The Board continually monitors performance, and 

during FY 2017 was in negotiations with the union about revising the attorney performance standards, to best position the Board to meet its goal of deciding appeals. 

As a result, new standards went into effect at the start of FY 2018. There are no 

anticipated additional costs to the Board for the technological changes being developed by DSVA, because their development work is ongoing and all funding for these 

changes is covered by the existing Appeals Modernization budget. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JON TESTER TO

HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 9. Does this budget allow for VA to accommodate those Veterans who 

are currently not enrolled in VA care but who may lose their other health insurance 

if Obamacare is repealed? 

Response. Any impacts on Veterans or VA would depend on the specific changes 

to the Affordable Care Act enacted by Congress. 

Question 10. I am concerned that the President has not accurately projected inhouse demand for health care services. Can you explain the utilization and reliance 

projections for FYs 18 and 19? Please also provide data showing budget projections 

and actual utilization and reliance statistics for FY 2013, 14, 15, 16, and 17 (as 

available). 

Response. The following information on utilization and reliance is from the 2017 

VA Enrollee Health Care Projection Model (EHCPM), which supported VA’s 2018 

Budget. The table below shows historical and projected annual change in utilization 

for ambulatory and inpatient services as modeled using the EHCPM. It separately 

shows data for Veterans eligible for the Choice Program based on the 40-mile distance criterion. 

• Utilization in VA facilities and of community care increased significantly from 

FY 2013 to FY 2014, in part due to VA capacity issues that led to passage of the 

Veterans Access, Choice, and Accountability Act of 2014 (Choice Act). 

• Choice Act funding helped VA sustain growth in community care from FY 2013 

to FY 2014 and continue growth into 2015. 

• From FY 2015 to FY 2016, utilization of community care increased significantly 

for Choice Program eligible Veterans based on residence. Utilization by eligible Veterans based on other criteria also increased but to a lesser extent. 

• The historical and projected decline in total inpatient days is due to a number 

of factors, including transition of inpatient care to ambulatory facilities (a general 

trend in health care across the Nation), VA’s efforts to reduce avoidable in VA’s 

management of inpatient care, and changes in the enrollee demographic mix. 

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The graph below shows historical and projected average reliance across all services (excluding LTSS). Reliance refers to the portion of an enrollee’s total health 

care he/she is expected to receive through VA rather than other health care sources. 

• The projected reliance reflects the impact of all known factors that affect enrollee reliance on VA health care, including economy, demographic changes in the 

enrolled Veteran population, and the anticipated impact of recent VA initiatives and 

changes in legislation and policy. 

• The FY 2018 Budget request assumes that reliance by Veterans eligible for the 

Choice Program based on distance is assumed to increase by 10 percent per year 

until it reaches 50 percent by approximately 2021. (We assume all of these Veterans 

will elect to receive care in the community). 

• Changes in the enrollee demographic mix results in slightly lower reliance in 

2018 and 2019. New enrollees tend to be healthier and less reliant on VA than the 

enrollees who are dying. 

Question 11. What projection methods are you using to anticipate costs of deciding 

not to appeal the court’s decision in Staab? 


614q3iGrowth.eps 614q3VAtReliance.eps
123 

Response. To implement the Staab decision, VA published Interim Final RuleAQ08 on January 9, 2018 to establish a payment methodology that will apply to 

claims where partial payment was made by the Veterans’ health insurance plan. 

The regulation incorporates the statutory limitation that VA unable to provide reimbursement for any copayment, coinsurance, deductible, or other similar payment a 

Veteran is responsible for under a health plan contract. VA’s current cost estimates 

for implementing the decision are based on this methodology and projected claim 

volume for outpatient and inpatient emergency treatment, including transportation. 

Question 12. GAO continues to list VA health care on its high-risk list. Explain 

how this budget addresses concerns raised by GAO. 

Response. VA continues to work diligently to mitigate the Government Accountability Office (GAO) High Risk concerns. VA is also addressing GAO High Risk List 

issues through Modernization efforts. VA leveraged FY 2017 resources to exercise 

an option year of an existing federally Funded Research Development Center 

(FFRDC) to aid in designing and implementing a strategy to mitigate the risks outlined by GAO. Under consideration for VHA will be the possibility of funding further 

support effort with the FFRDC for GAO High Risk List work. In May 2017, a Root 

Cause Analysis (RCA) presented to GAO was met with positive response. VA also 

met with GAO on Jan 11, 2018 regarding the root causes for the five risk area; this 

also was met with a positive response. VA is currently updating action plans for the 

five high risk areas based on the enterprise RCA and anticipates FY 2018 resources 

will support these efforts. There are no existing discretionary line items in the FY 

2018/FY 2019 budget to specifically address the five individual high risk areas. Requests for additional budgetary consideration will be driven by the corrective action 

plans. A VHA Office of Internal Audit and Risk Assessment, designed to conduct 

independent and objective risk-based audits to enhance oversight and accountability, has been funded and has achieved initial operating capability. 

Question 13. The President’s Budget Request includes $751 million for HEP C 

drugs. How many veterans have you treated? How many have you identified that 

still need treatment? What are you efforts to reach those who need treatment but 

may not be taking advantage of treatment at VA? What resources are you expending to provide education to veterans to avoid the spread of HEP C? Response. The President’s Budget Request includes $751 million for hepatitis C 

virus (HVC drugs. Since January 2014 through December 31, 2017, VA treated over 

100,000 Veterans with new direct-acting antivirals, with cure rates between 90–95 

percent. As of the end of December2017, there were approximately 40,000Veterans 

in VA care who needed hepatitis C treatment. Attempts have been made to contact 

most, if not all, of these patients by phone, letter, or direct provider contact, and 

many have refused treatment or were unable to be engaged in treatment. VA providers are continuing to reach out to these patients to ensure all who are interested 

and able receive treatment. VA estimates approximately 15,000–20,000 of patients 

who need HCV treatment may be difficult to engage in care and treat due to treatment refusal, inability contact and, treatment-limiting medical, mental health, or 

substance use co-morbidities 

VA’s outreach efforts include: 

1. Field-based VISN Hepatitis Innovation Teams deploying system redesign/ 

LEAN at the majority of facilities to address gaps in HCV testing and treatment, 

including outreach to at-risk populations 

2. National and local clinical informatics tools are in place across VA’s health care 

system for tracking all patients diagnosed with HCV 

3. VA encourages all Veterans who think they may have hepatitis C to get tested, 

and if eligible for VA care, to come in to VA for treatment. VA has an ongoing HCV 

testing and treatment ad campaign in 18 high prevalence cities in the US: 

www.hepatitis.va.gov/campaign-test-treat-cure.asp VA encourages all Veterans who 

think they may have hepatitis C to get tested, and if eligible for VA care, to come 

in to VA for treatment. VA has an ongoing HCV testing and treatment ad campaign 

in 18 high prevalence cities in the US: www.hepatitis.va.gov/campaign-test-treatcure.asp 

Resources for HCV prevention education include: 

1. Prevention information, including transmission risk and what to do if you test 

negative or positive for HCV, are included in the resources on the Veteran Portal 

of VA’s hepatitis website: www.hepatitis.va.gov 

2. More direct HCV prevention patient education materials are available at: 

https://www.hepatitis.va.gov/products/patient/hcv-prevention-factsheet.asp. 

3. Treatment as Prevention (TasP) is a successful intervention for the prevention 

of HIV transmission, which has shown that people with HIV who have an 

undetectable viral load (e.g., are successfully on antiviral treatment) have an incredVerDate Mar 15 2010 16:16 Jul 12, 2018 Jkt 000000 PO 00000 Frm 00127 Fmt 6633 Sfmt 6621 Z:\ACTIVE\061417.TXT PAULIN
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ibly low, if any, possibility of transmitting the virus to another person. This is also 

true for HCV treatment as an intervention for HCV prevention, particularly given 

cure rates of over 90–95 percent among Veterans treated in VA in care. 

While not explicitly focused on prevention, VA’s national hepatitis awareness campaign messaging on hepatitis C testing includes transmission risk information: 

www.hepatitis.va.gov/campaign-test-treat-cure.asp. 

Question 14. According to the OIG’s 2016 report on staffing shortages, Physician 

Assistants are one of the top five occupations in greatest need. What are you doing 

to fill PA positions and others identified as having the greatest need? 

Response. Several strategies have been employed to address the PA occupation 

shortage and to enhance recruitment and retention. The policy governing PA practice is currently under review to identify and eliminate barriers to PA practice in 

order to promote greater patient access, as well as making VHA a more attractive 

practice environment. Critical access disciplines such as primary care and mental 

health have been targeted for increased training and PA utilization. For example, 

the PA Post-Graduate Patient Aligned Care Team (PACT) Primary Care Residency 

has been successful in providing advanced training in the PACT Patient Centered 

Medical Home model of care and incorporating graduates into VA’s clinical workforce. The recent expansion of PA postgraduate residencies in Mental Health has 

been highly successful in attracting trainees, and has added to VA’s mental health 

clinicians. Establishment of additional PA residency programs in other critical specialties is currently under consideration. Nationwide, the PA profession has experienced a robust growth in demand with a resultant increase in salaries. The American Academy of Physician Assistants 2016 Salary Survey, confirmed by the Department of Labor, Bureau of Labor Statistics, reports the average annual starting pay 

for PAs is over $100,000. In contrast, current starting salary under the U.S. Locality 

Pay Schedule is $49,765. 

Local facilities prioritize hard to recruit and retain occupations based on local 

workforce needs. Medical Center Directors are authorized to approve special salary 

rates for PAs when recruitment or retention of occupations or individuals with specialized skills is difficult. VA is also considering using the Secretary’s existing authority to include PAs as a covered occupation in the Locality Pay System to transition PAs to a market based pay system. 

Facility leadership also determines which occupations are eligible for consideration of other existing recruitment tools such as the Education Debt Reduction Program and the Employee Incentive Scholarship Program. 

Question 15. Over the last few years, VA has taken action to create qualification 

standards to enable the recruitment of Licensed Professional Mental Health Counselors as well a Marriage and Family Therapists. The number of licensed professional mental health counselors employed by the VA declined from 72 in FY 2015 

to 64 in FY 2016 and the number of marriage and family therapists increased from 

only 15 in FY 2015 to 24 in FY 2016. This data suggest that VA’s efforts to expand 

hiring of these occupations is not succeeding. What new initiatives is VA undertaking to hire more counselors and MFTs? What aspects of the President’s Budget 

support this effort? 

Response. The addition of Licensed Professional Mental Health Counselors 

(LPMHCs) and Marriage and Family Therapists (MFTs) to the VA mental health 

workforce has expanded VA facilities’ staffing options. The number of LPMHCs employed by VA increased from 189 at the end of FY 2015 to 284 as of December 2017, 

similarly, the number of MFTs increased from 122 to131 over the same period. This 

data suggest VA’s efforts to expand hiring of LPMHCs is working, however, is still 

experiencing challenges hiring MFTs. 

As VA’s demand for mental health professionals grows, we expect that VA will 

continue to successfully recruit LPMHCs and MFTs i. Because LPMHCs and MFTs 

are relatively newer professions within VA, and decisions to hire into these occupations are made at a local level, the pace of hiring may vary from site to site. 

To promote the MFT and LPMHC professions throughout the country, VA’s Mental Health Offices also created a marketing plan to target stakeholders including: 

Mental Health hiring officials, Human Resources staff and VISN and Medical Center leadership. The marketing plan focused on the benefits of hiring LPMHCs and 

MFTs, including their contribution to inter-professional mental health teams and 

their cost effectiveness. 

Question 16. The VA requested separate occupational series from OPM for 

LPMHCs and MFTs in 2011. Considering VA’s hiring challenges for other mental 

health providers and the Secretary’s focus on veteran suicide, will VA reprioritize 

the creation of occupational series for LPMHCs and MFTs? If not, please explain 

how the lack of the series does not inhibit hiring efforts. 

125 

Response. Beginning September 28, 2010, VA facilities were authorized to hire 

LPMHCs and MFTs as specialty mental health providers after Congress recognized 

these as occupational categories of mental health specialists in the Veterans Benefits, Health Care, and Information Technology Act of 2006. VA has an approved occupational series and title codes for this occupation under Hybrid Title 38. 

Although a standalone occupational series for this occupation does not exist, this 

has not complicated hiring within VA. VA has developed and established a specific 

qualification standard and would continue to use this standard even if OPM developed a standalone series; therefore, the creation by OPM would not have a bearing 

on VA’s recruitment or retention. Qualified candidates have successfully searched, 

applied for, and been hired for VHA positions announced for this occupation as established under Hybrid Title 38 with the official title of Marriage Family Therapist 

or Licensed Professional Mental Health Counselor within the GS–0101 Series. 

Question 17. Please provide information on the number of social workers and psychologists hired by the VA in FY 2015, FY 2016, and FY 2017 to date, as well as 

the number of social workers and psychologists participating in Office of Academic 

Affiliation internships in FY 2015, FY 2016, and FY 2017 to date. 

Response. Please see table below for data through May 31, 2017. (Note: VHA’s 

data pull for mental health occupations includes psychologists and social workers. 

However, social workers include all hires, even though they may not work in mental 

health specifically). 

Occupation FY 2015 FY 2016 FY 2017 

thru May Total 

Psychology .......................................................................................................... 670 680 204 1,554 

Psychiatrist ......................................................................................................... 351 348 169 868 

Licensed Prof Mental Health Counselor ............................................................ 72 64 43 179 

Marriage Family Therapist ................................................................................. 15 24 7 46 

Peer Support ...................................................................................................... 121 68 23 212

Total Mental Health Hires ......................................................................... 1,229 1,184 446 2,859 

Registered Nurse ................................................................................................ 7,700 6,531 4,101 18,332 

Social Work ......................................................................................................... 1,887 1,173 783 3,843 

RN and Social Work hires are provided separately since all RNs and Social Workers are not assigned to a mental health area. 

Question 18. One of the Department’s goals is to change the culture of VA to be 

more welcoming to women. What in the President’s Budget Request supports that 

goal? 

Response. Women Veterans currently comprise 9.6 percent of the Veteran population and that is expected to increase to 10.5 percent by 2020. We are committed 

to providing increased access to gender-specific health care (genitourinary care; female cancer screening; osteoporosis; pregnancy and childbirth; care in a women’s 

clinic) in a safe and welcoming environment. The 2018 President’s Budget shows an 

increase of $33.5M for women’s gender-specific care from $471.2M in 2017 to 

$504.7M in 2018. 

VA provides health care services to women Veterans, including primary care, gynecology care, maternity care, specialty care, and mental health services. VA has also 

focused on improving its facilities to meet the needs of women Veterans. 

In order to review facility accommodations for women Veterans VHA has adopted 

Environment of Care (EoC) standards. These are incorporated into a tablet-based 

survey that is conducted regularly. The facility Women Veterans Program Manager 

is a member of the EoC team. EoC data is shared with each facility and VISN 

monthly, and is the responsibility of the VISN Capital Asset Manager. 

When a need arises to enhance facilities, the VISN follows the Strategic Capital 

Improvement Process (SCIP). The VHA Office of Women’s Health Services participates in this process and provides input on specific facility needs for women Veterans. Currently, there are 21 projects in process (either in design, solicitation/bid, 

or construction) specific to women Veterans’ health. 

VA has enhanced the provision of care to women Veterans through Designated 

Women’s Health Primary Care Providers (WH-PCP). By the end of FY 2016, VA had 

trained over 3,000 WH-PCPs, and has at least one at all of VA’s health care systems. In addition, 90 percent of community based outpatient clinics (CBOCs) had 

a WH-PCP in place. VA is training additional providers to ensure every woman Veteran has the opportunity to receive primary care from a WH-PCP. 

VA is proud of its high quality health care for women Veterans. VA is on the forefront of information technology for women’s health and is redesigning its electronic 

medical record to track breast and reproductive health care. Quality measures show 

126 

that women Veterans are more likely to receive breast cancer and cervical cancer 

screening than women receiving their care in the private sector. VA also tracks 

quality by gender and, unlike other health care systems, has been able to reduce 

and eliminate gender disparities in important aspects of health screening, prevention, and chronic disease management. 

Question 19. Does this budget support the new initiative to cover Veterans with 

other-than-honorable discharges, and how much do you anticipate that it will cost? 

Considering that you are unable to provide these veterans with beneficiary travel 

compensation and access to non-VA care, how will you provide services under this 

initiative to veterans who do not live near a VA facility? 

Response. Effective July 5, 2017, VA began implementing an initiative to expand 

urgent mental health care to former Servicemembers with other than honorable 

(OTH) administrative discharges who believe their mental health condition is related to military service. This marks the first time VA has implemented an initiative specifically focused on expanding these services to former Servicemembers with 

OTH administrative discharges who are in mental health distress and may be at 

risk for suicide or other adverse behavior. Under this initiative, former Servicemembers with an OTH administrative discharge may receive care for their mental 

health emergency for an initial period of up to 90 days, which can include inpatient, 

residential, or outpatient care. If after 90 days, the former Servicemember still requires emergency mental health services, he/she may receive another 90 day episode 

of care within the VA or be transitioned to services. Each VISN has developed their 

own protocol for requesting an additional 90-day episode of care, which must be approved by the VISN CMO. 

This initiative is focused on reducing suicide among those who served their Nation. VA will work to maximize existing capacity in support of this initiative. Because this initiative began after the budget request was submitted, VA did not include an estimate in the FY 2018 Budget. However, VA currently estimates the cost 

of this initiative to be $200 million in FY 2018 and is funding it within existing resource levels. 

Question 20. As the mental health-diagnosed veteran population continues to age 

and veterans develop age-related diseases such as dementia, please describe the Department’s efforts to develop long-term care options for these veterans. How is the 

Department monitoring changes in state-operated facilities that house this population of veterans? Please provide the Department’s projections for changes in stateoperated bed numbers over the next 10 or 20 years and how it plans to make up 

any gaps. 

Response. The growth in the aging Veteran population with multiple medical, 

mental, and neurocognitive disorder comorbidities is expanding the need for additional services for these patients. The ‘‘Complex Patient’’ Care Implementation Task 

Force (‘‘Task Force’’), launched in August 2016, is focused on providing safe and effective care for this growing group of Veterans, and to follow up on recommendations made by the Inpatient Care for Veterans with Complex Cognitive, Mental 

Health and Medical Needs Task Force (‘‘Care of Veterans with Complex Needs 

Report’’). 

The Task Force was created in response to multiple, repeated requests from field 

leadership and also the Congressionally-mandated Federal Advisory Committee for 

Geriatrics and Gerontology. The Task Force has created a definition for Veterans 

with complex problems and conducted a national needs assessment of all 138 facilities with inpatient settings. Through the effort, several innovative inpatient promising practices for this patient population have been identified. 

Additional efforts include building Community Living Center (CLC) capacity to 

care for aging Veterans with serious mental illness (SMI), and/or neurocognitive disorders, including integration of mental health professionals on all CLC teams, a 

range of dementia training programs, including STAR-VA, and development of a 

SMI toolkit. Additional efforts include National Investment Center for Seniors Housing & Care programs that support long-term care in the home and integration of 

mental health professionals in Home Based Primary Care, and Community Residential Care (CRC) and Medical Foster Homes. Relatedly, there are ongoing efforts to 

support family caregivers to care for Veterans with SMI and/or neurocognitive disorders (e.g., REACH-VA and other caregiver support programs) to support long-term 

care in the home. 

State operated beds or nursing home care of any type is generally not preferred 

by Veterans. Appropriate use of home and community based services provided by 

VHA can reduce the need for such nursing home beds in the future. Available data 

suggest the projected need for additional nursing home care for Veterans over the 

next 15 years can be met in Medicare and Medicaid-certified community nursing 

127 

homes; however, VA is having difficulty accessing many community nursing homes 

because of Federal Contract requirements. Community nursing homes frequently 

cite complexity of the Federal contracting process as an issue along with the requirement to comply with the Service Contract Act. VA is working on identifying 

best practices for managing these Veterans to honor their preferences for care whenever possible in home and community based settings. 

VHA Geriatrics and Extended Care is conducting a study of Long Term Services 

and Supports to understand Veteran needs for these services through 2030, and how 

they differ by rural and urban status. Moreover, the study is expected to provide 

policy options for addressing gaps in projected future needs. 

Question 21. Data provided to the Committee in April 2017 indicated that the 

Asheville, North Carolina and Salem, Virginia Medical Centers in VISN 6 were unable to hire psychiatrists, psychologists, social workers, and nurse practitioners due 

‘‘to budget constraints.’’ Please provide an update on their hiring abilities, as well 

as a list of any other mental health positions at any VA facility that are under a 

similar hold. 

Response. There are no mental health vacancies on hold due to budgetary constraints. The budget supports hiring actions for clinical positions vacated over the 

course of the FY. All Mental Health Service clinical vacancies are in an auto-fill status to expedite the recruitment process. 

Question 22. You have spoken about adding thousands of new mental health providers. Can you please update us on these efforts as well as the retention of existing 

employees? 

Response. VHA is making steady progress toward reaching the Secretary’s goal 

of a net increase of 1,000 Mental Health Providers by December 31, 2018. We have 

increased our net onboard of psychiatrists, psychologists, and mental health counselors by 258 as of November 30, 2017, and we are embarking upon a national recruitment and marketing campaign to attract the best mental health providers to 

meet our goal. 

VHA utilizes the Education Debt Reduction Program (EDRP) to repay education 

loans for healthcare professionals, including mental health, in critical positions 

where recruitment and retention is difficult. The EDRP, authorized by the Veterans 

Programs Enhancement Act of 1998, and implemented in 2002, as amended, allows 

participants to receive education debt reduction payments up to $120,000 for up to 

5 years. 

EDRP is one of VHA’s most effective tools for filling critical positions, however, 

it is a limited resource. Local medical centers are responsible for identifying and 

prioritizing positions that are the most critical for recruitment and retention based 

on local needs and funding. Since the implementation of the new maximum award 

amount authorized under Public Law 113–146, VHA has awarded nearly 2,500 new 

EDRP awards. Occupations identified in the FY 2015 Office of Inspector General 

Mission Critical Occupation Report (physicians, registered nurses, psychologists, 

physical therapists and physician assistants) account for nearly 79 percent of all 

new awards in FY 2015–2016. Physicians and registered nurses (including advance 

practice nurses) receive the most EDRP awards, at 37 percent and 23 percent, 

respectively. 

VA also utilizes other programs to recruit and retain highly qualified employees 

to mental health and other specialties. For example, the Student Loan Repayment 

Program (SLRP) improves recruitment and retention by offering assistance which 

enables VA to provide up to a lifetime total of $60,000 with a maximum of $10,000 

per year in payments to the lending institution. Full-time VA employees may also 

be eligible for loan forgiveness through the Public Service Loan Forgiveness (PSLF) 

program. Only the entity that holds a loan may forgive outstanding loan balances, 

therefore the authority for the PSLF resides with the Department of Education. 

Question 23. What lasting impacts did the hiring freeze have on your ability to 

recruit high quality staff? 

Response. Minimal impact. Four days after the Presidential Memorandum VA 

provided exemptions for its most critical positions; more specifically, patient care positions, safety positions in activation of leases and construction projects, and those 

supporting burial benefits. Since then, the Secretary has allowed the Administrations to fill positions they deem necessary to meet mission requirements. The 

prioritization of filling vacancies is determined by the requesting organization, in coordination with the servicing human resources office. 

Question 24. VA has articulated on multiple occasions that the flip side of accountability is the importance of recruiting high quality staff. It’s my understanding 

that much of that work with candidates is done through HR. So you can imagine 

that it seems somewhat counterintuitive that you have not ended the hiring freeze 

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for H.R. professionals, and now you have flat funded them for 2018. How do these 

factors align? 

Response. VA is undertaking a comprehensive Department-wide analysis at how 

to provide all internal support services, to include Human Resources (HR), in the 

most efficient manner. We are determined to provide a single enterprise-wide efficient and effective approach to HR. In light of this process, we are being deliberative 

in hiring H.R. professionals. At this time, frontline (i.e., those supporting a medical 

center) H.R. offices are able to hire against vacant H.R. positions. 

Once we fully understand our H.R. approach for the future, we’ll be in a better 

position to align budget requirements. 

Question 25. Can you explain the differences between the services provided by VA 

human resources and VHA human resources, and tell us why we need to fund both? 

They seem duplicative in many ways. Would there be cost savings for the Department if the two were consolidated? 

Response. In accordance with OMB Memorandum M–17–22, VA is undertaking a 

comprehensive Department-wide review of its support services, including HR. 

The mission of VA’s HRA is to develop and implement enterprise human capital 

management strategies, policies, and practices. Program offices comprising HRA 

focus on policy and programs such as Human Resources Management, Diversity and 

Inclusion, Labor-Management Relations, Equal Employment Opportunity complaints, and Senior Executive Management. HRA is closely reviewing where potential efficiencies may exist. 

In addition, each Administration, to include VHA, operates on-the-ground H.R. offices that provide daily operational and advisory functions for managers, supervisors, and employees. These include, but are not limited to, classification, recruitment, on-boarding, personnel actions processing, employee development, benefits, 

separation management, employee relations, performance management, etc. 

Question 26. Can you explain why the H.R. office is flat funded from last year, 

but the FTE level is effectively cut in half? Where is the funding going, and where 

will the staff go? 

Response. HRA’s FY 2018 budget request reflects no increase in the level of Budget Authority from 2017. Most of HRA funding is generated by reimbursable authority funding from other VA entities. Among the largest reimbursable services is the 

handling of EEO complaints by the Office of Resolution Management (ORM). The 

reduction in staff reflected in FY 2018 is based on the plan that 296 ORM staff positions will be re-aligned to the Office of Accountability and Whistleblower Protection. 

After further review by the Department, it was determined that ORM FTEs should 

remain in the organizational structure of HRA. 

Question 27. I note that FTE for Acquisitions and Construction management is 

increasing by over 60 people in your budget request for this year. I expected to see 

a cut, frankly. Major construction is taking a ‘‘strategic pause,’’ and the construction 

that is happening is being managed by the Army Corps of Engineers. What cuts 

have been made to reflect the Corps’ role, and why do you need additional staff in 

that office? 

Response. For the major construction staff request, the current estimated FTE 

number for FY 2017 is 139 and for FY 2018 the estimate is 197. The original estimate for FY 2017 was 177. The combination of project slippages and the hiring 

freeze have reduced the number needed and VA’s ability to hire staff still required 

for its major construction projects. 

VA will have 26 ongoing projects valued at $4.15B in FY 2017/FY 2018 and six 

new projects (primarily national cemeteries) totaling $0.24B. It will also be overseeing the execution by the Army Corps of Engineers (USACE) of 13 projects valued 

at $6.474B. There are four other projects in planning valued at over $2B that requires contracting officer support. 

It should be noted that the partnership between VA and USACE includes VA responsibilities to coordinate with USACE during construction and provide the interface with the medical center, as well as the on-site knowledge of VA technical requirements. VA believes Resident Engineer and Contracting Officer positions were 

not sufficiently staffed in the past. VA’s 2018 Budget reflects staffing to appropriate 

levels by following the model established by the Defense Health Agency in providing 

support and guidance to the USACE construction management team, and ensuring 

that the project meets the VA programmatic requirements. 

It should be noted that the appropriation language was changed in FY 2017 to 

allow major construction staff funding to include support for contracting officers 

working directly on major construction projects to ensure alignment with the program they are supporting. The inclusion of contracting officers accounts for 35 of 

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the 197 FTEs in FY 2018 with 162 resident engineers comprising the remainder of 

the FTEs. 

Since FY 2016, significant cuts have been made to the General Administration 

funding that provides support to Major Construction via project/program managers, 

planners, architect/engineers and other support personnel. 

Question 28. Your Budget rescoped and resized several major medical lease 

projects as well as eliminated two leases that had previously been proposed for authorization. Please provide specific information regarding any services that have 

been eliminated or reduced from these clinics. Please provide specific information 

that explains the underlying analysis VA used to determine these services or spaces 

were no longer needed. If the Department determined that the community would 

be able to take on this extra demand, please provide information that explains how 

the Department determined that capacity exists in the community. 

Response. Prior to the finalization of the FY 2018 Budget, VHA reviewed 28 

Major Lease initiatives. Out of these, 9 included reduction of Specialty Care services 

and associated square feet because it was determined such services were more readily available through community providers and/or at the parent VA Medical Center. 

VHA utilizes the VA Health Systems Planning Application, Veterans Choice Locator 

and other available databases, to project demand and match that to capacity, both 

in house and through community providers. This process helps ensure appropriate 

and sufficient services are available. In no cases were services removed because they 

were no longer required, and in all cases services will be available to Veterans. 

Question 29. Does this request take into account the partnerships you have with 

other agencies, such as HUD? Did you know, for example, that the HUD budget for 

supporting HUD-VASH vouchers decreased by 8%? Will the Administration be able 

to serve the same number of Veterans? 

Response. VHA has been in communication with the Department of Housing and 

Urban Development (HUD). If HUD does not receive additional funding for HUDVASH in FY 2018, it would not impact the availability of existing FY 2008-FY 2017 

awards, which mean VHA must continue to provide case management for recipients 

of nearly 90,000 existing vouchers, as required by statute. If HUD does not receive 

new funding in FY 2018, VHA will not need to add staff to support new vouchers, 

but will need continued funding to support existing vouchers. 

Question 30. Does VA have the resources in this budget to provide the wraparound services that are so critically important to doing more than just addressing 

a crisis situation? (VHA) 

Response. The FY 2018 budget request supports an additional 5,500 HUD-VASH 

vouchers from the FY 2017 HUD budget. HUD-VASH staff provides clinical case 

management and supportive services primarily in the community or the home, and 

which vary based on the needs of the Veteran. There are five basic levels of case 

management—intensive, stabilization, maintenance, preparation for discharge, and 

graduation/discharge. Each level has varied levels of engagement with Veterans in 

HUD-VASH. 

Question 31. Granted great progress has been made in the last five years on ending homelessness among veterans, but given that there are still 40,000 homeless 

Veteran nationwide, why has VA decided to put less emphasis on this core VA 

mission? 

Response. VA remains steadfast in its commitment to ensuring Veterans are able 

to obtain permanent, sustainable housing and have access to high quality health 

care and other supportive services. 

Question 32. Do you agree that consistent resources need to be dedicated to VA 

counter-homelessness programs in order to get as close to zero homeless veterans 

nationwide as we can? 

Response. Yes. 

Question 33. I was concerned by a recent military times article indicating VA has 

shifted its goals on veteran homelessness from zero to what you referred to as functional zero, and I quote here ‘‘12,000 to 15,000 that despite being offered options 

for housing and getting them off the street, there are a number of reasons why people may not choose to do that.’’ The 2016 PIT count included just over 13,000 

unsheltered veterans, and your homeless programs are operating at the same pace, 

as I believe they should. Can you explain how you arrived at this specific range as 

your goal for unsheltered veteran homelessness, and can I get your commitment to 

reducing veteran homelessness, especially unsheltered homelessness, as much as 

possible and to ensuring that all of the administration’s programs are collaborating 

effectively with each other, and community partners, to make veteran homelessness 

rare, brief, and nonrecurring? 

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Response. VA remains fully committed to ending and preventing Veteran homelessness, and continues to operate with the urgency to ensure it is rare, brief and 

non-recurring, especially for unsheltered Veterans. 

Question 34. Your own studies demonstrate the importance of research opportunities to recruiting and retaining clinical staff. In addition to VA’s own research cuts, 

other agencies are cutting their contributions to VA research also. Do you have an 

estimate of the impact that this overall Trump budget will have on your hiring 

efforts? 

Response. At this time, VA does not have the ability to predict a detrimental impact on hiring, although, many clinicians view the ability to conduct research as advantageous to a well-rounded clinical experience. 

Question 35. What percentage of the work on appeals currently sits with the VBA 

in the appeals management center? Is there a reason that addressing the existing 

appeals with additional staff was not a priority? 

Response. As stated above, in January 2017, VBA realigned its appeals policy and 

oversight of its national appeals operations under AMO. The realignment promotes 

increased accountability of appeals performance and establishes a clear division of 

labor between claims and appeals work, with dedicated appeals FTE. This realignment allows VBA to prioritize appeals by focusing on internal people, process and 

technology, and implementation of appeals reform legislation if enacted. Under this 

realignment, specific guidance has been disseminated instructing field offices that 

appeals staff must maintain authorized staffing levels. 

In 2015 and 2016, Congress provided funding for additional staff that included a 

total of 300 FTE employees for appeals processing at VBA. VBA’s appeals productivity through May 31, 2017, has increased by 32 percent over FY 2016 production 

during the same period. As of June 30, 2017, the Appeals Resource Center, the centralized processing resource for appeals remanded from the Board of Veterans’ Appeals, had 35.8 percent of the remand workload in VBA and 3.3 percent of the total 

appeals workload. 

VA continues to assess the current and future allocation of FTE employees to 

work appeals to ensure that the pending legacy appeals inventory is addressed in 

a timely and efficient manner. Whether VA will need additional resources for appeals since the August 23, 2017, enactment of appeals reform legislation is contingent upon resource allocation decisions made by the Department and the Administration during the annual budget process and cannot be predicted at this time. 

Question 36. Fiduciaries are some of the most vulnerable of the Veteran population and it is currently taking more than TRIPLE the time it should in order for 

a field examination to happen so that a fiduciary can be appointed. How is your 

budget, which flat funds this program, helpful in addressing this problem? 

Response. In 2017, VBA allocated an additional 51 FTEs to meet the program’s 

oversight responsibilities in order to avoid delays in the initial appointment of fiduciaries, and the FY 2018 President’s Budget codifies those additional FTEs. As of 

May 2017, VBA has reduced the average days to complete initial appointments to 

151.1 days—down from 287 days in FY 2016—and we are making progress toward 

the goal of 82 average days to complete initial appointments by FY 2018 and 76 

days by FY 2022. 

Question 37. If VA does not plan to hire additional FTE for the VR&E program 

how does VA intend to assist veterans in critically understaffed regions? 

Response. Staffing requirements for the Vocational Rehabilitation and Employment (VR&E) program are influenced by many factors. Currently, we are 

supplementing our Vocational Rehabilitation Counselors (VRCs) workload with the 

expanded use of and augmentation of tasks through National service contracts for 

the execution of certain VRC tasks, such as vocational assessments. We recently developed and deployed targets for these contracts by Region/District based on workload density to better serve Veterans and VRCs. Additionally, VBA is continually 

looking at VR&E system and process improvements to reduce administrative burden 

on VRCs. Current efforts include working to deploy a new case management system 

(in development), and examining ways to centralize VR&E administrative tasks like 

invoice processing. 

Question 38. In the past two years, ITT and Corinthian College both closed and 

left tens of thousands of veterans in an unacceptable and precarious position. We’ve 

also seen other predatory behavior by for-profit schools looking to take advantage 

of Veterans and their beneficiaries. Are you confident that the levels of staffing supported by this budget, and the amount of oversight that staff is able to do, will prevent these practices in the future? We want to identify these schools before we have 

a situation where a school is shut down, rather than after. Moreover, we want to 

ensure that VA has the resources to communicate with veterans far ahead of any 

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school closure in order to facilitate the transfer of the GI Bill beneficiary to an alternate school for the completion of their degree. 

Response. Based on the staffing levels requested for FY 2018, VA will facilitate 

proper oversight of GI Bill benefits. Since the closure of these schools, the Department has focused on improving the quality of the oversight process, increased communication and information sharing activities with other Federal agencies with 

oversight of post-secondary educational institutions, and has increased outreach activities and assistance to beneficiaries enrolled in ‘‘at risk’’ schools. 

Question 39. Will the staffing levels for these Education programs support continued rates of original and supplemental claim completion within a reasonable 

amount of time? 

Response. VBA has approximately 800 FTEs processing claims with a current Fiscal Year-to-Date timeliness for original claims at 22.8 days and supplemental claims 

at 8.0 days. At the beginning of FY 2017, VBA redirected 75 Atlanta Regional Processing Office employees from processing education claims to processing compensation claims. This increased the workload at the three remaining Regional Processing 

Offices. Also, during the fall peak enrollment period from August 2017 to October 2017, VBA received an increase in education claims. This year, VBA received a 

24 percent increase in claims for FY 2017 compared to FY 2016. Last, other factors 

(i.e., legislative changes and system changes) may impact future processing times. 

VBA did not meet its Fiscal Year To Date goal for original claims with an average 

days to complete (ADC) of 24.66 days; however, VBA did achieve the goal for supplemental claims with an ADC of 8.6 days. In addition, VBA continues to utilize overtime and a national brokering strategy to balance the workload and reduce the time 

it takes to process a claim. 

Question 40. Can you give us a timeline for the plan to modernize VA’s infrastructure you’re developing and hoping to pilot? 

Response. VA is committed to developing high performing healthcare networks 

that consider current and future Veteran demand for medical care, and responsive 

services by integrating VA-provided healthcare, community care, and telehealth 

services. VA is partnering with private sector healthcare experts to conduct objective 

assessments, based on a piloted methodology, to develop local health system optimization plans. A contract was awarded in September that will enable VA to recommend health system optimization plans in all 96 VA healthcare markets. Our 

current target is to complete this by the 3rd quarter of FY 2019. 

Question 41. Your budget includes a proposal that would allow VA to more easily 

transfer funding for infrastructure between agencies. How does that authority play 

into the modernization plan you’re developing? 

Response. The proposed legislation would allow VA to pursue joint projects with 

other Federal agencies, including DOD. Joint facility projects between VA and other 

Federal agencies (i.e., medical facilities not specifically under the jurisdiction of the 

Secretary) currently require specific statutory authorization. The proposed legislation would: (1) enhance VA’s ability to coordinate with DOD and other Federal agencies; (2) improve access, quality, and cost effectiveness of direct health care provided 

to Veterans, Servicemembers, and their beneficiaries; (3) permit joint capital asset 

planning and capital investments to design, construct, and utilize shared medical 

facilities; (4) provide VA authority to procure the use of joint medical facilities for 

itself and other Federal agencies like DOD, and transfer funds between agencies for 

such initiatives. 

Question 42. Please explain what legislative barriers exist that prevent the Department from disposing of the roughly 1,100 facilities that are described as underutilized and vacant buildings. 

Response. To clarify, at this time VA is only pursuing disposal or reuse of 430 

vacant buildings. The underutilized buildings will be reviewed, as VA works to determine where additional efficiencies can be identified and reinvested in Veterans’ 

services, and will be considered when VA completes the market area optimization 

assessments and plans. 

Occasionally, there are impediments that delay disposal or reuse stemming from 

environmental factors and/or the historic nature of a building. Impediments do not 

specifically prevent disposal/reuse, but can significantly slow the process. The National Historic Preservation Act (specifically, Section 106 consultation requirements) 

as well as the National Environmental Policy Act provide statutory requirements 

which VA must adhere to when pursuing this process. 

Additionally, other authorities would provide greater reuse flexibility of unneeded 

assets, and help improve services for Veterans. For example, VA’s FY 2018 Budget 

request proposed to expand VA’s enhanced use lease authority beyond the scope of 

supportive housing. This authority would provide more opportunities for VA to sucVerDate Mar 15 2010 16:16 Jul 12, 2018 Jkt 000000 PO 00000 Frm 00135 Fmt 6633 Sfmt 6621 Z:\ACTIVE\061417.TXT PAULIN
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cessfully repurpose underutilized and vacant properties nationwide, for uses that 

are consistent with VA’s mission and operations. 

Question 43. We understand that VHA is conducting a series of market-based 

analyses examining VA capacity and private sector capacity nationally. What role 

is OALC playing in these analyses? 

Response. VA’s Office of Construction & Facilities Management (CFM) is working 

closely with VHA to conduct market-based assessments nationwide. Previous VA Integrated Planning efforts did not comprehensively assess the optimal balance of 

services for VA to provide in its facilities, versus those that can be provided in the 

community. The market-based Service Delivery Planning will focus on community 

care providing additional services other than foundational and essential services 

(e.g. Primary Care, Mental Health and associated Rehabilitation). CFM will manage 

the planning process in partnership with VHA, once a contract has been awarded. 

Question 44. Please explain what factors go into determine SCIP ratings. What 

weights does each category and subcategory receive? How often does the Department update those needs? 

Response. The Strategic Capital Investment Planning (SCIP) process is reviewed 

each year to consider changes in medical delivery, technology, Departmental and 

Congressional mandates, and local or regional projections. Changes, related to VA’s 

Construction and Lease program, inform updates to the criteria and weights. The 

SCIP Board is comprised of nine senior management members from the three Administrations and the offices of six Assistant Secretaries. The Board works on a Departmental level with each member applying their specialized knowledge to discussions. The SCIP Panel, which is comprised of one staff member representing each 

Board member, supports the Board. 

Decision criteria and sub-criteria priority weights are developed using a multi-attribute decision methodology—the analytic hierarchy process (AHP). This methodology facilitates the development of criteria and sub-criteria weights, by allowing 

multiple evaluators to consider a number of diverse criteria when setting weights. 

Within the AHP, priority weights are set using the Pairwise Comparison method, 

which asks each Board member to rate the importance of criteria, one pair at a 

time, reducing the likelihood of inconsistent ratings. The results of the Pairwise 

Comparison exercise are the criteria weights. Priority weights for each group of subcriteria are developed that same way. 

The Board presents a recommendation to the SCIP process, including criteria and 

priority weights, through a formal executive review process. That process is developed through senior management, with approval of the Secretary to ensure consistency with the Department’s strategic goals. 

Below is the SCIP 2018 Decision model and criteria and sub-criteria weighting. 

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Question 45. The Department projects a large drop in the resources needed to support facility activations, dropping from an estimated $862 million in FY 2018 to 

$744 million in FY 2019. Please provide a list of facilities that are projected for activation in FY 2018 and FY 2019. Additionally, the request explains that VA has 

taken steps to better synchronize resources. Please provide further details of these 

steps. 

Response. Attached is the activations report that has been submitted to Congress. 

VA’s Office of Construction & Facilities Management and VHA are working to improve communication of updated project schedules for Major Construction and Major 

Lease projects, to help ensure improved activation project scheduling. Additionally, 

VA Facility Activation Project Management teams have been established to coordinate and synchronize resources. 

Question 46. We understand that VA has never before utilized a public interest 

exception to a full and open procurement. In fact, the exception has only been used 

in national security situations. The last time Congress was assured by VA that a 

contract was guaranteed and solid, VA lost badly in court and we were forced to 

provide an emergency appropriation to complete construction of the Denver VA 

Medical Center. What guarantee can you give the Committee that this procurement 

method will be the best value for taxpayers and veterans? 

Response. VA is taking the necessary precautions to ensure that the scope of this 

effort is well-defined, feasible, and will further the public interest of providing seamless care for our Veterans. 

Question 47. Your budget requests funding for a further review of the EHR decision through an IPT. Is this request still valid? Can you explain what new information this team will be looking at that wasn’t previously available? Or are these resources that can be shifted? 

Response. The June 5, 2017, announcement of the Determinations and Findings 

(D&F) by Secretary Shulkin supporting direct negotiations by the VA with Cerner 

Corporation alleviated the requirement for such an IPT. These costs and efforts are 

being supported by the present PMO budget requirements. In addition, VA has extensive testing, change management and data migration strategies to be fielded durVerDate Mar 15 2010 16:16 Jul 12, 2018 Jkt 000000 PO 00000 Frm 00137 Fmt 6633 Sfmt 6621 Z:\ACTIVE\061417.TXT PAULIN

614q3tModel.eps
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ing the Initial Operating Capability phase and will leverage lessons learned from 

DOD. 

Question 48. Your budget projects essentially flat staffing for OIT in FY 2018. It 

is our understanding that part of the MyVA project was looking at the OIT staffing 

levels present at VHA, VBA, and NCA facilities in order to provide proper IT support at those facilities. Can you update the Committee on the development of these 

staffing models? 

Response. OI&T is working on the draft for a Comprehensive Staffing Model that 

will perform an analysis of existing workforce, project needs and examine how to 

address identified gaps. As part of the Secretary’s initiative to increase efficiency, 

OI&T is currently reviewing existing workforce structuring and identifying positions 

that can be realigned to direct customer facing support. Starting in FY 2018, OI&T 

will work with VA customers to balance between service level requirements and industry best practices for IT staffing. 

Question 49. What resources are allocated in the Budget Request for the development of the Digital Health Platform? 

Response. The Digital Health Platform concept has transformed to be more inclusive, creating a gateway and interfaces for benefit, memorial, and corporate systems 

as well. The systems requiring interfaces and the resources of this Digital Veteran 

Platform will fund its development. 

Question 50. What VistA enhancement projects will this Budget Request support 

in FY 2018? In what ways has this roster of projects changed as a result of the decision to procure Cerner’s EHR? 

Response. The FY 2018 budget includes a request for development funding for the 

following VistA related activities as summarized below. 

Dollars in Thousands: 

NMOC (Medical MyHeV) $15,000 

• MHV Infrastructure and Interface Enhancements Phase 2 $10,000 • MHV Veteran-Facing Enhancements Phase 2 $5,000 

VistA Module Enhancement $9,000 

• Fileman 24 DME $5,000 • VistA Data Access (VDA) Phase 2 $4,000 

Access to Care (Medical Core) $2,495 

• Veteran Self-Scheduling Appointment System Faster Care for Veterans 

Act $2,495 

Health Provider Systems $2,400 

• CPRS Enhancements Phase 2 $2,400 • Registries $1,410 • Veterans Integrated Registries Platform (VIRP) $1,410 

Based on the Secretary’s June 5, 2017, announcement regarding VA’s path forward for VA’s EHRM, proposed health development and sustainment investments 

are being reviewed to ensure they are in full alignment with the Secretary’s decision. Many projects will continue until VA systems can be transitioned to the new 

EHR system. To minimize the impact to Veterans and the providers who use VistA 

to document care, the decommissioning of VistA and other legacy systems will be 

done along a structured timeline that ensures there are no compromises to Veteran 

patient privacy and continuity of care. 

The EHRM decision that the Secretary announced on June 5, 2017, comprises a 

large and complex replacement of VA’s EHR which would take place over a multiyear period. While VA is conducting an ongoing review to ensure all current projects 

included in VistA Evolution and beyond are aligned to the Secretary’s June 5 decision, it is clear that many projects will continue for a period of time because VA 

will need to continue to maintain its existing system until VA systems can be 

transitioned in an organized way to the new EHR system. Again, VA will be reviewing all relevant ongoing or planned projects to ensure they are aligned with the Secretary’s June 5 decision. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. BILL CASSIDY TO

HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 51. The VA’s several affiliations with academic medical institutions provide a significant opportunity to incorporate the input of the person who is actually 

treating the veteran. This process would eliminate many of the mistakes being 

135 

made when it comes to more complex and advanced technology in the med-surg 

items and device space. Processes and procedures driven from the top down cannot 

overcome a lack of informed decisionmaking from the beginning. 

What is the VA doing to better incorporate physician and clinical practitioner 

feedback into their procurement process, especially with regards to the Next Generation—Med- Surg Prime Vendor (NG-MSPV) program? 

Response. VA has embraced Clinically Driven Sourcing (CDS) to better incorporate physician and clinical feedback. Under the CDS concept clinicians identify, 

review and select products to be made available for their use under national, regional, or local contracts. Next-Generation Medical/Surgical Prime Vendor (NGMSPV) provides a good example of this concept. Before products are made available 

through the NG-MSPV they are reviewed by a multi-disciplinary integrated team 

that includes clinicians familiar with the products that are candidates for inclusion 

in the NG-MSPV formulary. The clinician’s role on the team is to select the products 

that meet their needs. 

Question 52. a. Last year, the VA established a new pre-authorization requirement for the procurement of certain medical products, with the stated goal of getting a contracting officer involved prior to a surgical case to ensure the government 

pays fair pricing for the products used. 

Response. In April 2016, VA started the pre-authorization process by establishing 

a not-to-exceed order, and then a post-procedure consult with VA contracting to finalize the purchase order (PO). In that process, pre-authorization consults are performed by VA clinicians/staff to identify implant components and pricing, which are 

then used by contracting staff to establish a price and product ceiling on the order 

(the ‘‘not-to-exceed’’ level). Following a procedure, vendors and VA staff confirm 

what products were implanted in the patient (units, cost, quantities, serial numbers, 

contract number, etc.), which is then submitted to VA contracting (the post-procedure consult). 

As understood, if a post-procedure consult is not submitted to contracting within 

24 hours of the procedure, it is considered an ‘‘unauthorized commitment,’’ and is 

subject to a ratification process that can significantly delay vendor receipt of a PO. 

Overall, I have heard numerous reports that this new process has indeed resulted 

in a significant backlog of payments to manufacturers for devices already implanted 

in Veterans. 

b. What is being done to establish an improved process that includes appropriate 

procurement safeguards but also ensures appropriate efficiencies in payments to 

manufacturers providing critical medical technologies to our veterans? 

Response. For clarification, a delay in a post-procedure consult does not result in 

an ‘‘unauthorized commitment’’ and is not subject to ratification; however, it does 

delay payment. VA is continuing to refine the implant contracting process to include 

changes to improve submittal timeliness for post-procedure consults, and the requirements for ratification to include expediting the process through completion of 

payment to the vendor. We are also monitoring payment timeliness, numbers of ‘‘unauthorized commitments’’ and ratification speed to determine if our improvements 

are effective. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. PATTY MURRAY TO

HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

MEDICAL AND PROSTHETIC RESEARCH

Question 53. VA’s medical and prosthetic research has contributed many vitally 

important advances in medicine. Yet, medical and prosthetic research is cut five 

percent in the President’s Budget Request. With cuts being made across President 

Trump’s budget to other Federal sources of research funding, such as the draconian 

cuts to the National Institutes of Health, critical Federal investments in lifesaving 

medical research will be eliminated. What specific research would be eliminated or 

curtailed under the Department’s request? 

Response. At this time we are unable to determine which projects may be impacted. VA’s Office of Research and Development will continue to perform robust research in priority areas and those of unique healthcare needs for Veterans such as: 

• Suicide prevention 

• PTSD 

• TBI/Neurotrauma and Neurotechnology 

• Chronic Pain and Opiate Abuse 

• Spinal Cord Injury 

• Precision Medicine and Patient-Centered Care 

136 

• Access, Choice and Coordination of Care 

• Implementation and Spread of Innovation 

• Limb Loss 

• Million Veteran Program 

Research program areas that would be curtailed includes: 

• Disorders of Aging 

• Musculoskeletal Disorders 

• Neurodegenerative Diseases 

Question 54. For years VA has been citing problems with recruitment and retention as a problem within the VHA system. VA studies have shown that 80 percent 

of VA clinicians cited research programs as a factor in coming to VA, and over 90 

percent cited it as a reason for staying at VA. How will these cuts impact VA’s ability to remain competitive in recruiting and retaining quality researchers and 

physicians? 

Response. The All Employee Survey data indicates that job satisfaction for physicians is closely linked to academic activities including involvement in research and 

teaching; however, VA is unable to predict any potential outcomes recruiting and/ 

or retention that may result from any decreases. 

HOMELESS VETERANS

Question 55. Since 2009 it has been the goal of VA to end veteran homelessness. 

Since that time, great progress has been made in addressing veteran homelessness. 

But this progress has only come from complete VA dedication to that goal and the 

utilization of an array of Federal resources. Earlier this month, you announced that 

zero homeless veterans is no longer an agency priority, and President Trump’s budget would cut the HUD budget for supporting HUD-VASH vouchers decreased by 88 

percent. 

• What impact will these decisions have on homeless veterans trying to access VA 

services? 

• What impact will these decisions have on veterans currently utilizing the HUDVASH program? 

• What services will VA offer to veterans that are adversely impacted by any 

change in homeless veteran services? 

Response. If HUD does not receive additional funding for HUD-VASH in FY 2018, 

it will not impact the availability of existing FY 2008-FY 2017 awards, which means 

that VHA must continue to provide case management for recipients of nearly 90,000 

existing vouchers, as required by statute. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOE MANCHIN III TO

HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 56. Originally, our understanding was that the VA anticipates that 

funds for the Choice Program will exhaust in November/December of this year. 

However, that is not the case. What is the actual date that Choice will run out of 

money? 

Response. In August 2017, the President signed the VA Choice and Quality Employment Act of 2017, which authorized an additional $2.1 billion for the Veterans 

Choice Program (VCP). These funds represent a short-term, temporary funding solution that will enable Veterans to continue receiving care through VCP while a replacement program is developed. 

A number of fluctuating variables influencing program utilization will dictate actual obligation rate. VA will continue to analyze program utilization trends and will 

refine funding projections as future utilization patterns become better defined and 

will stay in close communication with our Committees to apprise all members of 

current status. 

Question 57. Your budget asserts that ‘‘the number of VR&E participants has 

steadily increased and is expected to continue to increase over time.’’ In fact, program participation has increased by 15% since 2015. However, in your budget you 

propose a cut to the program of $13.8 million or 4.2%. If the VA does not plan to 

hire additional full-time employees for the VR&E program, how does the VA intend 

to support veterans in critically understaffed regions, like West Virginia? 

Response. VA utilizes several mechanisms to allocate resources to support VR&E 

programs, including the expanded use of and augmentation of tasks through National service contracts, which help to balance the caseloads for Vocational Rehabilitation Counselors (VRCs). We recently developed and deployed targets for the use 

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of these contracts by Region/District based on workload density, in order to better 

serve Veterans and VRCs. Additionally, VBA is continually looking at VR&E system 

and process improvements in order to reduce administrative burden on counselors. 

Current efforts include working to deploy a new case management system now in 

development, and examining ways to centralize VR&E administrative tasks like invoice processing. 

Question 58. It is my understanding that even though the hiring freeze has been 

lifted, VA has done a self-imposed hiring freeze. 

a. How are you reviewing which positions are exempted? 

b. What is your process? 

Response. Consistent with OMB Memorandum M–17–22, VA removed hiring restrictions for field positions at VHA’s medical facilities (for medical and non-medical 

positions), and for VBA regional and field offices. NCA had no restrictions and this 

remains unchanged. Hiring restrictions were also removed for the following Executive level positions: Medical Center Directors; Network Directors; Cemetery Directors; and VBA Regional Office Directors. This allowed the Administrations to fill positions they deemed necessary to meet mission requirements. 

For all other positions, VA is following a process that requires thorough review 

before hiring, and which also requires an approval at the appropriate Under Secretary level. VA Central Office and all other Executive level hiring must be approved by the VA Chief of Staff. 

Question 59. In March, you announced that veterans with other-than-honorable 

or ‘‘bad paper’’ discharges will be allowed to be receive mental health treatment. 

a. How do you ensure that access for an honorably discharged veteran is not diminished with this policy? 

b. If a veteran shows up at an emergency room today and says he is suicidal how 

will you treat him differently today than when your plan is in effect? 

c. We were told that we would have a comprehensive plan for implementation by 

June. Where is that plan? 

VA Response A-C: Effective July 5, 2017, VA began implementing an initiative to 

expand the provision of urgent mental health care to former Servicemembers with 

other than honorable (OTH) administrative discharges who believe their mental 

health condition is related to military service. This marks the first time VA has implemented an initiative specifically focused on expanding these services to former 

Servicemembers with OTH administrative discharges who are in mental health distress, or may be at risk for suicide or other adverse behavior. 

This initiative is focused on reducing suicide among those who served the Nation. 

Under the initiative, which utilizes existing legal authorities, if a former Servicemember with an OTH administrative discharge presents to a VHA Emergency Department and self-identifies as being in mental health distress, a provider will conduct a clinical assessment and determine the appropriate course of action in conjunction with the former Servicemember. Under this initiative, former Servicemembers with an OTH administrative discharge may receive care for a mental 

health emergency for an initial period of up to 90 days, which can include inpatient, 

residential, or outpatient care. In addition to presenting at an Emergency Department, individuals make seek help by calling the Veterans Crisis Line or visiting a 

VA Urgent Care Center or Vet Center. 

Regarding the implementation plan, VHA and VBA developed a joint action plan 

addressing required policy updates, internal and external communications, IT modifications to CPRS, field education and support. The field was notified of the OTH 

Initiative via memos dated 3/20/17 (Access for Mental Health Services for Other 

Than Honorable Discharged Servicemembers), 4/19/17 (Validating VA Mental 

Health Plan to Meet the Needs of Other Than Honorable (OTH) Discharged Servicemembers), and 6/26/17 (Eliminating Veteran Suicide: Emergency Services for Other 

Than Honorable Discharges). A training PowerPoint presentation was developed in 

May, 2017 for field staff who register OTH Servicemembers in the electronic health 

record (EHR). VHA Directive 1601.02A was updated on June 7, 2017 to include information about providing care to this population. A Communications Plan was completed in June, 2017, which included internal and external PowerPoint presentations and Fact Sheet. In addition to external presentations to VSO groups and 

congressional partners, a series of national webinar calls was completed for VA field 

education.VA began implementing this initiative on July 5, 2017. In September, 

2017, the IT contract was awarded to develop and implement necessary computer 

upgrades for the EHR, which will allow the field to track the 90-day episode of care. 

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RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MAZIE K. HIRONO TO

HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

VA HEALTH CARE OUTCOMES

Introduction: Despite the bipartisan investments made in the VA each year, there 

continues to be basic failings that impact the experience of Veterans: issues in accessing benefits, communications with the VA, problems with VA medical care, and 

others. 

Question 60. What will be different next year in how you address just one of those 

issues—for example, health care access? Under this budget how will access to care 

be different for veterans next year in how they get it through the VA or outside it? 

How will the average veteran feel these proposals in their everyday interaction with 

VA? 

Response. VA continues to work to ensure all eligible Veterans have their urgent 

care needs met in a timely fashion. A year ago, VA implemented same day services 

at all medical centers and some of its community based outpatient clinics. On January 12, VA announced that 100 percent of its more than 1,000 medical facilities 

across the country now offer same-day services for urgent primary and mental 

health-care needs. . VA is also working to ensure new referrals to specialists are 

screened for urgent needs, and that these Veterans are referred for timely care. 

Since FY 2014, the average wait time to complete the most urgent consults decreased from 31 days to 2.8 days during December2017. VA is also working to ensure follow-up appointments for time-sensitive issues are managed in a timely fashion. In late 2016, VA also implemented a process to ensure timely follow-up appointments for time-sensitive medical needs. Since then, over 200,000 such appointments 

have been completed. A year ago 90% of such appointments being no later than the 

provider recommended appointment date. Over the past 3 months, this number increased to 95%. 

Patient Self-referral Direct Scheduling, the ability for Veterans to schedule a routine appointment without a consult from a primary care provider, was implemented 

in Optometry and Audiology in 2016. In 2017, it was implemented in all nutrition 

clinics and is nearing full implementation in podiatry, amputee and wheelchair clinics. In 2018, VA will be adding direct scheduling in cancer Care (Veterans new to 

VA or transferring their care to VA with a known cancer diagnosis), smoking cessation, mammography (when provided at VA), weight management, social work and 

pharmacy clinics. 

Expansion of telehealth services continues to be a priority for improving access 

to care particularly to parts of the country where there is a shortage of providers. 

The use of a national hub and spoke model in VA for Telehealth allows virtual medical appointments to occur in sites that may be rural or have difficulty recruiting 

providers, where otherwise Veterans would not be able to access care as quickly. As 

of the beginning of this CY, VA has 11 fully operational Mental Health Hubs and 

9 fully operational Primary Care Hubs. Additionally, some of our VISNs are setting 

up their own hubs. Additionally VA is in the process of implementing a tele-urgent 

care initiative in five VISNs this year. The initiative is designed to enhance first 

call resolution, properly addressing the Veteran’s need the first time they call to 

prevent the need for a second or follow up call. 

VA is also working to implement VA Video Connect, a simplified mobile and webbased application connecting Veterans with providers via encrypted video, is also 

being implemented. It allows Veterans to see and talk to their health care team 

from anywhere, making appointments more convenient and reducing travel and 

wait times. VA is in the process of implementing this across the Department. 

VA has also been implementing Veterans Scheduling Enhancement in all of its 

healthcare facilities. This system eliminates many of the previously occurring scheduling errors and improves the scheduling experience for the Veteran. 

In April, VA launched the ‘‘Access and Quality in VA Healthcare’’ website at 

www.accesstocare.va.gov. The website promotes transparency and enables Veterans, 

their families, and caregivers to view data related to: 

• Patient wait times at VA facilities in their area; 

• Veteran experiences scheduling primary and specialty care; 

• Available options for same day services; and, 

• Quality of healthcare delivered at every medical center. 

The contracts through which we purchase care in the community are undergoing 

significant changes based on lessons learned. New contracts will be significantly different based on experiences with current contractors and their performance (e.g. access, coverage, etc.). VA followed a methodical approach to receive, categorize, analyze and incorporate feedback from all stakeholders. 

139 

The new Community Care Network will increase the number of service areas from 

two to four, divided by state boundaries, thus allowing each new contractor to provide more local flexibility, improved customer service and increased access to care. 

Responsibilities for care coordination and scheduling of appointments, which were 

once assigned to the contractor, will return to VA field sites, unless there is the exercise of an optional task. Interactions with Veterans will be maintained by VA staff 

on a more face-to-face and timely basis. 

Question 61. Do the investments outlined in this budget provide any particular 

support for veterans in rural communities—like Hawaii—where geography and 

generational differences in the veteran community require different outreach and 

communications strategies? 

Response. The FY 2018 budget supports Veterans residing in rural communities. 

VHA’s Office of Rural Health (ORH), in concert with VHA national program offices, 

diligently works to create enterprise wide initiatives and create new and innovative 

programs that are increasing access to care for rural Veterans. Examples include: 

Tele-Primary Care and Tele-Mental Health Hubs, Clinical Pharmacy Staffing, and 

Rural Veteran Transportation Services. 

Ensuring access to timely and high-quality care is one of VA’s highest priorities. 

VA Research works to identify and evaluate innovative strategies to improve access 

and quality, especially for rural Veterans. 

Question 62. Will the fact that you are not using the exact platform used by DOD 

lead to interoperability issues at implementation? What conversations have you had 

with Secretary Mattis about ensuring interoperability with community providers or 

CHOICE providers? 

Response. With the decision to acquire and implement the same Cerner system 

that DOD is currently implementing will address the interoperability challenges between the VA and DOD. VA is working with the Department of Defense (DOD) and 

other subject matter experts, both in government and in the private sector, to ensure our new system will be interoperable with that of community partners. The 

exact mechanics of the interoperability will be addressed to provide seamless care 

across a common system is critical to providing the best care for Veterans. VA also 

realizes the importance of interoperability with our community care partners and 

educational institutions, and is determining how best to meet this need and will update the Committee soon. 

Question 63. Secretary Shulkin you have said that ‘‘we’re still looking at a multiyear process’’ and reducing the number of homeless veterans nationwide from 

roughly 40,000 to 10,000 or 15,000 is an ‘‘achievable goal.’’ What is this Administration’s specific goal to reduce homelessness and how will this budget help achieve 

that? 

Response. VA is committed to ending Veteran homelessness. While significant 

progress has been made to reduce Veteran homelessness, there are sub-populations 

of homeless Veterans who are hard to reach and engage (e.g., chronically homeless 

Veterans, those with serious mental illness, justice involved Veterans, and those ineligible for VHA health care services). 

The 2018 President’s Budget includes $1.7 billion for VA’s Veteran homelessness 

programs, including case management support for approximately 93,000 existing 

HUD-VASH vouchers, grant funding for community-based prevention and rapid rehousing services provided through the Supportive Services for Veteran Families program, clinical outreach and treatment services through Health Care for Homeless 

Veterans, service intensive transitional housing through the Grant and Per Diem 

Program and prevention services to justice involved Veterans in the Veteran Justice 

Program; and employment supports in Homeless Veterans Community Employment 

Services. 

STATUS OF MAUI COMMUNITY BASED OUTPATIENT CLINIC REPLACEMENT CONSTRUCTION

Question 64. Secretary Shulkin, it is my understanding that the VA has received 

a land donation offer for the Maui CBOC replacement from the State of Hawaii and 

is currently going through review and concurrence in VA’s Central office. What is 

the current status of this review and concurrence process and when can we expect 

the concurrence process to be completed? The project is very important to veterans 

on Maui. Can you ensure that this process is completed as quickly as possible? 

Response. The donation of a ground lease from the State of Hawaii was approved 

by the Office of Construction & Facilities Management on June 23, 2017. VA’s local 

contracting office is now able to proceed with the project. 

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A P P E N D I X 

PREPARED STATEMENT OF JOSEPH R. CHENELLY, NATIONAL EXECUTIVE DIRECTOR, AMVETS (AMERICAN VETERANS) 

MR. CHAIRMAN ISAKSON, RANKING MEMBER TESTER AND MEMBERS OF THE COM- MITTEE: As the largest veterans service organization open to all veterans who served 

honorably, regardless of when or where they served, it is a pleasure to present our 

views on the fiscal year 2018 budget for the U.S. Department of Veterans Affairs 

(VA). 

On behalf of AMVETS National Commander Harold Chapman, we are proud to 

fully support the requests for funding as outlined in The Independent Budget (IB). 

It is crucial that the VA Secretary has all the resources needed to successfully, efficiently and responsibly run the many facets of the Department. 

One area of great concern that AMVETS wants addressed immediately is the 

White House’s proposed cut to Individual Unemployability (IU) compensation for 

veterans eligible for Social Security. 

AMVETS National Headquarters has received thousands of emails, calls and messages over the past two weeks from veterans decrying the proposal to steal 225,000 

Social Security eligible aged veterans the U.S. Department of Veterans Affairs’ IU 

compensation program if they have paid into Social Security at any point during 

their life. 

Individual Unemployability is a VA program for veterans who cannot work because of their service-connected disabilities. These veterans are rated below 100 percent per the VA rating schedule. But each recipient of IU has been through an exhaustive verification process to ensure they are unable to earn wages above Federal 

poverty guidelines because of their wounds, injuries or illness. 

Cutting this earned and needed benefit would ‘‘save’’ $3.2 billion in 2018 and $41 

billion over the next decade, which is slated to go toward an expanded VA Choice 

program, which has yet to be fully developed. We feel if President Trump knew of 

the serious repercussions, he would have not included this in his budget request. 

These veterans earned a lifetime disability benefit for their service to this Nation. 

They did not ask to become disabled or to become unemployable as a result of their 

injuries or wounds. Our nation owes it to them to keep its promise, so they may 

continue to make ends meet. 

If veterans lose their IU, it would trigger the loss of: 

– Civilian Health & Medical Program of the VA (CHAMPVA) 

– Dependency and Indemnity Compensation (DIC) 

– Chapter 35 Educational Benefits for the family 

– Commissary privileges 

– Property tax relief 

– VA Dental & Vision Care 

– Vehicle exemption fees 

We firmly believe that if this measure of the budget passes, that it would put the 

lives of these veterans at serious risk. VA’s most recent report on suicide notes that 

about 65% of all veterans who died from suicide were aged 50 years or older. 

We urge your committee to reject this dangerous part of the President’s budget 

and not include any cuts to IU in your budget. Every day those who would be affected are growing more distressed. They deserve to keep this earned benefit and 

live their senior years with some peace of mind knowing that the country they 

served is not deserting them in the time of their greatest need. 

AMVETS is grateful for the Committee’s hard work to provide oversight and the 

resources necessary for our Federal Government to keep its promises to veterans, 

their families and survivors. Any questions or need for additional information may 

be addressed to AMVETS National Legislative Adviser Ms. Amy Webb. 

Æ