Transcripts For CSPAN2 VA Secretary Shulkin Testifies On FY 2018 Budget 20170615

[inaudible conversations] this morning epa administrator scott pruitt testifies before House Appropriations subcommittee on Donald Trumps fiscal year 2018 budget request for the agency. Live coverage at 11 00 am eastern on cspan3, cspan. Org and the free cspan radio apps. Next, Veterans Affairs secretary doctor David Shulkin testifies on the president s 2018 budget request for his department. The hearing also has representatives of veterans groups talking about budget proposal. This hearing is about two hours. [inaudible conversations] let me apologize for being a little late. A couple things coming down the hall, i dont want to flip up on me but stand at ease. In the air force, and for just one minute, my trusted friend, Ranking Member, will open the [inaudible conversations] [inaudible conversations] call this meeting of the Veterans Affairs committee together. I apologize again for being a little bit late but i want to make sure we are on the right track and i didnt mess anything up. I want to welcome secretary shulkin who has had a great start. I dont think anybody in this administration started better when confirmed and voting last week on accountability with extraordinary, the way we got to the decision, working together, was extraordinary and i commend the Ranking Member on his help in doing this and we have other things to do today to talk about budget wise. We have several decisions to make but we can keep the same tempo, the same commitment to make sure we know what each other knows before that happens and financing after the fact. I welcome doctor shulkin and other members of the staff that are here today and appreciate where we are going with the Veterans Administration which is upward and outward. I want to make a long statement, to say a couple things. One thing i have to brag about, the cerner decision getting our Electronic Medical records issues solved after years of unwillingness to address it. It is extraordinary. I think from what i have heard there are signs people are coming together in the past that havent been together to make sure this happened and works efficiently for our veterans and the department of defense and the promise of Veterans Affairs at the same time. Thank you, much. And thanks for having this hearing, and i think its important to say that our thoughts are with the colleagues who were the victims this morning. We wish a speedy recovery for congressman scalise and everybody else who was injured. And a, 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 with your v. A. Team. We spoke last week at some length about the future of Choice Program, and i hope i made my perspective clear the Choice Program was intended to supplement care provided directly by the v. A. , not replace it. Not now, not in the future. I worry the budget proposed by this Administration Starts us down a path of unfettered choice that will hollow out the v. A. In doing so, it proposes to increase funding by third by proposing the v. A. s own hospitals receive an increase that that is less than half the medical inflation budget. Further, the budget does nothing to address the aging infrastructure. Actually provide care for veterans while also denying them money to address the environment care concerns, we know what that outcomes going to be. Soon enough, there wont be any quality v. A. Hospitals staffed by quality providers and v. A. Care will become nothing more than a voucher plan to hunt for a doctor who has the time, capacity and knowledge to treat them. That is not what the veterans need or want to happen, and for a rural state like montana, it would truly be a disaster. Each year more and more rural hospitals are at the risk of closing, and if there are rollbacks to recent medicaid expansions, its likely these closures would accelerate. Is we cant assume the private care will work in rural commitments or where there arent sufficient networks. We know the vast majority of veterans are eligible to long wait lines not because they live too far from a v. A. Facility. Data shows rural veterans arent just choosing choices much, but they actually do depend on v. A. Care. But now, based on your quest yesterday, we may have to shift additional funds around to get the Choice Program through the fiscal year. For months weve being asking about the choice to spend rate and the amount of remaining funds. We were never provided with those answers x now were in a difficult spot. Mr. Secretary, no one wants delay in 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 frustrations compounded by a budget that cuts services that veterans rely on, makes cuts to education oversight, makes cuts to i. T. Which impacts every business. Im most concerned theyre being made in order for certain veterans to get private care. And the new policies are simply untenable. To put forward a proposal that would, without warning, top earned benefits payments to the most severely disabled vets is unacceptable. In this case, were not talking about folks milking the system for uncompensated must be that they dont money that they dont deserve. It must be determined that a veterans able to engage in work as a direct result to service to their country. 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. Thats a nonstarter, and i hope we can get your commitment today to keep this important benefit in place. So 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 directly from the v. A. And finally, i would like to wish the u. S. Army a happy birthday. I look forward to your testimony, secretary hull quinn. Sec shulkin. Secretary, welcome. We appreciate those use brought with you. Edward murray, Richard Chandler are, Deputy Assistant secretary, mark yao, james manniker, acting Principal Deputy undersecretary for benefits and matthew sullivan, finance and planning. Mr. Shulkin, secretary shulkin, the floor is yours. Well, thank you, chairman isaac soften, Ranking Member tester and other members of the committee. As you can see, i brought a big team with me because i kno youre going to have i know youre going to have lots of questions, and in particular with the Opening Statement, 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 Members concern that this is a sad day for the nation where public or servants who work as hard as i know all of you do have to worry about their personal safety. And our thought ands prayers are with the congressman if the stay 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, and we appreciate the legislation that recently has been passed. As you know, you passed just within the past week the accountability bill, and that went through the house yesterday. Were looking forward to actually next tuesday bringing it for a it for the president , and for a signature for the president , and thats 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. Thisthis has really allowed us o make Real Progress for veterans. Were grateful for that support. Ive submitted the full written statement for the record, so let me just start by thanks you again for allowing us to participate in the hearing last week. Seems like we were just here with you. But i thought it was an excellent hearing, a good discussion on choice, and that type of discussion and dialogue is going to allow us to help get it right for veterans. When i testified before the house Veterans Affairs committee on march 7th, we had 2 billion in the choice account. Less than a month and a half later when the president signed the choice extends act into law are 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. Weve authorized 8. 2 Million Community care appointments since january of this year, thats 2. 6 million more than be last year or a 46 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 weve all been working to fix with choice, and weve been increasing our use of choice. One of the reasons why is the 17 budget, as you may remember, actually had 2 billion less in Community Care, so weve been putting more through choice. Two years ago, im sure youre going to remember, in july of 2015 we had too little money in our Community Care accounts within the v. A. 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 were working to solve, again working with you, with the legislative authority, to replenish funds into the choice account. Is so this is the situation that weve described before where for a single purpose of providing care in the community, we have two Checking Accounts. And i 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 and, obviously, its not a science, its an art. Were having difficulty with that once again. And thats 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 moarpdizing and consolidating all of the Community Care accounts including choice. The president s budget provides additional funds for choice, and the resources necessary to continue the ongoing modernization of v. A. 104. 3 billion in mandatory funding and 82. 1 billion in discretionary funding for a total increase of 6. 4 billion or 3. 6 over 2017. It provides 2. 9 billion in mandatory funding to continue the Choice Program in 18, plus a 7. 1 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 and consolidating v. A. 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 v. A. This budget reflects the president s strong personal commitment to the nations veterans. Its also a budget we need to achieve my priorities as secretary; providing greater choice for veterans,ed modernizing our systems, focusing our resources towards whats most important for veteran, improving the timeliness of our services and suicide prevention. Were already taking steps to meet the challenges that we face. At the president s direction, weve established a v. A. Accountability office. The recent decisions made by the senate and house will help us with that. Weve 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. Ive directed the v. A. Central office remain under a hiring freeze for administrative positions as we consolidate program offices, implement shared services and realign overhead to get more money back to the field. We now have Sameday Services for primary Care Mental Health at all of our Medical Centers. Veterans can use an on line tool to online tool to understand access and quality. No other Health System in the country has this type of transparency. Weve made it easier for veterans to fill out Online Health care applications. Since last summer weve received eight times as many online applications than the year before. Last month we were able to the process a disability claim in just three days. I said that right, a disability claim processed in three days using a new process could decisionready claims. Well be introducing decisionready claims nationally september 1st. At our regional offices, well be completely paperless for claims by mid 2018. A few months ago the Veterans Crisis line had a rollover rate of 30 , today its less than 1p. Weve launched a new tool called reach vet allowing v. A. To provide proactive support for veterans who are at higher risk for suicide. Were also launching a new initiative, getting to zero, to help us end veteran suicide. This is my top clinical priority. Weve identified over a thousand facilities that are vacant or underutilized, and were working now to move forward with 142 of those facilities, and with your help, we could do more of the same. We need congress to fund our i. T. Modernization to keep our legacy systems from failing and to replace vista with a system already in use by the department of defense. This will ultimately put all patient data on one shared system enabling seamless care between the v. A. And dod without manual and Electronic Exchange can have reconciliation of data. We also need congress to overhaul our broken appeals process. Weve worked closely with vsos and other stakeholders to draft a proposal to modernize the system, and we are pleased to see house unite behind the bill last month. Now we just need the senate to act. Most of all, we need congress to veterans are responding to our modernization efforts by choosing v. A. More than before. To keep up with those choices, we need to fully fund choice and to help us modernize v. A. Community care through the Veterans Care Program. The Veterans Care Program will coordinate care so veterans get the right care at the right time with the right provider whether in a v. A. Facility or from a high performing Community Care provider. Of we just need your help to make it happen including funding to keep up with veterans as they choose v. A. Thunk and we look forward thank you and we look forward to your questions today. Thank you, dr. Shulkin. We appreciate you 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 of and dealing with the 470,000 veterans whose claims are pending today at the v. A. Would you agree with that in. I would like to see that happen. Im going to give you the same question once i give you a chance to make a commitment on that. If both the appeals reform and budget requests are adopted in this budget, would v. A. Be able to given accelerating decisions for those 470,000 appeals that are pending . The appeals that are in the board of veteran the board of appeals are the ones that were most concerned about. If the senate votes to move the appeals modernization forward, as i think youre saying, mr. Chairman, we will have a process to expedite those from the time that the haw the law passes moving forward. Youre asking about the legacy claims. Correct. And appeals. We do not have a plan to make Senate Progress on those. Significant progress on those. Were 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 wed 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 get current veterans who were in the appeals process the option of opting into the new process. And if they choose to opt in but its 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. So that 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. Well, first of all, let me commend you, because you just gave a patently honest answer to my question. Not that i expected anything else, but its easy for a Department Head sometimes to talk departmentese, and we think we heard one thing and we heard something else. But what i heard you say and, in fact, as far as or those legacy appeals are concerned, this really is not going to do much even if its adopted to take those legacy claims and move them forward. Which mean well still have 470,000 veterans claims out there. At least. Eventually, hell die and well get that one solved. And i hate to im going to quote now what ive heard secondhand, and ill say up front this is secondhand, but ive been told that the v. A. Recently told the Congressional Budget Office that v. A. s plan is to, quote, very gradually, end quote, address the 470,000 legacy appeals if appeals reform is passed. Is that the plan, and how long will that take, and i heard your answer being, yes, itd be very gradual and, yes, itd be 2026 before we got to it . Yes, yes. And, mr. Chairman, let me just add, because we share that frustration. I find it really difficult to tell people who have submitted into the appeals process that they have six years to wait on average to get a response. So ive asked the question how much more would it take to get that backlog addressed. And the answer is . Im not sure you want to know, because i was astounded i want to know. Around 800 million. Senator sanders, senator tester, senator eller, senator r boozman, senator moran, everything we do in this committee, senator manchin, will pale in compareson to comparison to the hell were going to catch if its going to take 800 million to handle those claims before 2026. Were going to clean up appeals prospectively in the future with what this budget proposes, but for the legacy appeals theyre going to still be out there yes. The angers going to get louder and the frustration deeper. So we really need you need to know the number 800,000 will do it, we need to be prepared to try and find somebody to do that. All thats going to happen is there are a lot of people that are going to get more and more anguish, heads and less service, and its less and less service. Thank you for being candid about that. I want all of us to be aware as members of this committee what were dealing with, and weve got to make the hard decisions. One of thems going to get those legacy claims done and not let them build up in the future. Prospectively, its sure as hell better because if we fix the ones that are back there and we have another buildup, were going to be madder than a wet hornet. Very quickly, i took too 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 then meets the qualifications necessary for them to be qualified for v. A. 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 . That is correct. Anybody up here at the dais disagree with that . Be this is not a trick, by the waker im 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 backlog, waiting time, things of of that nature. We did good things and it brought about some problems which we have eliminated and begun to solve. Were 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 v. A. Budget to the other. I just want to make sure im right on this. You have seven accounts that Fund Health Care benefits, is that correct . Community care. Community care, but theres seven accounts. Yeah, seven right. One of those is choice, one of those is Community Care so when you asked to move that money so you have enough money, youre not asking for new money to be given to you by appropriators or by the congress, youre asking to move existing appropriated money for Health Care Benefits under one stove pipe in the v. A. To another stove pipe to achieve balance. But its no new appropriations. [inaudible] am i correct . That is correct. We have enough money 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. And im raising this only as a good talking p point for all of us on the committee to have a discussion which im sure we will have on this. I want to get to that point also, but we get bogged down sometimes in legislative speak, words like mandatory and discretionary and this and that acronym when its all the same money in the case youre talking about. Its for veterans Health Care Benefits. Its in your current appropriations. Its not any new money, were just trying to meet our obligation to our veterans. So we need to find out the way to do that on not just a stopgap manner, but permanent. One of those ways might be able to see to it that all the Veterans Benefits for health care are paid out of one account. That not correct . That would make sense to me, mr. Chairman. Senator tester. Thank you, mr. Chairman. Once again, thank you for being here, dr. Shulkin. You talked about, and i want to follow up on the chairmans 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, and you wanted to transfer it. You had put out a rule, edict i dont know what you want to call it, whats it called . Directive. Directive, thats better. A few days ago you said you wanted to go to the original intent on choice, and so that would dry up a lot of how the dollars were spent. And then a today or two later you rescinded that. Thank you for the breakfast yesterday. We had a great breakfast x we talked yesterday about potentially doing a fix legislatively. I was told today that another direct i was put out today that reinstated that rule to go back to the is that correct . Let me try to be accurate about what happened. We noticed that there was a imbalance in our two Checking Accounts. Yes . On friday we sent out a directive saying stop spending from this account right. Okay . Start spending from this account. Correct. We were afraid, after seeing that directive, that we were going to confuse the field bingo. And so we rescinded that. Thats correct, right. The field, once we rescinded the memo said, okay, we get it. Youre 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 while were working with you to figure out the best solution about how to get the appropriate money in each of those Checking Accounts. And did those four principles i dont have a problem yeah. All i want is predictability, because i think its important. Did those four principles tell the folks to go back to the original use of choice . It told them, it told them to use choice for the appropriate use of choice which is colorly, as you 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. Okay. So with all due respect, the directive was put back in place x. By the way, i dont have a problem with the first directive. I dont have a problem with staying the way it was. Its got to be driving your folks on the ground, and its going to be driving our veterans crazy if its yes, no, yes, and then in a week went we fix this, itll be no again. So thats all i ask. And that uncertainty, by the way and i wont speak for everybody on this committee, but ive got a notion it will be for everybody on this committee does not add confidence to the v. A. Moving forward. Ill just tell you. Is so you get my drift . Absolutely. Let me just say yes. I would not disagree or argue with you. The Choice Program has been difficult to administer yeah, yeah. Difficult to understand and very complex. Yep. The first memo was rescinded and remains rescinded because what it said is do not go to choice. We do not mean that. What weve 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, but its different than the first memo. Okay. I would just say this, and communication is a very good thing, and we need to have communication. The breakfast we had yesterday was very, very important. I think everybody was at that breakfast, hopefully we can do 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 v. A. , its your baby. Youd hang me out to dry if i tried to do it x rightfully so. But we just need predictability, and thats all. And by the way, and when i say we, this committee, but more important are the people sitting behind you need that predictability absolutely. Other side, things are going to go upside down. Ive got a bunch more questions, but ill refer to the next person in line. Senator moran. Chairman, thank you. I want to be in the position of agreeing with senator tester and disagreeing with senator tester. The memos are different, and theres a significant consequence to the difference. When we visited about the first memo, the consequence of that would be that the Third Party Administrators would have no role to play in the networks potentially could go away, lie dormant . Exactly. And so the second memo says choice is alive and well absolutely. And its to be used in these circumstances which are the ones that were defined by the original choice act. Right. I dont actually know right. What, why thats different than how it was being used how was choice being used different than 40 miles and 30 days . Because we were also putting everything that we could through choice, especially services that werent being offered at the v. A. So, senator moran, you have it correct. That was exactly what we tried to do between the first and second. Senator testers pointing out that we have some work to do in getting our communications thats the part i was going to agree with. [laughter] yes, i agree with him too. Because on that point i would make the case op behalf of Senate Tester right. That we had a hearing on wednesday on choice. Yes. Your first memo goes out on thursday and friday friday. And this conversation never occurred with people who care a lot about choice, but care a lot about i will say everything that both of you have said is accurate x i will tell you and i hope that a politician, i must confess. Yeah. But 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. And i assumed that was the case. Yeah. Thank you. Let me then again try to highlight why keeping choice in existence and its 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 then when we potentially reauthorize its existence into the future. When i say that it matters was if choice isnt being used, then our intermediaries arent being paid. The network established under choice goes away, and you have Community Care but no choice and no network, no third or or party intermediary. So its not just a mart of transferring money a matter of transferring money back and forth, its a matter of making sure that choice is viable so that the network stays in place. Does that make sense . Yes. And weve worked very hard to do that, and i agree with you, we want to keep that in place. A part of this i still am confused about because your response in regard to chairman isakson was that we just need transfer authority. And i certainly have been in these hearings enough to know that youve said that more than once. And i think thats something that were interested in it makes no sense to have unneeded barriers. But 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 viable available so that the program stays viable. Heres what i wonder, is that just and, again, in response to the chairman i think you said were not asking for any new money. Right. My understanding is that you have about 2 billion in the Community Care account, is that an contract number . Unobligated, yes. At some point in time, and i dont know how soon that is, that money becomes scarce. To the fix can only last so long before both the choice account and the Community Care account are insufficient to meet the community that the the Health Care Needs through Community Care. That true . We have enough money to get us through the end of the fiscal year in both if we could balance the accounts correctly, we could make it through until the end of the year to get Community Care paid for in both choice and internal Community Care. So the 2. 9 billion in the fy18 budget request is not needed until fy8 . Im going to defer to my ceo, but i would have said, yes. Yes, sir, thats a requirement for next year. The one caveat is in the budget we assumed we were going to carry over 600 million into next year, our actual requirement for 18 is 3. 5, so 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. And that hole will exist in mandatory dollars, not discretionary dollars. Yes, sir. Which then means in this committee has to act the authorize additional mandatory spending for whatever the account is then called. Yes, sir. Is that true . Unless we were to find some orr offset somewhere in our direct appropriated discretionary funds. I guess my takeaway is assuming that your budget numbers are right, mr. Secretary, that there is no emergency, is what youre 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 its Discretionary Spending into the mandatory account in yeah. That true . The haas part that you said 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. And 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. Thats correct. So the emergency is not more money right. 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, dollars shortfall in fy18 even if we appropriate the 2. 9 billion in the president s request. I think everything you said is correct, and as mr. Yow said, you know, we are not seeking, though, additional monies. If we needed to, we will identify the offset to the 600 million for 18. The chairman has his finger on the i think that ive had my fair shot. We may have another chance. Thank you. Very helpful. I apologize, im going to take one minute just the clarify a couple of points. Dr. Shulkin, im a veteran, i served in the military in afghanistan, served my years to necessarily make we eligible for v. A. Health care. Im a veteran, im in v. A. Health care. If i go to v. A. Hospital for a medical need related to my service or to just regular health care, youre obligated as the v. A. To pay for it and deliver that health care to me the best possible way possible, is that not right . Yes. So if its mandatory you dont have the discretion as head, director of the v. A. To not provide me with health care because you didnt get must enoh money. Correct. You have the obligation to manage the money you have and if not, come and get more. Yes. Thats why we talk about mandatory and discretionary be, i dont think its a matter of discretion. Weve got to find the money x its mandatory that we provide that money. I would agree. What youre talking about in transferability is after we decide to put x number of dollars in however many accounts it is that are in the v. A. , you want to be able to take money out of those accounts to pay for the benefit of that veteran without having to go through a secondary step to get money removed by someone else because somethings named mandatory or named yes. I just wanted to get that, im not sure i said it right. You said it perfectly. Its clear as mud. Senator sanders. Thank you very much. Dr. Shulkin, great to see you. Op page 3 of your testimony, you point out, i think, what most veterans organizations can and vetnds know veterans know, that by and large, the v. A. Has a pretty Good Health Care system. And you quote a study published by the journal of the American Medical Association where researchers compared hospitallevel quality care on 129 v. A. Hospitals with over 4,000 nonv. A. Hospitals, and you found that you had Better Outcomes in the is v. A. On six of nine Patient Safety indicators, and the other three were about the same. Thats pretty good. That speaks pretty well for the system that youre running despite all of the criticism we hear every day. Yes, sir. 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 talking about preventable deaths in american hospitals. Accordingaccording to, im lookn 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 v. A. Doing compared to nonv. A. Hospitals on that issue . Well, as the article in jama suggested, the v. A. s actually performing better on Patient Safety, and Patient Safety is define by medical errors, than on average the private sector. Of course, every hospital in america including v. A. Is always looking for ways to get better. But the v. A. Has systems in place that help it perform better than many of the private sector hospitals. 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 v. A. Health care. And what i do not want to see, and i think senator tester, many of us do not want to see, is shifting of funds that go to tradition Alva Health Care to the choice traditional v. A. Health care to the Choice Program. Weve had a long discussion, we will continue to discuss that. But i am a little bit distressed that a significant amount of money in president trumps budget is going to choice, not quite so much going to tradition ar v. A. You say that vha is the Largest Health care system in the u. S. , and in an industry where there is a National Shortage of health care provide earth, we have a major doctors crisis, maybe psychiatry, psychology those are the two biggest, yes. Okay. 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 x. What that does essentially, mr. Chairman, is what it does, as you know, medical school is now outrageously expensive which is a very serious problem. So i talked to young doctors who are 3, 400,000 in debt, okay . Theyre not going to go working probably at the v. A. , theyre going to go working 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 v. A. For x number of years, we will forgive the debt that you have incurred in medical school. Is that an idea that makes sense to you . Senator sanders, both of the ideas that you said and that the Ranking Member talked about make a great deal of sense to me. I do not want to see v. A. Care diluted because were getting more veterans into the community. I want to see more veterans in the community because they need the care and v. A. Cant provide it right now. So what were proposing and hoping to work with you in this new Choice Program are the two things youve talked about. Right now were restricted to a 1 transfer from care in the Community Back into the v. A. Or vice versa. Wed like to see that aperture opened so that we could actually take money that was in the budget for sending veterans out can and reinvesting more of it into the v. A. We think thats very important. It should be done at the local level when every local business makes its decision about what services the v. A. Needs to strengthen. On gme issue, graduate medical education, couldnt agree with you more. The program that you were helpful in crafting was a great success. Is it working well . It is. It is. And we need to do more of it. We are proposing exactly what youre saying, which is creating more gme spots. The country needs them. V. A. Would pay for them. And in exchange, it would be like the military or Public Health service or [inaudible] national Health Service corps. Afterwarksdz they would give five years back to v. A. Right. Mr. Chairman, this is an issue where i think we can go a long way in attracting excellent physicians and nurses perhaps yeah. Into the v. A. By doing a debt, expanding the Debt Forgiveness program which i understand is already working well, and i would look forward to working with you on that. Last question is, im 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 one in the ten, have medicaid as a source of coverage. If Republican Health care plan goes through and im going to do everything i can to see that it doesnt but if it does go through and medicaid is cut by over 800 billion in a tenyear period, i assume that means a lot more veterans are going to be flocking into the v. A. Am i correct on that . I would think so. We are a safety net organization, is and we tend to have veterans without other Health Access come to the v. A. And i dont want to sound like a politician, but, you know, as the chairman said, our role is to provide that care. And so we with would so if veterans lost their made decade, theres a reasonable possibility many of them would turn to the v. A i believe so. And you would need additional help to accommodate that large number of veterans. Thank yes. Thank you very much. Thank you, senator sanders. Senator rounds. Thank you, mr. Chairman. Mr. Secretary, last week we had a rather, i guess id call it a spirited discussion about the Emergency Care fairness act. And under the v. A. s fiscal year 2018 budget proposal, a budge line to pay for a budget line to pay for Emergency Care still acting. However, the vsos independent budget has included a recommendation of 1 billion for 2018. I guess my question would be what is the status of the appeal on the Emergency Care fairness act the way that it, its being interpreted . And at what point will the v. A. Formally request the necessary funds to pay for the Emergency Care for our veterans . Well, first off, 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 weve talked last. First, we have completed all of the regulations to be able to move forward with payment of the stub claims, and we have now transmitted them to the office of management and budget. So that parts complete. So thats moving forward. Thats good news. 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 case. Oh, thats great news, mr. Secretary. I think what that means is then, that means 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 . Well, we still have to go through the rulemaking process. Thats why we transmitted those rules to omb, and they need the go through the process. I dont want to set time expectations but, yes, we are move anything that direction to adhere to the judges ruling on this. Thats a very positive development. For those 370,000 individuals, this is great news. Any possibility of expediting that rulemaking process . We, we did. We got, we got the rules over there very fast, and what happens now well certainly encourage the administration and be supportive of that. I cant tell you how glad i am to hear that. I appreciate the fact that youve taken the time to get personally involved in this and to work through that issue. I think thats what veterans want to see coming from the v. A. , a focus on what the veterans need, what the veterans care should be. And then when we make a promise, we honor that promise. And i think thats what veterans are expecting from the v. A. I think this is a major first step in that, and thank you very much for your work on it, your attention to this, and i think thatll pay dividends for the entire organization for years to come, so thank you. Mr. Chairman, i will yield back time. Thank you, sir. Thats great news. Thank you. Good. Thank you, senator. Senator manchin. Thank you, mr. Chairman. Secretary shulkin, recently you announced that you would be scrapping the current Electronic Health care records system and adopting the same system that dod uses from ther is that corporation based in st. Louis. While im certainly in favor of making it easier, my concern is that speed of this decision will have second and third and order of effects that could be detrimental, and heres where her. My concern to you is are you concerned that there will be increased risk in one Company Managing all these assets . Be. 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. Okay. That considering the maintenance requires on vista, the expense that will be required and our lack of ability to maintain qualified software adopters within v. A developers within v. A. , 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. Theres always a risk, senator, especially when you transfer systems. Theres another part. I have two more parts the this. By waiving the the bidding process which you just spoke about, how are you guaranteeinger iser ins not taking v. A. For what we would consider a little bit of a ride . Well, because all ive done is start the negotiations. How will you know if the price is competitive if theres nothing to compare it to . Well, we certainly know the price that dod paid. We know the price that were currently paying to maintain our systems. And we are going to be seeking the best way to do this for tax a payers. Now, most of the cost of a transfer of system is actually in internal change management, not in Software Licensing its not in your budget right now, so how are you going to absorb the cost . Were 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. Well, we mow this hearings about care and the community. While insuring the records transfer between dod and v. A. , its important to also insure that records transfer in interoperability, will serner be undertaking that as well . Yeah. What ive said in the decision on the emr is that while it is a decision to move forward with a common platform with dod can, this will not be the dod system. V. A. s needs are much different in that we have to be interoperable with our Community Partners. And many, many, in fact, 80 of our Community Partners are not necessarily on the cerner platform. So were going to have to create a system that does several things that dod didnt. Were not going to be scrapping vista. Were going to have of to connect into and maintain our 30year database, and were going to have to be interoperable with Community Partners. Very quickly, i have one more, and then i have a real quick question. Theres no assistant secretary of i. T. , nor is there an undersecretary for health, is so how are you undertaking these without those well, fortunately, we have competent people in those roles you feel like you have the personnel to do it . I feel like we are very lucky to have very competent acting people, but i need to have permanent people in those roles soon. My other question is concerning opiate epidemic which is my number one problem i have in my state yeah. Not just with the yen population, but with general population, but with the v. A. Yeah. My veteran community. What im concerned about is [inaudible] im looking for assurances that when we do new provider agreements on any contracts if not v. A. Care providers, were going to be making sure they understand they will not tolerate the overprescription of opiates. More or less, we have a lot of pill mills x they get these people hooked and keep them hooked. Whats your oversight, are you prepared for this in. Well, i have to say i dont think were doing a good enough job in this. I think the country needs to do a lot better we have challenges within the v. A. Ourself yeah. We know that, and you all have been addressing that. And i appreciate that. You have very little control out in the private sector. I think weve really made Good Progress in the v. A. On the oversight. Weve seen the 33 reduction in opioid uses since 2010, we monitor patterns of prescribing. I have the concern about going out into the community that you have what im saying is the contract you write if im a nonv. A. Provider, so the new act lets that person come to me. I contract with the v. A. To take care of these people. Is there conditions on that if i prescribe do i have to follow prescription guidelines . Are you going to be monitoring that as far as the opiate prescription guidelines . Today there are not those requirements. I think this is a really good area for you to come back to with some thoughts sir, need your help, because youre on the front license. I know. Yeah. Thank you, mr. Chairman. Thank you, senator chairman. Senator heller. Mr. Secretary, glad to have you here. Want the talk about the budget for just a minute, if i may, and i want to talk about the individual unemployability cuts. Yeah. Can you explain the rationale of what went through the thought process that went through this . Yeah. Well, 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 sense best for veterans and for taxpayers. And 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 process better. As i began to listen to veterans and their concerns and vsos in particular, it became clear that this would be hurting system veterans and that this would be a takeaway from veterans who cant afford to have those benefits taken away. And im really concerned about that. So what id like to say is that this is part of a process. We have to be looking at ways to doing things better. But i am not going to support policies that hurt or veterans. And so i would look forward to working with 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 shouldnt be doing things that are going to be hurting veterans that cant afort ford to lose afford to lose these benefits. I appreciate hearing that. Kuhn hum veterans do you know how many veterans would have been affected by this yes. We have jamie. 300,000 . About 210,000 of those are over the age of 06 and, therefore, would have been 60 and, therefore, would have been affected. Would have been. Correct. So it would have been retroactive . To include all veterans in receipt of i. U. , i dont believe wed pull any p benefits weve distributed back, however no, no, im just saying if you had the benefit, you could lose the benefit if youre currently receiving it. Thats correct. That was the proposal, but we do look forward to working with you to figure out how we could do this better. I appreciate your concern. Do you know what the average is per veteran on this i. U. , what the average intake is . The average payment . Yeah. Its roughly 1600. Roughly 1600. Yes, sir. Thats op top of, you have to be rated between 60 to 100 , and it takes you to a temporary 100 . 60 is roughly 1600. All right. So you can understand the financial burden it may pose for an individual. That 1600 and what im more concerned about, of course, is their longterm are time. They may have not prepared or been prepared in believing that that 1600 might be there. I think thats 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 wouldnt have used Unemployment Insurance to fund peoples retirement. I think that was the conflict. But 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. I appreciate your concern for this. Can i change topics for just a minute and make sure i understood this correctly. Did you say that you had a decisionready claim in three days . Weve had 12 of them so far, i think. Yes. [laughter] yeah. And thats and september 1st were going to be rolling that out across the country. I mean, thats big news. Thats big news. [laughter] of. And im glad, because ive been working with these issues, this issue for years. And to think that you could actually turn one around in three days is pretty incredible. That is a big deal, and were pilot anything st. Paul right now. Piloting in st. Paul right now with a couple of our vsos. And if the vso brings in the claim ready to be decided do its got to be ready, i get it we had a previous secretary say he could get the claims down to zero by, i think it was 015. 2015. Whats the status now . If this works as well i can tell you i wont say that. [laughter] no. I mean no predictions. No we right now were at 90,000 . As of this morning it was 94,000 yeah, thats about a what i have. Theres about 1200 of them in nevada. Yeah, yeah. And i think our goal, jamie, is by the end of the calendar year to about 70,000 . Thats right. But these decisionready claims, we think, will take 1015 of them off. So we wont start rolling them out until september, but that will begin to whittle that down, and we hope in two years to be down below around half of where we are now. Okay, okay. Mr. Secretary, thank you. Mr. Chairman, thank you for the time. Thank you, senate heller. Senator murray. Thank you, mr. Chairman. And thank you all for being here. Secretary shulkin, in last years budget request the v. A. Estimated it would need 725 million in fiscal year 2017 and 840 million in 2018 for the veteran caregiver program. Finish yet in the first budget of the trump administration, you plan to only use 521 million in 17 and 604 in 2018. Those are cuts of about 30 . And meanwhile, i am hearing from so many of my constituents, as im sure everybody is, of caregivers being dropped from the program with no explanation and no justification. And an investigation by npr found the charleston Medical Center actually dropped 94 of its caregivers, 83 north 83 in prescott, arizona, and 83 in augusta, georgia. It seems to me in watching this this is just another way the administration is balancing its budget on the backs of veterans in need. How do you explain those numbers . Lets just talk about the three things, quickly, that you said. So what was reported on in charleston, completely unacceptable. 94 revocation of caregiver benefits, unacceptable. Thats 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. So thats the freeze that youre talking about. Right. Right, thats the freeze. Thats only a temporary measure. Its a temporary measure until we revise policy, because i will not accept giving benefits and then taking 94 of them away. Thats ridiculous. 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. About two months ago. Of course. Absolutely. Let me go to the shortfall. I know that you wrote to try west and healthnet telling them to return referrals for care including for veterans that are curly waiting for care. How many veterans will be affected by that . When they cant appoint an appointment within a period of time in the contract we asked them to return it. They are returning large numbers to us. Do you know, mark . I dont. This is an ongoing process. Before they would just wait until it took weeks and weeks to give an appointment. We said if you cant give an appointment within five Business Days for a routine appointment, return them to the va so we can take care of the veteran. But its a big percent we get back. Do you know how long care will be delayed for veterans as result of that . This is speeding at care rad than letting a veteran stay out there Choice Program, they returned them to the va and in the va Community Care program goes out and tries to find that appointment. Im concerned about where the money is going to come from from this and how you would get the money to continue nonva care. Seems to be two different stories here. Transfer of authority is what im hearing from this year, correct . If you transfer money from this year, then what youre doing is impacting which of those going to be a carryover for next year so what you need additional money for next year . The problem of having these two separate Checking Accounts and predicting what you need the money is, frankly, impossible. Thats why we want to work to get the program into a single Community Care account. But look, these guys are going to help make the best predictions possible. So he will help us understand the right amount of money to transfer over to predict it but it will impact 18. We cant do our job if we dont know what the costs are. So you know im already hearing from veterans in my state about the delays and burdens they are seeing as a result of this. I veterans in walla walla who are being told to have to drive eight hours roundtrip to portland or seattle just for some simple imaging task as a result of this. Im hearing a lot more. We are happy to get those two but this this is having impact i dont want you to know that. We want to know where this money is coming from, so we will followup with you on that but i think this committee needs to be aware of that. Okay. And im running out of time, or i am way over time. I have other questions, mr. Chairman, and i will submit them for the record but im deeply concerned about that. Listening to all these questions about Checking Accounts reminded that wish i was asked yesterday on my 49th wedding anniversary. Someone asked my wife and i what we attribute 49 years together, i still would have had a joint Checking Account that both of the set to sign so we never had those arguments. Lets dont get into that situation either. Senator boozman. Thank youthank you, senator , senator tester. Thank you for being here and we appreciate our veterans advocacy will testify shortly. Senator sanders talk to you about the problem with the fact of providers. And so many people are at the age now where a group of baby boomers that are aging out, they practice because they like and medicine has gotten more comforted and stuffed her i think well see a bunch of those actually decide to do something else, or not do anything. The idea of increasing, first of all i agree the fact that we can reward people for going in is a great idea and i think it would work, and i think we have good evidence of that. The problem is, is actually creating new slots versus taking slots away for veterans. If you could work with some of your counterparts, the va is a huge entity, this is a huge problem for the country. Besides of the va. If you could craft a situation where you can actually increase the medical School Classes and then also the residencies which are huge problem, too. That would be a great deal better with relationship, va with the teaching hospitals, i think that could be done pickets going to take some work but actually could be a great legacy. Right. Were 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. Its in there. The residency spots are capped by medicare. What you did in the Choice Program that senator sanders helped lead was expand those graduate medical education spot. Thats what we need desperately. Very much so. And again we need to do that with whatever takes pick in the future well get ourselves in trouble. 8. 4 billion and Mental Health, 6 increase, thats great. Mental health hasnt put so much in the va in the last years. When not at the point now where we are just writing prescriptions like so many providers. Not just in the va but threat the country giving a prescription. On the other hand, we need to go farther. How are going to prioritize that 6 as far as increasing our ability to provide good care . We targeted the higher mental professionals. This year to where seeing 58,000 more Mental Health appointment that we did last year at this time. We are expanding our tele Mental Health programs. We just as you kno this past you have given full Practice Authority to advance Practice Nurses as many of them will be putting their skills to work and expanding the training, psychiatry psychology and nurses is what we need more help in. We need to do a lot more. I think youre right we reprioritize middle but separate it needs a lot more help. You talked about the core mission of the va. The Foundational Services of the va. Can you walk us through those of what you feel like is these are the services 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, that you cant find us in the private sector. If we just turned her our veterans onto the private sector, they would really be lost. So these are services that veterans have a high predilection for from post traumatic stress, Behavioral Health issues, spinal cord injury, prostheses orthotics, holly, poly trauma, comprehensive primary care and Behavioral Healthcare services are foundational as well. Environmental exposures, blanck reappeared i do want to leave out a group because i know i will offend them, but these are things that the va does extraordinary well that you would not find easily except in very specialized geographies where the art centers of excellence. So its important we keep those strong. In your testimony you also talk about Community Care and how doctors make decisions on providing care in facilities. How do you do this . How do you make sure that we have an institution, we have a bureaucracy. How do you make sure that those decisions are based on whats best for the veterans as opposed to whats best for the facility . Well, i think, i wish there were 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. Thats all he saw in the Choice Program. Were having veterans call call centers, people who didnt know them, and that was frustrating to veterans. What weve learned is delay the process, get back into the exam room. Were now in more modern terms, that tele monitors. But let the doctor, the patient, the provider of the patient make the decisions that together in a partnership about whats best for them and thats the system werwere trying to design now. Thank you, mr. Chairman. Senator tillis. Thank you, mr. Chair. Mr. Chairman, i will be married 30 years two weeks from today. With a slightly different approach to longevity. We do have a joint together i just dont have access to it. [laughing] that works also. Im not even allowed to go out and network. Thank you all for being here. Im actually running between committees do we have an aging Committee Going on right now and were talking about supporting caregivers, the Hidden Heroes project that senator udall is heading up thats critically important. I wont spend on talk about it here but one thing that was striking as his opening testimony was the fact it was 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 overtime. I understand in order for us to do that with to talk about the resources to make sure we are shifting attention away from so many other pressing things but it is something i look forward to talking about in a future. Dr. Shulkin, i want to know how were doing. Some of the estimating a got to believe some of the uncertainty with respect to accounts and how much we need in one of the other, one thing 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 you can actually get to that information pretty quickly. How are we doing on getting, i,i understand the cio nominee has withdrawn their name from consideration. How i would do if trying to get administration stacked up so that you got a good organization, Permanent Organization under you . Not only the cio at the cfo candidate. If we are attracting a good viewing audience, we need help. We need people to want to, and to come and help. Having a permanent cfo will be important getting your Financial Planning in order and getting your financial processes and planning processes in order. Yes. I think youve touched on something important. Hopefully somebody can step forward. I know its a sacrifice and you somebody who is highly skilled but weve got to get those positions filled. I think it would be one of the ways we get back on track for the transformation effort. Im not going to spend much more time because im going to get back to the other committee, but im going to echo again what i said in the last committee. Im sure there are various factors that led to the shortfall in one account versus another, but there are probably other things we need to do to make sure were facilitating the process and not give you additional distractions or uncertainties. You go through the Financial Planning, please, speak candidly to the Committee Members to make sure wind are things we can do or shouldnt do that a getting in the way of you getting as definitive answers so we can count on and also want to reiterate what, senator murray made several good points. I agree with all of them. I think she is actually right, the sony articulate what youre funding levels are, the better so we can go and be advocates for it. Thank you, mr. Chairman. Thank you, senator tillis. Senator blumenthal. Thank you, chairman. First of all i want to express my appreciation on the Richard Staab versus mcdonald. I join my colleague send arounds in 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 vocational rehabilitation employment program, as you know, it provides career counseling and Rehabilitative Services to veterans with Service Connected disability to over, employment barriers. It also assist with postsecondary training and educational institutions. Ive been told by Connecticut University that there are delays in vocational rehab housing and education payments for Service Disabled veterans. The va has previously attributed those delays to lack of vocational rehabilitation. The Hartford Regional Office has staffing shortages. The va purported goal ratio of vocational rehab counselor to client is one counselor per 125 veterans but the average ratio in july of 2015 im told was one counselor to every 139 veterans. Despite the payment delays and the das inability to meet the ratio, the fy 18 budget cuts to this program is 13. 8 million. You are probably more fully with the numbers that 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. Id like to know whether you plan to delay, to address the delays, and your view of the apparent underfunding of this very valuable program. Senator, first of all, thank you for your outspoken leadership on the staab the case. In terms of education, we may have different numbers. I like to go over with you. We see 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, but we think this important program, we believe in and we believe the president s budget adequate defensive. But if youre different numbers and we are wrong, we want to address that. I would like my staff perhaps to get together with you all yes. But i think the overriding issue here is not necessarily even the numbers, because even if there is a slight increase, this program is so valuable it out to be a major increase, and certainly not a reduction. And again this is not criticism of the va. In fact, on the contrary it is saying you are doing great work, we dont want to see it diminished. We see these delays in hartford and wed like your help in solving them. Yes. We will follow up with you. And i dont know whether it has been asked about, but i wonder if i could ask again about the Veterans Benefits administration, whether you feel Real Progress in reducing the claims backlog. Im guessing someone has asked about already and i apologize. Thats not a problem. Whats your prognosis . Well, ill briefly just tell you we are 94,000 now. We hope by the end of you to be at approximately 70,000, and then a year following that or two years from now, below about half the level, 45,000. We Just Announced that we have done 12. So far in three days called decision but he claims. We will roll that process out nationally september 1. First. That will impact around ten to 50 of her claims because they have to be, all the information is ready, they are presented and we give a decision in three days. Days. So i think were making some progress. We are trying to actually look at some breakthrough ways to do better, but as of today i give you the most Accurate Information we have. And the progress that you are making is the result of a different reform in the process or is it more resources . The budget, the budget stays flat for next year, so whats not necessarily more theyve added in the past couple of years i was in the major changes of process improvements. Theres something called the National Work queue which is really allowing productivity adjustments, and so therefore you can distribute the workload across the country evenly. Have just enhanced and increased the productivity standards for the people who work in vba and theyre doing a terrific job and we have great staff work in vba for up to the challenge. And we are seeing improvements. So mostly process improvement but over the past couple of years they have added to their staff. Well, i want to thank you for your focus. And you know this is a problem that has continued to bedevil us over many years, and im glad that youre making those process changes and there may be some breakthrough changes in the foreseeable future. Yes. Thank you. Thank you. I have been asked by senator sanders and senator tester to be able to make brief statements. Im going to wait anytime i happen recognizing senator tester and senator sanders. Thank you, mr. Chairman. I have beaten of the source in the past and i will be it one more time. The vsos will hear from next want to have the bs a primary care provider. I thought it over and over again. Senator sanders have talked about it. Others have talked about in this committee. Ive been in public life long enough to know that you want to know where things are headed, you follow the money. And the fact that we have 1. 2 increase for inhouse medical care and 33 for outside medical care is disturbing. Moving forward, because you said over and over again to me to worry about this, john, its going to be fine, we will make the va the best it can be in the va will fill in the gaps. We just need to try that. 0. Oh because we will hear from a panel of vso representatives and i got a notion they will talk about va care and dave will be reasonably couple min to talk about other ways we can fix it. So i would say that. Number two, this is an Authorization Committee. Electronic coal i. T. Fundy, year 200 million in this budget. You should be asking this committee to plus that budget appeared you need to do it so it represents the money you will be dumping out for the dod, electrical platform that we all support you doing by the way. And i think its really important how were honest with ourselves. Ill tell you why. I happen to be on both committees and i dont want to get nailed and say the Authorization Committee didnt do that, and these spendthrift appropriators are just dumping money into it i would just say we did have a budget accurately reflects what we need to do. In this case we know this i do think will cost dough. We need to act accordingly. The last thing is we will have carl blake from pba and leroy acosta from disabled vet, and Carlos Fuentes from dfw and john appear in a second i just want to thank those guys for the service. We need to take our direction from the vsos. Im not going to try to be although ill try to get back before the end. We do need to take the direction from the veterans. I think its critically important so thank you all. Senator tester, thank you. The one thing is we always clear on where you stand, and appreciate that. I do want to try to work with you to you and your staff because we have different numbers than you have in terms of the Community Care internal care. And we have an interest in making sure the va is the best system. The ability to transfer more, right now were limited to 1 of what help i us a great deal and that something will continue to work with you on. And i what you say, and were going to work with you on that. Johnny and i both agreed. As i said you the breakfast yesterday you can outsource care but you cant outsource the responsibility. Thats right. 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 dod and the va were criticized for overdependence on opioids. I know that there has been some significant changes. Ive been pleased to go to the hospitals around the country and see very robust programs regarding alternative complement to medicine, yoga, nutrition and so forth and so on. Can you say a word about how the va can lead this country away from opioids so obvious is sometimes their necessary, into less type of dependent drug approaches . Ill try to do it briefly, but i will tell you i published an article on this for five months ago in the journal of American Medical Association about the va approach because i think it is a National Example that others can learn from. We started this work in 2010 where we identified problems for the rest of america did as the va often does. We did this to a multifactorial approach. We essentially now monitor the patterns of all of our providers in the give them feedback on how they perform compared to their peers. If there overprescribing. If they are overprescribing. Pharmacist go out and teach our providers the ways to use opioids appropriately. We have our patients sign informed consent so their part of the process when they get an opioid. We participate in the state prescription data monitoring programs. Thats mandatory that our providers do that. We are providing alternatives such as you said, metric your pick in fact, the best practice for us in the country i dont know if you know this, is actually White River Junction where we have a 50 reduction opioid use, using those exact techniques complementary medicine acupuncture. Yoga, biofeedback, you know, mind, body type of techniques. So we tried to get others to be as good as were doing and White River Junction. We are working in a number of these areas and, of course, what kind of work on research with the fda and nih on nonaddictive narcotics as well because we think thats important. Thank you very much. Venky mr. Chairman. I would like to thank all of you for [inaudible] [inaudible conversations] its an unbelievable National Crisis now. [inaudible conversations] [inaudible conversations] [inaudible conversations] let me thank secretary shulkin and his staff for the testimony and their support and continue response to the committee. Where are very grateful for that. Let me welcome our second panel, and ill begin with introductions. Mr. Carl blake, associate executive director of regulations paralyzed veterans of america. Mr. Leroy acosta, assistant National Service director, disabled american veterans. Mr. Carlos fuentes, director of daschle legislate services, veterans of foreign wars. Mr. John rowan, National President , Vietnam Veterans of america. Mr. Blake. You each recognize or five minutes. Thank you for the opportunity to testify today. Would like to submit our fiscal year 2010 independent budget report into the official in record. Thank you. Id like to spend my time talking about what weve heard here today rather than just specific to the recommendations that include in our budget report. Lets recap. I appreciate senator heller bring up the question about iu. Although i would say its not readily apparent the va has severed its going to drop the proposal altogether. Sounds like the secretaries willing to discuss it further. I appreciate senator manchin and send it to test the bring of the ehr modernization. Senator rounds continues to beat the drum about and senator moran starts to probe of the question about holes seem to be appearing in the das budget. I appreciate the secretaries made the commitment he has as relates to the ehr modernization doing the right thing with the stop rolling and trying to address issues like character expansion of it is not a easy job. I dont envy the position he is placed in. But lets forget, lets set aside the fact that it sounded like to me we may be staring a budget shortfall right in the face just for this current fiscal year, based on the transferability problem and moving money between Community Care and choice, or all those things have added up to a shortfall somewhere. Lets look at fiscal year 2018. I think thats a good way to snapshot the bigger hole the va has to deal with. Senator heller mentioned iu. Iu in this proposal was reasonably going to find a large majority of choice Going Forward in perpetuity as it were, lease 3. 2 billion. If we assume that that is not going to happen, thats 3 billion in Community Care under choice that has to be addressed somehow. If not addressed in the discussion part of the va budget. Its 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 mention the decision. I think on policy thats probably the right decision to make for va and for dod. But i read an article recently that said the department of defense obligation is something on the order of 9 billion i think in the lifecycle of that program. It also said vas obligation will be at least thre three to r times that great. How does the das budget rationalize that point . Im sure it doesnt. Send it around mentioned staab. Its the right thing to do is what the secretary said. I think he knows it and hes acting upon that. I was amused he said the expedited the rulemaking process. I think is a way to omb. Thats where the expletive process goes to die. He said last week it might be nine months. Omb will be on the clock nine months norther track record. Put that aside, the stop rolling has already let va with an obligation in previous years of at least 2 billion. Where is that money at thats going to pay for that issue . The average in subsequent years is 1 billion, 1. 1, 1. 08, something in that range. Where is that money at . Its not in the va budget either. So now were keeping score. We have 3. 2 billion hole for choice. We have an approximately 1 billion hole for staub. And then we have the other issue we dont know if thatll looks like i could make the argument looking out the fy 20 19 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 exactly the same dollar figure approximate 3. 3. 5 billion. Are we going to decrease Community Care usage in 2019 . I think think we all at the table no thats not going to happen. So right now the va could be staring at a huge hole in its budget for 2018 and with expressive this to the appropriators and a fortune because of the time and everything the appropriators have already moved forward on the house side. They will market their bill tomorrow, and none of these questions are answered. Yet the va is left with billions of dollars in unanswered questions, and its not enough to simply say we have enough money, we can move it around. Thats not true. Thats just simply not true. Mr. Chairman, appreciate the opportunity to testify and have it into any questions you may have. Thank you very much for your testimony. Mr. Acosta. Mr. Chairman, members of the committee, as coauthor of independent budget along with vfw pva, were pleased to present our views regarding fy 20 18 photo requirements for Veterans Benefits programs. Thfidel focus on critical fundig needs for vba compensation service, vocational rehabilitation an appointment and veterans appeals. Also cover our strong opposition to a couple of illconceived and unacceptable Administration Proposals to scale back veterans disability compensation. Mr. Chairman, we recognize dva has made progress in reducing the claims backlog. We prosecute more claims than ever before yet workload continues to rise. To manage current and future workload we recommend an additional 1007 and 50 fte for Compensation Services which would require an increase of boxley 183 million. Vas Rehab Service needs additional funding took over the past few Years Program participation is increased by 50 over all. Based on historical trends it would increase by another 5 in fy 20 18. These rising demands to achieve and sustain the one, 100. 5 client accounts racialist alley counsel racialist tally from both rehab by law the recommend an additional two and 66 ftes which would require a 32 million increase their overall a total funding for vba be increased by 278 million. Thats 10 increase and maintain Current Service levels for the rest of the vas. Unfortunately the administration is recommended and outright cut in funding for vba of 12 million. For over all funny that is 300 million less than the recommended by them. Mr. Chairman, vba has made significant progress on its claims backlog. One cant switch has been a long increase in the backlog of appeals for denied claims. Today there are over 450,000 appeals pending either at vba or the board. It takes almost six use an average for decision by the board. Fortunately those of a part of a stakeholder workgroup to develop and enact comprehensive reform of the appeals process. As 1024 the veterans appeals improvement and modernization act of 201 2017 is built upon te takeover framework and has received broad bipartisan support. We urge you to move forward expeditiously and pass this legislation. The house is passed similar legislation earlier this year. An enactment of this legislation would lead to a more modern response and flexible appeals system, one that will provide quicker decisions on appeal waffler protecting veterans due process rights. Even with the passage of the reform, the board will continue to require resources commensurate with workload. Last Year Congress authorized the board to increase by 242 to authorize staffing level of 922 ftes. The board has yet come has not yet filled all those positions. For fy 2018 we expect the board to continue hiring to fill all authorized positions. Yet we do not recommend for the staffing increases while this legislation is being approved and implemented. Moving forward, the board and Congress Must carefully monitor implementation of the new appeals system to assure staffing remains adequate to meet further workload demand. Finally, mr. Chairman, we enthusiastically opposed to legislative proposals in the administrations budget. First, we strongly oppose the proposal to round down cola or tenures which would hurt our nations veterans, their families and survivors. Via cumulative effect of this proposed tax would cost beneficiaries 2. 7 billion over ten years. We are asking congress to sell reject it. Furthermore, we object to the proposal to cut eligibility for an ability, or iu. Cindy because disabled veterans reach an age in which they might qualify for Social Security retirement benefits. Mr. Chairman, total compensation is not a retirement benefit. As provide for us conversation provided to suffer lifelong serviceconnected disabilities and to determine unable to work. Furthermore this leads to veterans losing benefits that result from a total disability rating. Such as educational assistance, commissary election 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 rejected these dangers proposals that that would be harmful to disabled veterans. That concludes my testimony and ill be happy to respond to any questions of you or members of the committee. Thank you very much. Mr. Fuentes. Chairman isakson and members of the committee, on behalf of the men women of the vfw id like to thank you for the opportunity present our views on the va budget. The basis proposed increase in discretionary budget. We support the continued focus on expanding access to healthcare, expanding, expedited decision on benefits, claims and appeals, increased focus on combating veterans suicide and addressing the stigma associated with Mental Health. Ensuring va is ready and able to care for Women Veterans who are the fastestgrowing federal population are however, i would like to make it clear to vfw strongly opposes efforts to clawback benefits from our most every disabled veterans to pay for such improvements. In the past week nearly 40,000 0 letters and emails from vfw members and supporters have been sent to members of congress opposing the administrations proposal to revoke individual unemployability benefits for veterans are unable to work because of their serviceconnected disabilities. The vfw opposes the proposal and the coal of round down proposal and of the measures to balance the budget on the backs of our nations veterans. We are also concerned administration has to make the veterans Choice Program a permanent Mentor 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 oppose cuts to veterans programs in order to expand the Choice Program under mandatory spending instead of including it in Discretionary Committee care accounts. Sequestration is draconian spending caps limit our nations ability to provide Service Members veterans and their families they care and benefits they have earned. The vfw calls on this committee to join our campaign and finally in sequestration and do away with federal budget processes based on arbitrary budget caps. In partnership with her independent budget coauthors, dav and pva, i would like to focus my remarks on vas construction and National Cemetery budget request. For more than a decade we have 115th congress and va that perpetual underfunding has allowed the infrastructure to erode while its capacity has slowed from 81 in 2042 sides 121 in 2012. We continue to believe that this needs space and chronic underfunding of Construction Projects could force va to ration care. The budget request said improving the condition of va facilities to a Major Construction project account for the largest resource need to keep pace with the growing demand for va outpatient care. The administrations Major Construction request only funds one vhs basic construction project. We believe va has requested an adequate amount for its fiscal year 2018 Major Medical leases need. However, Congress Must find a way to quickly authorize leasing projects. There are nut now 27 major medil facilities leases awaiting congressional authorization. 18 of which have been waiting since 2015. Delays and authorization of these leases have a direct impact on the eighth ability to timely care to veterans. The National Cemetery administration has a sacred duty to provide our nations 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 place additional demand on nca, and the ib vsos are glad to see the administrations request for nca recommend dish which only made one of the only ones. We commend va for continued commitment to our mission. Mr. Chairman, this concludes my testimony. Im happy to answer any questions you and the other members of the committee may have. Thank you. We appreciate it. Mr. Rowan. Thank you, mr. Chairman. Senator sanders, nice to see you. Nice to see you, centered. Its good to see becker i missed you when i had my annual testimony this year. I missed you more than you might think. [laughing] glad to be vertical again. Me, too. I was coming out of the hospital when youre going in, i think that anyway, i would like to put first of all thank you for the accountability act. Its an issue we been dealing with since we started vba frankly 35 years ago calling on congress to take full accountability of all the va operations and hopefully this will work. And we support that bill. Iu has got to be rescinded. That whole proposal is a classic budget year proposal that has no idea how it impacts on people. Its just a dollar amount to somebody in omb. The effects of you even what everybody understood the first time which is this all nonsense of social scale was going to pick up the amount of money lost in iu. Not even talking about the effects of the family members, the loss of dental care, the loss of chip va, the loss of local benefits as was mentioned earlier, tax abatement in new york city. We discussed expansion of our tax abatement for real estate. That would be cut significantly by that. So that this is just got to be one of the things were calling upon, we would like since the secretary has alluded to the fact that they may agree with the idea that this could be shelved to come with love to see a joint effort between the va and the leadership in both the senate and the house Veterans Affairs committee publicly denouncing this idea and saying we are not going to pass it so that we can to all those scared people out there who have been sending emails and letters about all of the horrors that theyre concerned about, that they have nothing to worry about. We have got to bring these people down about ten notches because their climbing the walls right now. That something i hope the Committee Vote in the senate and the house and the va would take into consideration so that they can public acknowledge that this was one bad idea. The Choice Program is not a choice. Its a false choice, and to think we need to understand how its done. I just came back from idaho where i met with my state council of the north sandpoint idaho in northern idaho. Almost everybody there utilizes the Choice Program because they are hundreds of miles in any va facility. But they also can tell me all the problems they have with choice in finding doctors who will take a choice. Who will take the vas money, who even signon because the problem, we know theyre trying to resolve those problems but its 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 the. I managed to outlive him. So that was great. Hes retired. Im still sick and i got to go see the doctor. I called up my Emblem Health which is one of the Largest Healthcare providers in the country, and they couldnt find me a dermatologist that i could talk to at the earliest in august and really were talking about october. So thats a false choice. Thats 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 dont sign up for the va. They wont take the vas payments. Just like weve seen in medicare and medicaid with problems with doctors not signing on. So were concerned about that. Its, emily needs to be rethought significantly. Because the private sector is not ready whatsoever to take on the va patients, no way. A couple of things i want to point you also, the r d budget has been cut. It shouldnt be cut. It should be increased. We need more r d for all of the programs we have. We need to get more evidencebased programs testing of ptsd and how do we really handle it. I cant tell you all the different programs, what a great panacea the that for ptsd. Sounds great. I love my dogs, they are helpful and yesterday help some veterans but without counseling that doesnt in your problem. We need to get more evidencebased actions, research into these programs. Im also concerned, we passed the bill last year that would look into the effects of toxic exposure on the children of Vietnam Veterans and veterans who came after us. Where is that money going to come from if the r d budget is cut . Weve got a nice belfast avenue to we thought. Where is the money . We need the money. If they va budget isnt there, how are you going to get that done . Last let me say one quick thing about broader veterans appeals and the whole appeals process. Typical a lot quicker if the va took outside doctors opinions and didnt have to redo everything that somebody came in with with an outside doctors opinion. That would be nice. The other thing is, if we need to blow the board of veterans appeals. It just doesnt function. Nobody should lose 70 of the time, which the va does, every year. Id been in this position 12 years, and in 12 years, every year our vsos, 70 of the time, either get a remand are a direct payment from the board of veterans appeals on cases we bring in. 70 . We win, va losers. Year after year after year. And i guarantee you that the same with the rest of the gentlemen on this table. All their cases around the same percentage. Thats ridiculous. The other problem is, no precedent. Carl can put in the claim. I can put in a claim for the exact same thing. He cant judge a, i get judge of the. We two different opinions. Both go down. He wins, i lose, too bad. His opinion doesnt count to anybody that falls after them. Theyve been approved, and neither does my for that matter. The denial doesnt either. Its just regurgitating the same program over and over and over again, the same problems over and over and over again. We need to get the issue of president s like in any other court. Frankly will be happy to look at them doing class action lawsuits. I would be happy at any and all questions that anybody may have. Thank you. Thank you for your testimony. I dont have a question. I have a proposition for you though. Id like to find a time i would like my staff to listen to this confined to tell you and i can lunch one day in the next three weeks or month. Because your comments about the iu, Unemployment Compensation recommendation, which is a nonstarter with you and i think anybody else will take that spree much a nonstarter. Its not hard to pass benefits. Its hell taking the back. Once you pay you will not take the back or if you do you lose a lot more than what you gave. It also heard the comment i think mr. Acosta may have referred, somebody did, about the cola roundup. There are lots of things out there that over the period of years of Veterans Administration in its existence and benefits existed in healthcare, were whee time to change the things that change. We probably ought to look at everything that weve got out there. There may be some pearls of wisdom and there may be some benefits that in the scheme of things will help us. We need some folks who dont have any agenda except to our veterans to solve our problems rather than go to court. Sit down and talk. Ill call you and we will have that lunch. Im not avoiding you, mr. Acosta, mr. Fuentes, or mr. Blake either. But you made the comment. Well do that because i think we open a little oneonone dialogue. There may be in some of these things that we bring up, staff brings to us or omb brings it up or your organization, you earn the benefit of looking out for the best interest of your organization and appreciate that. We ought to start having some meetings and talke talk some ofe stuff didnt we may end up finding no, event anywhere, but we might find some pearls of wisdom to if we do i would love to work with you and anybody else on doing this. We will try to set that up as a regular. Senator sanders. Thanks, mr. Chairman. I shouldve known but but i tht we get rid of this round down thing finally. My hearing about it probably the first thing to congress i was chairman can we get rid of it. The idea of nickel and dining veterans didnt seem a lot. What youre telling me, acosta, or mr. Fuentes, is it is back again . Yes, sir. Thank you very much for your leadership while you were chairman of this committee, and really eliminating that cola round down, that practice. Now the president s proposal laid out proposed to reinstate the cola round down as a way to pay for it, and expansion of the Choice Program as a Mentor Program. Essential taking money away from va benefits and using it aninother purposes. How much with this, if this were implemented, how much would it cost veterans . Does anyone know . The tax would cost close to 2. 7 billion over ten years. Mr. Chairman, i dont think we should be nickel and dining veterans. We have been through this for years. I thought we got rid of it and its had to say it is coming back. Let me ask what i think is the elephant in the room. And that is the concern at a know the numbers seen to be disputed. 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 any concern to you guys . I think one of the concern is, and the secretary addressed this in his, scope there was a lot of talk about marriages and checkbooks. The bottom line is we believe all of the committee care should be streamlined under one authority, one account and managed it that way. I think i understand why they put choice over on the mandatory site. There are a number of reasons, things like discussion kneecaps that wholly that discretion spending that place that risk, but from the independent budget perspective weekly they are still shorting even the larger discretionary pot. I mean, the differences for construction in particular which are tremendous, and when you take into account that outside of healthcare account virtually every other line item takes a reduction of some type. Let me get other comments if i could. Anybody else want to comment . I concur with mr. Blake. Also would just like to add, this whole notion of having a mandatory program in discretionary and not being able to transfer, i think its more about having, as carl said, having one checkbook instead of requiring va to have to balance both. But ultimately you are absolutely right, senator. We cannot forget they need to invest in vas ability to provide direct care for hire more physicians, expand facilities. Because ultimately that is the preferred choice of veterans and we need to continue that. Yeah, i would just like to add, look, i study privatization. I worked for the city of new york as a manager for 26 years with the last in the city council in the comptrollers also get all those kinds of programs. I watched and 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 a doctor. Youre going to a plan. The plan will be administrated by somebodys making 2 million a year. And thank god rpa people are not pay that much. They may be should be, as i will tell you in my hospital care that i got in the manhattan hospital. But thats not what we should be doing. Let me ask you just are very brief thoughts on a crisis thats impacting vermont, new hampshire, the whole bloody country, and this is this opioid epidemic. My impression is that the va is trying to do the right thing. What are your thoughts on that . It certainly is an epidemic that must be addressed. We hear about veterans are being overmedicated. One of our concerns i think would be the reverse as well. Because what we have heard is veterans cutting off veterans without proper alternatives. And we certainly dont want that either. So we dont want an overcorrection buggy want to eliminate the medication. Other thoughts . Senator sanders got out to thank all of our vsos and members, i know would you go after the big i can we take two hours and then everybody is gone and you are stuck with me. And the secretary i want to commend the sector first thing here. Your words are heard. We appreciate your input. Look for to working with you towards providing the benefits that are earned and deserve by our veterans and do it the most efficient way possible for the taxpayer and that is our ultimate goal as a committee. We thank you very much for you tend to stay. The record will stay open for seven days for any additional, which you may have. The committee stands adjourned. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] the use senate is meeting