Transcripts For CSPAN3 VA Secretary Shulkin Testifies On FY 2018 Budget 20170616

I wanted to make sure we were on the right track and i didnt mess anything up. Wanted to welcome secretary. I dont think anybody who had a better unanimous vote. It was extraordinary and the way we got to the decision working together and was extraordinary. I commend the Ranking Member on his help doing the same. We have some thing to talk about budget wise. We can keep the same tempo and same commitment to make sure we all know what happens before it happens and well be better off. I appreciate all they have done in our meeting to explain where they are going. It is upward and outward and further ahead all along. I will make a long statement except to say a couple of things. I dont want to make this today but one thing i have to brag about, the certainer decision in getting our electronic after years of unwillingness is extraordinary. There are signs people were coming together in the past and makes sure it happens and works for our department of defense and the department of veterans affairs. It was silly to have an agency in the same government serving the same soldiers fighting the same constitution that had two medical systems that were not n inoperable. I think it will prove to be a tremendous move economically for the va and benefit wise for our veterans. No way to do any better than that. With that instead of getting into details i will turn for an Opening Statement john tester. Thank you mr. Chairman and thanks for having this hearing. I think its parent to simportae wish a speedy recovery for congressman scalise and everybody that was injured and a big thank you to the Capitol Police officer to make sure this place is a safe place. My thoughts are with them. Secretary, thank you for being here. We spoke at some length about the future of the Choice Program. I hope i made my perspective clear. It was to supplement care not to replace it not now or into the future. I worry that the budget proposed starts us a down a path. In doing so it proposes to increase funding by a third and proposing that the vas hospitals receive an increase that is less than half of the medical inflation rate, not much. Further that the budget does absolutely nothing. If we are starving and actually provide care for veterans and denying care concerns. We know what that outcome will be. Soon enough there wont be any hospital staff by quality providers. The va care will become nothing more to send veterans to hunt for a doctor who has the time and capacity and knowledge to treat them. That is not what our veterans need or want to happen. For a rural state it would truly be a disaster. We need to be honest. Each yore more and more at the risk of closing. If there are roll backs its likely that these would accelerate. We cant assume that the private care would work in Rural Communities or where they dont have sufficient networks. We know that the vast majority of veterans are eligible to long wait lines, not because they live too far from a va facility. It shows they arent just choosing choices but they do depend on va here. But now based on your request yesterday we may have to shift add digsz additional funds around. For months we have been asking about the amount of remaining funds. We were never provide with those answers we need to make informed decisions. Now we are in a difficult spot. Mr. Secretary, no one wants delayed care for veterans, no one. We will act in a timely manner to solve this problem. For that to happen this late in the game is a bit frustrating to me. It is which impacts every business line and department operates. Im most concerned it appears these cuts are being for certain veterans to get private care. The new policies to pay for private care, to put forward a proposal that would stop earned benefits payments is unacceptable. In this case we are not talking about folks milking the system for things they dont need or dont deserve. It must be determined that a veteran is able to engage as a direct result of service to their country. President trumps budget that we stop paying at a time when more americans are having to work longer to make longer in their lives to make ends meet. It is all in the name of finding more and i hope we get your commitment today to keep this important benefit in place. I look forward to working with my colleague to address these concerns and look forward to hearing from you and how you intend to prioritize funding who get care and benefits directly from the va. I would like to wish the u. S. Army a happy birthday. With that thank you mr. Chairman. I look forward to your testimony. Welcome. Let me introduce you. We need to back you up. We appreciate them being here today too. Thank you for being here and chief Financial Officer. Richard chandler, Financial Officer of Health Administrat n administration. The floor is yours. Thank you members of the committee. As you can see, i brought the big team with me because i know you will have lots of questions and in particular with Opening Statements i look forward to getting to some solutions and some closure on some of these issues. Also wanted to echo the Ranking Members concern that this is a sad day for the nation where Public Servants who work as hard as all of you do have to wore i have about their personal safety and thoughts and prayers are with the congressmen thank you for allowing us to be here today. We want to talk about the advanced apropuations. It is in way of showing support for veterans. We appreciate the legislation that had been passed. You passed within the past week the accountability bill. It went through the house yesterday. We are looking forward to next tuesday bringing it far signature for the president. 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. It really allowed us to make Real Progress for veterans. We are grateful for that support. I submitted the full written statement for the record. So let me just start by thanking you again for allowing us to participate in the hearing last week. When i testified we had 2 billion. Last month our choice account was at 1. 5 billion. Today that account is at 821 million. As we know, more veterans than ever are using choice. We authorized 8. 2 Million Community care appointments since january of this year. Thats 2. 6 million more than last year or 46 increase. In fact march, april and may were the largest months ever for choice. Frankly it happened because we fixed so many of the problems that we have all been working to fix and we have been increasing our use of choice. One of the reasons why is the 17 budget, as you may remember actually had 2 billion less than Community Care. We have been putting more through choice. Two years ago im sure you will remember in july of 2015 we had too little money in our Community Care accounts within the va which we solved with your help by accessing unused funds in the choice accounts. We now have too little money in the choice account which we are working to solve, again, working with you with legislative authority to replenish funds. This is the situation far single purpose we have two checking accounts. I will tell you, i wish it were easier than it is. We have to figure out how to balance these two checking accounts at all times. Obviously its not a science. Its an art. We are having difficulty with that and we need to work with you to solve it. The Veterans Care Program that we outlined for you last week will solve this recuring problem permanently by modernizing and consolidating all of the care accounts includes choice. The president s budget in 2018 and 2019 provides the resources necessary to continue ongoing modernization. It requests 186. 5 billion for va, 81. 1 billion in discretionary for 3. 6 over 2017. It provides 2. 9 billion in mandatory funding to continue the Choice Program in 18 plus 7. 1 increase in discretionary funding to improve patient access. It supports the strengthening of Foundational Services as well as consolidating Community Care through the veteran care Program Announced last week. Veterans can make the right decisions together with their physician or provider giving them yet another reason to choose va. This budget reflects the president s strong personal commitment to the nations veterans. Its a budget we need to achieve as secretary providing greater clois for veterans, focusing resources towards whats most important for veterans, improving timeliness of our services and suicide prevention. We are already taking steps to meet the clal lehallenges that face. I directed the Central Office remain under a hiring freeze as we consolidate Program Offices and realign overhead to get more money back to the field. We now have same day services for primary care and Mental Health. Veterans can access wait time data using an online easy to use tool to understand access and quality. No other system has this type of transparency. We made it sooizer to fill Online Health care applications. Last month we were able to process a disability claim in just three days. I said that right. A disability claim processed in three days using a new process called decision ready claims. Well be introducing decision ready claims nationally december 1st. At our reej flgional offices wee by mid2018. A few months ago the crisis line had a rollover rate over less than 30 . We launch add new tool allowing va to provide proactive support for veterans who are at higher risk for suicide. We are launching a new initiative to help us. This is my top clinical priority. To keep moving forward we will need your help. We identified over a thousand facilities. We are working now to move forward with 142 of those facilities. With your help we could do more of the same. We need congress to fund our modernization to keep our legacy systems from failing and to replace vista with the system already in use. It will ultimately put all enabling seamless care without manual and electronic conciliation of data. We also need congress to authorize broken and failing claims appeals process. We worked with closely with stake holders to draft a proposal so modernize the system. We were pleased to cease the house last month. We need the senate to act. It is through the Veterans Care Program. The Veterans Care Program will coordinate care so veterans get the right care with the right provi provider we just need your help to make it happen. Thank you and we look forward to your questions today. Thank you. It must in dealing with claims who are pending today at the va. Would you agree with that . I would like to see that happen. I will give you the same question with a chance to make a commitment. If both appeals and budget ri quests are adopted would va be able to begin axel vating decision for those appeal that is are pending . The appeal that is are in the board of veteran the board of appeals are the ones that we are most concerned about. If the snenate votes to move it forward we will have a process to expedite those from the time the law passes moving forward. Youre asking about the legacy claims and appeals. Right. We do not have a plan to make significant progress on those. We are going to have to wid l away at them. The budget will add 142 more staff to the board that will allow us to make progress. I think to deal with the backlog we would be looking at 2026 before we deal with the backlog. The one hope that i have, mr. Chairman, rather than adding a large number of staff to deal with the backlog is that we will give current veterans who were in the appeals process the option of opting into the new process. 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. So that is my hope to be able to accelerate the backlog to encourage veterans who unfortunately would have to wait years to get decisions to opt into the new process. Well, first of all let me commend you. You just gave an honest answer to my question, not that i expected anything else, but its easy for a Department Head to think we heard one thing and we heard Something Else, but what i heard you say this really is not going to do much even if it is adopted so take the basic things and move forward. Well still have veterans claims out there. One of them is 25 years ole. At least. And eventually he will die but we have 269,999 more to get to. I have been told it to address the legacy appeals. Is that the plan and how long will it take . I heard your answer being yes, it will probably be very gradual and it would be 2026 before we got to it . Yes. We share that frustration. I find it really difficult to tell people who have submitted they have six years to wait on average to get a response. I have asked the question, how much more would it take to get that backlog addressed . The answer is . Im not sure you want to know. I was astounded by ou muhow muc was. Around 800 million. And everything we do as a committee will pail in comparison to the hell it will catch if it is 800 million to handle those claims before 2026. We will clean up with what this budget proposes. For the legacy appeals that sit out there they will still be out there and the anger is going to get louder and frustration deeper. So we really need you need to know the number. We need to be prepared to find some way to do that. All thats going to happen is a lot of people are going to get more and more anguish, less service and cause more problems. Thank you for being candid about that. I want all of us to be aware of what we are dealing with. We have to make the hard decision. One of the things is not let them build up in the fuchture. Now, very quickly, i thought that ought to be out on the table. When a an american citizen signs up in the United States military and commitments them to a period of service carries out that service and then meets the qualifications necessary for them to be qualified for Va Health Care in their retirement or when they leave the service then we are obligated as a nation to pay for those benefits. Is that not correct . That is correct. Anybody disagree with that . Im trying to get everybody engaged. We did choice. Senator sanders and mccain did leadership on that. We did the backlog, waiting time, things of that nature. We did good things and it brought about some problems which we have eliminated and then begun to solve. We are now in a situation and you we lieluded to it where you to find money to finish out choice in this current budget period by moving money from one part of the va budget to the other. I want to make sure im right on this. You have seven accounts that Fund Health Care benefits, is that correct . Community care. But theres seven accounts . Yes. One of those is choice and one of those kplCommunity Care. So when you asked to move that money so you have enough money youre not asking for new money to given to you, youre asking them to move existing apropuated money for Health Care Benefits from one stove pipe to another to achieve balance. Its no new apropuation, am i correct . That is correct. We have enough money to make sure 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 point for all of us on the committee to have a discussion, which im sure we will have on this. We get bogged down in words like mond mandatory and discretionary. Its for vert rans Health Care Benefits. Its not any new money. We are not raising any expenditures. We are trying to meet obligations to our veterans. Is that not correct . That would make sense to me, mr. Chairman. Thank you. Thank you for being here. You talked about and i want to kind of follow up on if questions. You talked about in your Opening Statement choice being down to 821 million abdomen t 821 million and there was a fact you wanted to transfer it. You had put out a rule i dont know what you want to call it. Directive. Thats right. A few days ago that said you wanted to go to the original intent on choice. So that would dry up a lot of how the dollars were spent. We had a great breakfast. We talked about potentially doing a fix legislatively. I was told today that another directive was put out today that reinstated that rule to go back to the initial is that correct . Let me try to be accurate about what happened. We noticed that there was an imbalance in our two checking accounts. On friday we sent out a directive saying stop spending from this account and start spending from this account. We were afraid after seeing that directive that we were going to confuse the field. So we rekrended that. Okay. We have more money in Community Care. We sent out four principals about the appropriate use of choice and appropriate use of Community Care while we are working with you to figure out the best solution about how to get the appropriate money in each of those checking accounts. And did those four principaling and i dont have a problem here. All i want is predictability. Did those four tell the folks to go back to the original use of choice . It told them to use choice for. With all due respect the directive was put back in place. By the way, i dont have a problem with the first directive. I dont have a problem with staying the way it was and in a week when we fix this it will be no again. So thats all i ask. In that uncertainty, by the way and i wont speak for everybody but i got a notion that it will be this way for everybody ton committee does not add confidence to the va moving forward. Ill just tell you. Do you get my drift . Absolutely. I would not disagree or argue with you. It has been difficult to understand and very complex. The first memo was resended and remains because it says do not go to choice. We go do not mean that. We provide guidance so say you can use choice but we have Community Care funds. We want you to use those. We understand but its different than the first memo. I would just say this communication is a good thing. I think everybody at that breakfast was. There was never an indication of this happening at the breakfast yesterday or we could have talked about it some more. It is your baby. By the way, more importantly the people behind you need that or things will go up. I have a bunch more questions but ill refer to the next person. Chairman, thank you. I want to be in the position of agreeing with senator tester and disagreeing with senator tester. The memos are different. Thats significant consequence to the difference. When we visited about the memo the consequence would be they would have no role to play in the networks could go away, lie dormant. Exactly. The second memo says choice is alive and well. Absolutely. It is to be use until these circumstances. Right. I dont actually know what why thats different than how it is being used. How is it being used than 40 mile s in 30 days . We were putting everything we could through choice especially services that were being offered at the va. So you have it correct. That was exactly what we tried to do between the first and second. Senator tester is pointing out we have work to do in getting our kplun cacommunications. Aagree with him too. So on that point i would make the case that we had a hearing on wednesday on choice. Yes. Your first memo goes out on thursday or friday. This conversation never occurred with people who care a lot about choice. I will say that everything that both of you have said is accurate. I will tell you [ inaudible ]. Yeah. I will tell you that look, my integrity is very important. On wednesday, senator, i did not know this information. I learned about it on thursday. I assumed that was the case. Thank you. Yes. Let me highlight why keeping choice in exist ens and its not just a matter of what pot of money it comes from is an important issue. That revolves around whether or not choice has a future and when we reauthorize the kpes ens into the future. When i say that it matters because if choice isnt being used then our intermediaries arent being paid and you have Community Care and no third party intermediary. Its not just transferring money back and forth, its a matter of making sure choice is viable so the n the network stays in place. We want to keep that in place. A part of this im still confused about because your response in regard to chairman is we need transfer authority. I have been in these hearings to know you have said that more than once. It makes no sense to have unneeded barriers. We also need to make certain that this issue of mandatory is handled in a way that choice is mandatory and that money has to stay available so that the program stays viable. She here is what i wonder. In response to the chairman we are not asking for any new money. You have about 2 million, is that correct . Unobligated. I dont know how soon that is, that money becomes scarce. So the fix can only last so long before both the choice account and Community Care account are insufficient to meet the community, is that true . We have enough money to get us through the end of the fiscal year. If we could balance the accounts correctly we could make it through to get Community Care paid for in both choice and internal Community Care. So the fy 18 budget request is not needed until fy 18 . I will defer to my skrrceo b would assume yes. We were dwing to carry over into next year. Our requirement is 3. 567. We are going to consume that before the end of this year. We will have a hole next year of about 600 million. And that will exist many mandatory dollars, not discretionary dollars . Yes, sir. Which then means this committee has to act to authorize additional mandatory spending for whatever the account is then called, is that true . Unless we find some other offset in our direct apropuated discretionary funds. I guess assuming your budget numbers are right that there is no emergency is what youre telling us, that choice will continue between new and without input of money as long as there can be a transfer. The last part you said is true. If there is no action at all by congress then the Choice Program will dry up by midaugust. And you have no ability in your view to fix the transfer issue, the discretionary, two component to combine them. Thats correct. The emergency is changing the law to spend money you dont have. It sounds like it creates a likelihood of dollar shortfall in fy 18 even if we appropriate in the budget request. I think everything you have said is correct. As he said, we are not seeking though, additional moneys. If we needed to we will identify the offset to the 600 million for 18. I think i have had my fair shot. We may have another chance. Thank you. I apologize. I will take one mr minuinute to clarify a couple of points. Im a veteran. I served in the military in afghanistan, served my years to make me eligible for Va Health Care. Im a veteran. Im in Va Health Care. If i go to the va hospital for a medical need related to my service or to just regular health care, your obligated to pay for it and deliver that health care to me the best possible way possible, is that not right . Yes. So its mandatory. You dont have the discretion to not provide me with health care because you didnt have enough money. You have to obligation to manage the money you and if needed come and get more. I dont think its a matter of discretion. We have got to find the money money. I would agree. What youre talking about of transferability is after we decide to put x number of dollars it is that are in the va. You want to be able to take money out of those accounts to pay for the benefit of the veteran without having to go to a secondary step to have money removed by somebody else because its named mandatory. Yes. Im not sure i said it right. You said it perfectly. Its clear to me now. Clear as mud anyway. Senator sanders. Thank you very much, mr. Chairman, dr. Shulkin. Wow point out what most veterans know that by and large the va has a pretty good Healthcare System. You quote a study published by the journal of the American Medical Association where researchers compared hospital care on 129 va hospitals with 4,000 nonva hospitals and you found that the you have Better Outcomes in the va 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 youre running despite all the criticism we hear every day, true . Yes, sir. Let me ask you a question that has always fascinated me maybe you can give me an answer. I held a hearing few years ago talking about preventible deaths in american hospitals. According to, im looking at an article right now, new england journal of medicine. And they say that Hospital Medical errors are the third leading cause of death in the United States. 700 people every single day die in this country from Hospital Medical errors. How is the va doing compared today nonva hospitals . The va is actually performing better on Patient Safety and Patient Safety is defined by medical errors. Than on average the private sector. Of course, every hospital in america, including va is always looking for ways to get better. But the va has systems in place that help it perform better than many of the private sector hospitals. Congratulations for that. I know that the veterans appreciate that which takes me to the point made a moment ago. And that is what we hear every time there is a hearing with veterans, they like va healthcare. 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 traditional va healthcare to the Choice Program. The Choice Program, weve had a long discussion, well 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 traditional va. Other question, you mention on page 9 what is obvious, you say that vha is the largest Healthcare System in the u. S. And in an industry where theres a National Shortage of healthcare providers. We have a major doctors crisis, especially in certain areas, primary healthcare relief. Maybe psychiatry, psychology. Those are the two biggest, yes. A couple years ago when i helped work on the major veterans bill, we put we expanded a program for medical education. It was the section 302 of the Health Professionals educational system program. What that does, essentially, mr. Chairman, is what it does, as you know, medical school is outrageously expensive which is a very serious problem. I talked to young doctors who are 300,000 in debt. Theyre not going to go work probably at the va. Theyll work where the money is. I would like to see that program expanded. What it does is it provides Debt Forgiveness. You want to work for the va for x number of years well forgive the debt youve incurred in medical school. Is that an idea that makes sense to you . Senator sanders, both of the ideas you said and that the Ranking Member talked about make a great deal of sense to me. I do want to see va 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 va 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 va or vice versa. Wed like to see that opened so we could take money that was in the budget for sending veterans out and reinvesting more into the va. We think thats important. It should be done at the local lev level. On the 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. We need to do more of to. Were proposing exactly what youre saying, which is creating more gme spots, the country needs them. Va would pay for them. And in exchange it would be like the military or Public Health service. National Health Service corp. Afterwards that would give five years back to the va. Mr. Chairman, this is an issue, where i think we can going a long way in attracting excellent physicians and nurses perhaps into the va by doing a debt expanding the Debt Forgiveness program which i understand is already working well. I would look forward to working with you on that. Last question. 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 ten have medicaid as a source of coverage. If the republican Healthcare Plan goes through and im going to do everything i can to see that it doesnt. If it does go through and medicaid is cut by over 800 billion, i assume that means a lot more veterans are going to be flocking into the va, am i correct . I would think so. Were a Safety Net Organization and we tend to have veterans without over Health Access come to the va. 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 would if veterans lost their medicaid, theres a reasonable possibility many of them would turn to the va and you would need additional help to accommodate that large number of veterans . 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. Under the vas fiscal year 2018 budget proposal, a budget line to pay for Emergency Care is still lacking. However the independent budget has included a recommendation of 1 billion for 2018. My question, sir, would be what is the status of the appeal, which is the appeal on the Emergency Care fairness act the way that its being interpreted . At what point will the va formally request the funds to pay for the Emergency Care for our veterans . Well, first off, senator, i appreciated the interchange you and i had. I think that you were making excellent points and you were actually on the right side of this issue. We have done two things since we talked last. First, we have completed all the regulations to be able to move forward with payment of the claims. And we have now transmitted them to the office of management and budget. So that parts complete. Thats moving forward. Thats good news. The second thing is is that after considering what you said and also i think senator blumenthal, i have decided today voluntarily withdraw the appeal to that case. Thats great news, mr. Secretary. I think what 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 . We still have to go through the rulemaking process thats why we transmitted those rules to omb and they need to go through the process. I dont want to set time expectations, but yes, were moving in that direction to adhere to the judges ruling on this. Very positive development. For those 370,000 individuals this is great news. Any chance of expediting that process . We got the rules over there very fast. 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 work through that issue. I think thats what veterans want to see. Coming from the va, 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 va. And i think this is a major first step in that, thank you very, very much for your work on it. Your attention to this. And i think that will 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. Good. Thank you, senator. Senator manchin . Thank you, mr. Chairman. Secretary shulkin, recently you announced you would be scrapping the current electronic Healthcare System and adopting the same system that d. O. D. Uses. Im in favor of making it easier on veterans transitioning from d. O. D. To va. My concern is the speed of the decision will have second and third effects that could be detrimental. Heres where they are. My question to you is, are you concerned there will be increased ruisk in having one company manage all of these records . 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. That considering the maintenance required on vista, the expense that will be required and our lack of ability to maintain qualified Software Developers within the va, the risk of doing nothing was worse. I think that d. O. D. Went through a strong Due Diligence process. I think that they selected a stable platform. We have benefitted a lot from their Due Diligence and expertise and that was one of the reasons with why i went in that direction. Theres always a risk, senator, especially when you transfer systems. I got two more parts to this. By waiving the bidding process which you just spoke about, how are you guaranteeing senators not taking the va for what we would consider a little bit of a ride . All ive done is start the process of negotiations. We have not committed to any funding, we have not how will you know if the price is competitive if theres nothing to compare it to . We certainly know the price that d. O. D. 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 taxpayers. Now, most of the cost of a transfer of systems is actually in internal change management, not in Software Licensing its not on your budget right now. How are you going to absorb the cost . Were going to have to go to the appropriators and lay out a plan to see if they also think this is a good decision. Well, this hearing is about care in the community. Im showing the records transferred between d. O. Domd. Va we must be sure the transfer is seamless. What ive said in the decision on the emr is that while it is a decision to move forward with the common platform with d. O. D. This will not be the d. O. D. System. Vas 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 that platform. Were going to have to create a system that does several things the d. O. D. Didnt. Were not going to be scrapping vista. Were going to have to connect into and maintain our 30 year data base and were going to have to be interoperable with community partner. Very quickly i have one more and a real quick question. Theres no assistant secretary of i. T. Nor is there an undersecretary for health. How are you undertaking it without those positions fill . We have competent acting people in those rules. We look do you feel like you have the personnel to do it . I feel like were very lucky to have very competent acting people. But i need to have permanent people in those roles soon. My other question is concerning the opioid epidemic. What im concerned about with the new nonva care redesign looks like, im looking for assurances that when we do a new provider agreements on any contracts if not va care providers, were going to make sure they understand they will not tolerate the overprescription of opiates. We have a lot of pill mills. And they get these people hooked and they keep them hooked. How are you going to insure . Whats your oversight . Are you prepared for this . 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 challengehead withs wita ourselves. You have very little control when youre out in the private sector. I think weve made Good Progress in the va. Weve seen an reduction since 2010. We monitor patterns of prescribing, i have the concern about going in the community you have. What im worried about the is the contrast if im a nonva provider. The new act lets that person come to me. I contract with the va to take these people. Do i have to follow prescription guidelines . Are you going to be monitoring that as far as the opiate prescription guidelines . I think this is a good area for us to come back to you with thoughts on. Sir, we need your help. Youre on the front lines. Thank you. Thank you. Thank you mr. Chairman. Senator heller . Mr. Chairman, thank you. I want to talk about the budget for just a minute, if i may. I dont want to talk about the individual unemployed ability cuts. Can you explain the rationale of what went through the thought process that went through this . Well, senator, 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 toto use our current funds in a way that makes sense best for veterans and taxpayers. We proposed a part of the process that would revise the individual unemployability benefit. The budget is a process. 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 some veterans. And that this would be a take away from veterans who cant afford to have those benefits taken away. 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 im not going to support policies that hurt 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 benefit numbers and targets we have to hit. But we shouldnt be doing things that are going to be hurting veterans that cant afford to lose these benefits. I appreciate hearing that. Do you know how many veterans would have been affected by this change . Yes, we have 300,000, jamie . There are 300,000 that are in receipt of iu. About 210,000 are over the age of 60 and therefore would have been affected. Would have been . Correct. It would have been retro active . It would have been point forward but to include all veterans in receipt of iu. When you say retroactive, i dont believe wed pull benefits we had given back. You could lose the benefit even if youre currently receiving it. Correct. That was the proposal, and but we do look forward to working with you to figure out how to do it better. I appreciate your concern. Do you know what the average is per veteran on this iu . What the average intake is . The average payment . Its roughly 1,600. Roughly 1,600. You have to be rated between 60 to 100 and it takes you to a temporary 100 . 60 is roughly 1,600. So you can understand the financial burden it may pose for an individual, that 1,600 may be. What im more concerned about is their long term retirement. They may have not prepared or been prepared in believing that 1,600 may be there. I think thats the issue. 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 will be very difficult to do. I appreciate your concern. Can i change topics for just a minute and make sure i understood this correctly. Did you say you had a decision ready claim in three day . Weve had 12 so far i think. And september first were going to be rolling that out across the country. Thats big news. Thats big news. And im glad because ive been working with 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 we are piloting in st. Paul right now. And, again, with the couple of our vsos and if the vso brings in the claim ready to be decided got to be ready i get it. No further and development and we decide the claim. A previous secretary said he could get the claims down to zero by, i think it was 2015. Whats the status now . If this works as well as i can tell you i wont say that. No predictions. No. Of what the claims will be . No, we right now are worried about 90,000. As of this morning it was 94,000. Thats about what i have. 1,200 of them in november. I think our goal, jamie, by the end of it calendar year to 70,000 . Thats right. But these decision ready claims, we think will take 10 to 15 off. We wont start rolling them out until september. 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. Mr. Chairman thank you for the time. Senator murray. Thank you, mr. Chairman. And thank you all for being here. Secretary shulkin, in last years budget request the va estimated it would need 725 million in fiscal year 2017 and 840 million in 2018. In the first budget of the trump administration, you plan to only use 521 million in 17 and 624 million in 18. Those are cuts of 30 and im hearing from so many of my constituents 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 in arizona and 83 in augusta, georgia. It seems to me, 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 . Well, lets just talk about the three things quickly you said. What was the reported on in charleston, completely unacceptable. 94 revocation of caregiver benefits unacceptable. Thats why we suspended the program. There are no revocations across the country going on until we get the guidelines better understood and better and better shape. Thats the freeze youre talking about . Thats the freeze. Thats only a temporary measure. Its a temporary measure until we revise policy. I will not accept giving benefits and taking 94 away. Thats ridiculous. Second thing is, on the right amount of money to request, we only spent even though 750 million was in the budget, we only spent 521 million. In Budget Planning for next year, they requested 600 million. Okay. Which is a modest increase from where we are. Our hope as you know and youve been a tireless advocate for this is to expand caregiver benefits and we do plan on working with you with that. We hope by expanding benefits, particularly to older veterans, which today arent getting the benefit the way they should we actually find thats going to be cost effective. Remember, we pay for long term care. So my plan is to be responsible to taxpayers, i am going to seek to expand caregiver benefits to older veterans but im going to take care of it myself without asking the taxpayers to increase the bill. The Ranking Member and i wrote to you a couple months ago suggesting a series of important reforms. Those issues havent been addressed. I would like to see the freeze extended until all of those issues in that letter were discussed. Can you do that . Do you happen to have the date of the letter . About two months ago. Of course, absolutely. Let me go to the shortfall in the Choice Program. I know that you wrote to triwest and health net telling them to return referrals for care, including veterans that are currently waiting for care. How many veterans are going to be affected by that . When they cant appoint an appointment within a period of time in the contract we ask them to return it. Theyre returning large numbers to us. Do you know . I dont. This is an ongoing process. Before they would wait until it took weeks to get an appointment. 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. Its a big percent. It is a big percent. Do you know how long care is going to be delayed for veterans as a result of that . This is actually speeding up care rather than letting a veteran stay out in the Choice Program they return them to the va and the Community Care program goes out and tries to find a appointment. Im concerned where the money is going to come from from this and how youll get the money to continue nonva care. Seems to be two different stories here. Transfer authority is what im hearing from this year, correct . If you transfer money from this year, what youre doing is impacting what you thought was going to be a carryover for next year. Wont you need additional money for next year . The problem of having these two separate checking accounts and predicting where you need the money is frankly, impossible. Thats why we want to work to get the program into a single Community Care account. Look, these guys are going to help make the best predictions possible. So mr. Yow is going to help us understand the right amount of money to transfer over to predict it. But it will impact 18. You know, we need real numbers here. We cant do our job i. Im hearing from veterans in my state about the delay and burdens theyre seeing as a result of this. I had veterans in walla walla who are being told theyll have to drive eight hours round trip to portland or seattle just for some simple imaging tests as a result of this. Im hearing a lot more. Im happy to get these to you. This is having an impact and we know to know where the moneys coming from. And so we will follow up with you on that. But i think the committee needs to be aware of that. Okay. Okay and i am running out of time way over time. I have other questions, mr. Chairman, and i will submit them for the record. But i am deeply concerned about that. You listen to the questions about checking accounts and authorities reminds me of the question i was asked yesterday on my 49th wedding anniversary. Somebody asked my wife and i what we attributed 49 years ago. We never had a joint checking account. We never had that argument. Lets not get into those predicaments. Thank you for being here. Also, senator sanders talked to you about the problem with the fact of providers. And so many people are at the age now where big group of baby boomers, you know, that aging out. They practice because they like, you know, medicine has gotten complicated and stuff. 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 actually would work. I think we have good evidence of that. The problem is, is actually creating new slots versus taking slots away. You know, for veterans. So if you could work with your counterparts in the va as a huge entity. This is a huge problem for the country besides the va. If you could craft a situation where you could actually increase the medical School Classes and also the residencies, which are a huge problem, too. That would be great deal. And with your relationship, va with the teaching hospitals, i think that could be done. Its going to take some work, but that truly 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 their benefit. The residency spots as you know are capped by medicare. What you did in the Choice Program that senator sanders helped lead was expand those graduate medical education spots. Thats what we need desperately. Very much so. Again, we need to do that with whatever it takes in the future well get ourselves in trouble. 8. 4 billion in Mental Health. 6 increase, thats great. Mental health has improved so much in the va in the last years. Were not at the point where were just writing prescriptions like so many providers, not just in the va but throughout the country giving a prescription and, you know, that simply doesnt work. On the other hand, you know, we need to go further. How are we going to prioritize that 6 as far as increasing our ability to provide good care . Well, weve targeted to hire thousand Mental Health providers. Were expanding our health programs. Just as you know, this past year weve given full practice authorities to our advance practice nurses, many of them will be putting their skills to work in behavioral health. And expanding the train, as senator sanders said, psychiatry and psychology and nursing all are areas of shortages that we can use more help in. Not only in the va, but the entire country, quite frankly. So we need to do a lot more. I think youre right. You know, weve prioritized Mental Health, but its an area that needs a lot more help. You talked about the core mission of the va. The Foundational Services with the va, can you walk us through those or what you feel like is these are the services that make me so strongly believe that a strong va is essential for veterans and the country. I believe that without the types of services that the va provides that you cant find those in the private sector. If we turned our veterans over to the private sector theyd really be lost. These are services that veterans have a high predilection for. Post traumatic stress, spinal cord injury, comprehensive primary care and Behavioral Healthcare Services are clearly foundational as well. So environmental exposures, blind rehab. I dont want to leave out a group because i know ill offend them. But these are things that the va does extraordinarily well that you would not find easily except in very specialized geographies where there are centers of excellence. Its important we keep those strong. In your testimony also you talked about Community Care. And how doctors will make decisions on providing care in va facilities versus in the community due to clinical need and whats best for the veteran. How do you do this . How do you make sure that with we have an institution, you know, somewhat we have a bureaucracy. How do you make sure those decisions are based on whats best for the veterans as opposed to whats best for the facility . Well, i think i wish there was an easy answer to that. What we have to do as an organization is get out of the way of the doctor and the provider making those decisions together. So we need to get rid of the administrative rules and the third parties in between. Thats what we saw in the Choice Program. We were having veterans Call Call Centers of people who didnt know them. That was frustrating the veterans. What weve learned is delayer the process. Get it back into the exam room or now in more modern terms, you know, the telamonitors. Let the provider and the patient make the decision together in a partnership about whats best for them. Thats the system were trying to design now. Thank you, mr. Chairman. Thank you, senator. Senator tillis . Mr. Chair im going to be married 30 years a few weeks from today. We have a slightly different approach to longevity. We have a joint account, i just dont have access to it. That works also. Im not allowed to go out of network to get an atm withdrawal. Thank you all for being here. Im actually running between committees. We have an aging Committee Going on right now and were talking about supporting caregivers, the Hidden Heroes project thats critically important. I wont spend time talking about it here, but one thing that was striking in the opening testimony was the fact that theres about 14 billion a year in care giving being donated by these husbands and wives and sons and daughters that we need to find way to provide support over time. I understand in order for us to do that we have to talk about the resources and make sure that were not shifting our attention away from so many other pressing things. Its something i look forward to talking about in a future hearing. Dr. Shulkin, i want to know how were doing. Some of the estimating ive got to place some of the uncertainty with respect to accounts and how much we need and 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 systems in place so you can get to the information quickly. I understand cio nominee i think has withdrawn their name for consideration, how are we doing on trying to get that administration stacked up so that youve got a Permanent Organization under you . Well, not only the cio but the cfo candidate. If were attracting a good viewing audience, we need help. We need people to want to come and to come and help. Permanent cfo will be important to 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 need somebody who highly skilled but weve got to get those positions filled. I think it will be one of the ways we get 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 that there are various factors that led to the shortfall in one account versus another. But there are probably other things we need to day to make sure were not giving you additional distractions or uncertainty. Please, you know, speak candidly to the Committee Members to make sure when there are things we can do or shouldnt do that are getting in the way of you giving us definitive answers so we can count on it. I want to reiterate that senator murray made good points. I think shes absolutely right. The sooner you articulate what your funding levels are the better so we can be advocates. Thank you mr. Chair. Thank you. Senator blum blumenthal. I want to express my appreciation on the thank you, senator. I join my colleague in expressing my appreciation for your decision to withdraw the appeal. And also join with me in asking for a quick rule making, which i know you will do. On the vas vocational rehabilitation employment program, as you know it provides career counseling and Rehabilitative Services for veterans with Service Connected disabilities to overcome employment barriers. It assists with post secondary training at 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 counselors at the hartford regional benefit office and nationwide staffing shortages. The vas reported goal ratio of vocational rehab counselor to client is one counselor per 125 veterans but the average ratio in july 2015 im told was one counselor to every 139 veterans. Despite payment delays and the vas inability to meet the ratio. The fy 18 budget cuts to this program, vocational rehabilitation, is 13. 8 million. Youre probably more familiar with these numbers than i am. 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. And 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 out spoken leadership on the staab case. In terms of vocational rehab and education, we may have different numbers, so id like to go over it with you. We see a 1. 5 million increase in the president s budget for these programs. But there are some staffing issue and delayed in the hartford region that we do want to get improved and we do want to fix. We think this is an important program. We believe it in and we believe the president s budget adequa adequately funds it. If you have different numbers and are wrong well want to address that. I would like my staff, perhaps, to get together with you all. But i think the overriding issue here is not necessarily even the numbers, because even if there is a slight increase, this program is so valuable it ought to be a major increase and certainly not a reduction. Right. And again, this is not a criticism of the va, in fact on the contrary, its saying youre doing great work. We dont want to see it diminished. And we see these delays in hartford and wed like your help in solving them. Yes. Well follow up with you, yes. And i dont know whether it has been asked about, but i wonder if i could ask you again about the veterans benefit administration, whether you see Real Progress in reducing the claims backlog . Im guessing someone asked about it already and i apologize no, thats not a problem. Whats your prognosis . Well, ill briefly tell you, were at 94,000 now. We hope by the end of the year to be at approximately 70,000. And a year following that or two years from now, below about half the levels, so 45,000. We Just Announced that weve done 12 claims so far in three days called decision ready claims. Were going to roll that process out nationally september 1st. That will impact around 10 to 15 of our claims. They have to be all the information is ready, theyre presented and we give a decision in three days. So i think that we are making some progress. We are trying to actually look at breakthrough ways to do better. As of today, ive given you the most Accurate Information we have. And the progress that youre making is the result of a different reforms in the process or is it more resources . Yeah. The budget stays flat for next year so its not in vva, so its not necessarily more resource although they have added in the past couple years. I would say the major improvements are process improvements. Its allowing productivity adjustments and you can distribute the work load across the country evenly. They have enhanced their producti productivity standards and theyre doing a terrific job. We have great staff who are up to the challenge. And were seeing improvements. Mostly process improvements but they have added to their staff. Well, i want to thank you for your you know this is a problem that has continued to bedevil us over many years im glad that youre making those process changes and there are some breakthrough changes in the foreseeable future. Yes. Thank you. Thank you. Thank you. I have been asked by senator sanders and senator teister to make statements. Im going to recognize senator teister. I have beaten this horse in the past, im going to beat it again. The bsos are going to speak shortly, ive been in public life long enough to know that if you want to know where things are headed, you follow the money. And the fact that we have 1. 2 for inhouse medical care and 33 for outside medical care is disturbing. Moving forward, because you said over and over again to me dont worry about this, john, its going to be fine. Were going to make the va the best it can be and the va is going to fill in the gaps, we just need to drive that point home. Well hear from a panel of vso representatives and i got a notion theyre going to talk about va care and talk about other ways we can fix it. Number two, this is an Authorization Committee. I. T. Funding youve got at 200 million in this budget. You should be asking this committee to plus that budget up. You need to do it so it represents the money that youre going to be dumping out for the d. O. D. Electronic platform that we all support you doing by the way. And i think its important that were honest with ourselves. Ill tell you why, i happen to be on both committees. And i dont want to get nailed and say you know what . The Authorization Committee didnt do that. And the spend thrift appropriators are dumping money in. In this case we know the i. T. Thing is going to cost some dough. So we need to act accordingly. The last thing is were going to have carl blake from pva and leroy acosta from disabled va. And joe rowan from vva in a second. I want to thank those guys for their service. We have said we need to take our direction from the vsos. Im not going to be able to be here but i will try to get back toward the end. We need to take direction from the veterans. Thank you all. Senator, thank you. Were always clear on where you stand and appreciate that. I do want to try to work with either you and your staff because we have different numbers than you have in terms of the Community Care and internal care. And, you know, we have an interest in making sure the va is the best system. The ability to transfer more right now, were limited at 1 , would help us a great deal. Thats something well continue to work with you on. And i would just say, were going to work with you on that, too, we both agreed to that. As ive said at the breakfast yesterday, you can outsource care but you cant outsource 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 the d. O. Domd. And the veteran were criticized for an overdependence on opioids. I know there has been significant changes. Ive been pleased to go to va hospitals around the country and see robust programs regarding alternative complimentary medicine, yoga, nutrition, and so farth aorth and so on. Can you say a word about how the va can lead this country away from opioids, although, obviously, sometimes they are necessary into less type of dependent drug approaches . Ill try to do it briefly. I will tell you i published an article of this four or five months ago in the journal of the American Medical Association about the vas approach. I think its a National Example that others can learn from. We started this work in 2010. Where we identified problems before the rest of america did, as the va often does. We did this through a multifactorial approach. We essentially now monitor the patterns of all of our providers and we give them feedback on how they perform compared to their peers. If theyre overprescribing. We do academic detailing where pharmacists go out and actually teach our providers the ways to use opioid appropriately. We have our patients sign informed consent so that theyre 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 complimentary care. 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 in opioid use using those exact techniques, complimentary medicine. Acupu acupuncture, yoga, mindfulness, biofeedback. Mind body type of techniques. Were trying to get others to be as good as we are doing in white river junction. Were working in a number of these areas and were trying to work on research with the fda and nih on nonaddictive narcotics as well. We think thats important. Thank you very much. Thank you, mr. Chairman. [ inaudible ] let me thank secretary shulkin and his staff for their testimony and support and continued response to the committee. Were very grateful for that. Let me welcome our second panel and ill begin with the int introductions to mr. Leroy acosta, assistant National Service director, disable american veterans. Mr. Carlos munez, mr. John rowan. Mr. Blake . Youre each recognized for five minutes. Mr. Chairman, thank you for the opportunity to testify today with your approval and the committees approval. Wed like to submit our fiscal year 2018 independent budget report into the official hearing record. Thank you. Id like to spend my time talking a little bit about what weve heard today rather than specifically the recommendations that are included in our budget report. Lets recap. I appreciate senator seller heller, im sorry, bringing up the question about iu. Although i would say, its not a readily apparent the va has said for sure its going to drop that proposal all together. It sounds like the secretary is willing to discuss it further and see where this goes from here. I appreciate senator manchin for bringing up the question about the modernization. Senator rounds continues to beat the drum about the staab ruling. And i appreciate the secretary has made the commitments he has as it relates to modernization, doing the right thing on the staab ruling and trying to address issues like caregiver expansion. I dont envy the position hes placed in. But lets forget for a minute, 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. Lets look at fiscal year 2018. I think thats a good way to snap spot the bigger hole the va has to deal with. Senator heller, at least 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. Its not addressed in the discretionary part of the vas 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 mentioned tcernr decision. I think thats the right decision to make. I read an article recently that said the department of defenses obligation is something on the order of 9 billion i think in the life cycle of that program. It also said that vas obligation will be at least three to four times that great. How does the vas budget rationalize that point . Im sure it doesnt. Senator rounds mentioned staab. Its the right thing to do, what the secretary said. I think he knows it and hes acting upon that. I was actually sort of amused he said they expedited the rulemaking process. I think he said it went to omb. Thats where the expedited process goes to die. He said last week it might take nine months. Omb will be on the clock for the next nine months im sure knowing their track record. That aside, the ruling has already left va with an obligation of at least 2 billion. Where is that money at thats going to pay for that issue . The average in subsequent years is a billion dollars, 1. 1, 1. 08. Something in that range. Where is that money at . Its not in the va budget either. Were keeping score, we have a 3. 2 billion iu hold for choice. We have an approximately one billion dollars hold for staab. And then we have the kerner issue and we dont know what that hole looks like. I could make the argument that looking out into fy 2019 that that is short. The Community Care budget in that year alone is less than the protecti projection for 2018 and the choice plan has it at the same figure, approximately 3. 5 billion. Are we going to decrease Community Care usage in 2019 . I think we all at this table know thats not going to happen. So right now, the va could be staring at a huge hole in its budget for 2018 and weve expressed this to the appropriators and because of the timing and everything they have already moved forward on the house side. Theyre going to milk up their bill tomorrow. And none of these questions are answered. 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, i appreciate the opportunity to testify, ill be happy to answer any questions you may have. Thank you, very much for your testimony mr. Acosta . Mr. Chairman, members of the committee, the coauthor of the independent budget along with vfw, were pleased to present our views on the budget. Today ill focus on critical needs for vas Compensation Service, rehabilitation and appointments and the board of veterans appeals. Ill cover our strong opposition to a couple of ill conceived and unacceptable Administration Proposals to scale bougack compensation. The ib recognizes the va has made progress in reducing the claims back log. Workload continues to rise. To manage current and future workload, we recommend an another 750,000 fte for Compensation Service which would require an increase of 183 million. Vas voke Rehab Service needs additional funding. Over the past few years, Program Participation has increased by 15 overall and based on historical trends, it would increase by another 5 in fy 2018. To meet rising demands to achieve and sustain the one to 125 counselor to prime ratio established for voke rehab by law, the ib recommends an additional 266 fte. Which would require a 32 million increase. Overall, the ib recommends the total funding for vba be increased by 270 million. Thats 10 increase in order to fund these two staffing increase and maintain Current Service levels for the rest of vba. Unfortunately, the administration has recommended an out right cut in funding for vba of 12 million. For overall funding thats 300 million less than that recommended. We are here to support our recommended funding levels to continue vbas progress in delivering earned benefits to veterans, their families and survivors. Mr. Chairman, we have made significant progress on the claims backlog. Chairman, eba m on the claims backlog. One consequence has been an alarming increase in backlog of claims. Today, there are over 450,000 appeals at eba or the board. It takes almost six years on average for a decision by the board. The ibvso is part of the work group with v. A. For the comprehensive reform of the appeals process. The veterans appeal of improvement is built upon the stake holder framework and received broad, bipartisan support. We are going to move forward expeditiously and pass this legislation. The house passed similar legislation earlier this year. Enactment would lead to a modern response, one that will provide veterans with a quicker decision, fully protecting veterans due process rights. With the passage of appeals, the board would continue to require the workload. Last year, congress authorized the board to increase by 242 to an authorized staffing level of 942 fte. The board has not filled the positions. For fy 2018, they expect the board to continue hiring to fill all positions. We do not recommend further additions. Moving forward, the board and Congress Must monitor the new appeals system to ensure the staffing remains adequate to meet future workload demands. We oppose two legislative proposals in the administrations budget. First, we strongly oppose rounding down for ten years, which hurts veterans, families and survivors. The cumulative affect would cost 2. 7 billion over ten years. The entire congress, the sounding rejected, further more, rejected proposal to cut off eligibility for it or iu. They reach an age which they might qualify for Social Security retirement benefits. Total compensation is not a retirement benefit. Its for those who suffer lifelong disabilities and unable to work. Furthermore, this leads to benefits that result from a total disability rating such as educational assistance, economy sar exchange and state benefits such as property tax exemptions. We call on members of this committee and the congress to soundly reject the dangerous proposals that would be harmful to veterans. That concludes my testimony and i would be happy to respond to questions you or the committee may have. Thank you. Mr. Fo the administration has an increase in the budget. We support the focus on expanding access to health care and expediting decisions on benefits, claims and appeals, increase focus on combatting veteran suicide and addressing the stigma associated with Mental Health. V. A. Is ready and able to care for women veterans, the Fastest Growing of veteran population. However, i would like to make it clear the vfw opposes efforts to call back benefits from the severely disabled veterans to pay for such improvements. In the past week, 40,000 letters and emails from vfw members and supporters are sent to congress opposing the proposal to revoke individual benefits for veterans who are unable to work because of their service disabilities. They propose the other measures to balance the budget on the backs of the nations veterans. We are concerned the Administration Quest to make it permanent mandatory program to lead to the gradual erosion of the v. A. Health care system. The inability of congress to do this forced the proposed cuts to veterans programs to expand the Choice Program under mandatory spending instead of including it in discretionary Community Care accounts. Sequestration and spending caps limit the nations ability to provide care for veterans and families the care they have earned. We call on this committee to join our campaign and end sequestration and do away with federal budget processes based on the budget caps. In partnership with the budget, coauthors i would like to focus remarks on v. A. S Construction and Administration Budget requests. For more than a decade, the ibvso warned congress and v. A. That underfunding allowed v. A. s infrastructure to erode and capacity swelled from 81 in 2004 to 21 in 2012. We continue to believe this need for space and chronic underfunding of Construction Projects could force the ration care. V. A. s budget request says improving the conditions of va facilities through the Construction Projects account for the largest resource need to keep pace with the growing demand for the v. A. Outpatient care. The administrationS Construction request funds one project. The ibvso believes v. A. Requested an adequate amount for the fiscal year 2018 Major Medical leases needs. However, Congress Must find a way to quickly authorize leasing projects. There are now 27 Major Medical facility leases awaiting authorization, 18 of which have been waiting since 2015, delays in authorization of these leases have a direct impact on vas ability to provide timely care to veterans. The administration has a duty to provide veterans a final resting place that honors their service. In 2016, nca entered more than 130,000 veterans in eligible family members. The number of internments is expected to increase until 2022. Other factors in place additional demands by nca and the ibvsos are glad to see the administrations request for ncas higher than our recommendation, which may be only one of the ones. We commend v. A. For commitment to the mission. Mr. Chairman, this concludes my testimony. Happy to answer questions you or the 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, senator. Nice to see you back. I missed you when i had the annual testimony. I missed you more than you might think. Im glad to be vertical again. Me, too. I was coming out of the hospital when you were going in, i think. Anyway, i would like to thank you for the accountability act. Its an issue we have been deals with since we started bva calling on congress to take full accountability of all the v. A. Operations. Hopefully this will work and we support that bill. Iu, as was noticed has got to be rescinded. That whole pro po sal is a budget that has no idea how it impacts people. Its just a dollar amount. The effects are beyond what everybody understood the first time with the nonsense Social Security was going to pick up the amount of money lost in iu, not even talking about the affects of the family members, loss of dental care, loss of local benefits as was mentioned earlier, tax abbatements in new york city. We got the tax abbatement for real estate. That would be cut significantly by that. This has got to be one of the things we are calling upon, we would like since the secretary alluded to the fact they may agree that this be shelved, we would love to see a joint effort between the v. A. And leadership in the senate and House Veterans Affairs committee, publicly denouncing this idea and saying we are not going to pass it so we can tell all those scared people out there who have been sending emails and letters about the horrors they are concerned about that they have nothing to worry about. We have got to bring these people down about ten notches because they are climbing the walls right now. Thats something i hope the committees in the senate and the house and v. A. Would take into consideration to publicly acknowledge this was one bad idea. Choice program is not a choice. Its a false choice. I think we need to understand how its done. I just came back from idaho where i met with my state council in north sand point, idaho in idaho. Almost everybody there enjoys the program because they are hundreds of miles away from a v. A. Facility. They can tell me all the problems they have with choice and finding doctors who take choice, who will take the v. A. s money or sign on because of the problems. We know they are trying to resolve the 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 just retired on me. I managed to outlive him. Thats great. Hes retired and im still sick. I called up my emblem health, one of the Largest Health care providers in the country. They couldnt find me a dermatologist that i could talk to at the earliest in august and really they were talking october. Thats a false choice. Thats dermatology, i think i can throw a stick out of my window and hit a dermatologist in new york city. They are not there because they dont sign up for the v. A. They wont take the v. A. s payments just like we have seen in medicare and medicaid with problems with doctors not signing on. We are concerned about that. It needs to be rethought significantly. The private sector is not ready to take on the v. A. Patients, no way. The last thing, a couple things i want to point, also, the rnd budget has been cut. It shouldnt be cut, it should be increased. We need more rnd for the programs we have. We need to get more evidence based programs testing on ptsd and how to handle it. I cant tell you all the different programs i see, what a great thing they have for ptsd. It sounds great. I love my dogs. Yeah, they are helpful and they help some veterans. Without counseling, that doesnt end their problem. We need more evidence based actions research into the programs. Im concerned we passed a bill last year that would look into the effects of toxic exposure of Vietnam Veterans and veterans after us. Where is that money going to come from if the rnd budget is cut . We have a nice bill, where is the money . We need the money. If the v. A. s budget isnt there, how are we going to get it down. One quick thing about veterans appeals and the whole appeals process. It would go quicker if the v. A. Took outside doctors opinions and didnt have to redo everything somebody came in with. That would be nice. The other thing is, we need to blow up the board of veterans appeals. It doesnt function. Nobody should lose 70 of the time, which is v. A. Does, every year, i have been in this position 12 years. In 12 years, every year, rbsos, 70 of the time, you either get a remand or direct payment on cases brought in. 70 . We win, v. A. Loses. Year after year after year. I guarantee its the same with the rest of the gentlemen on this table. I bet their cases are around the same percentage. Thats ridiculous. The other problem is no precedence. Carl can put in a claim, i can put in a claim for the exact same thing. He gets judge a, i get judge b. They come down with different opinions. I win, he loses, too bad. It keeps regurgitating the same problems over and over and over again. We need to get the issue of precedence like in any other court. Frankly, now we understand the court of veterans appeals and are going to be happy to look at them and the idea of class action lawsuits. I would be happy to answer any and all questions anybody may have. Thank you. I dont have a question, i have a proposition for you, though. I would like to find a time and like my staff to listen to this. Find time we could have lunch the next three weeks or month. You piked an interest in my mind. Your comments about the iu or Unemployment Compensation recommendation, which is a nonstarter for you and anyone else would tell you its a nonstarter. Its not hard to ask benefits to take them back. If you do, you lose more than you are going to get. I also heard the comment, i think mr. Acosta may have heard of it. There are lots of things out there that over the period of years of the Veterans Administration and its existence and benefit existence and health care, where times have changed, we probably ought to look at everything we got up there. There may be some pearls of wisdom, there may be some benefits in the scheme of things to help us apply a different way today than when they were passed. We need folks without an agenda except to help our veterans and solve our problems and go to court. Ill call you and well go to lunch. Im not avoiding you other guys. You made the comment that piked an interest. Well do that. I think if we open oneonone dialogue, there may be in some of these things we bring up because staff brings it up or omd. You are in the benefit of looking out for the best interest of your organization and members. I appreciate that. I serve them as a master, but i serve the taxpayers as master and other people. We ought to have meetings and talk this through. We may find no Common Ground anywhere. We might, words of wisdom if we do. I would love to work with you and anybody on doing this. Well try to set this up. Senator sanders . Thanks, mr. Chairman. I should have known, but i thought we got rid of this round down thing finally. Hearing about it from the first day in congress, i was chairman, we got rid of it, the idea of nickel and diming veterans. What you are telling me is its back again . Yes, sir. Thank you very much for your leadership while you were chairman of this committee and really eliminating that practice. Now the president s proposal as carl laid out, proposed to reinstate the round down as a way to pay for expansion of the Choice Program as a mandatory program. Actually taking money away from v. A. Benefits and useing i. How much, if this were implemented, would it cost veterans . The effect of the proposed tax would cost beneficiaries 2. 7 billion. Over what, a tenyear period . Ten years. I dont think we should be nickel and diming veterans. Its sad to see its coming back. Let me ask what i think is the elephant in the room. That is the concern and i know the numbers seem to be disputed, not quite the clarity we like. But, the increase in appropriations for the Choice Program and the very, very modest increase for v. A. Care. Who wants to comment . Is that a concern of you guys . Mr. Blake, well start with you. One of the concerns and the secretary addressed this, a lot of talk about marriages and checkbooks. The bottom line is we believe the Community Care should be under one authority, one account and manage it that way. I think i understand why they put choice over here on the mandatory side, discretionary caps holding down the Discretionary Spending that place it at risk. From the independent budget, they are shorting the larger discretionary pot. The difference for construction in particular, which are tremendous and when you take into account outside of the health care account, virtually every line item takes a reduction of some type. Let me get other comments if i could. Anybody else want to comment . Chuck . Icon cur with mr. Blake. This notion of having a mandatory program and discretionary and not being able to transfer, its more about having, as carl said, having one checkbook instead of requiring v. A. To balance both. You are absolutely right, senator, we cannot forget the need to invest in v. A. s ability for direct care, hire more physicians, expand facilities because ultimately that is a preferred choice of veterans and we need to continue that. I would like to add, i study privatization, i work in the city of new york in the controls office looking at those kind of programs. I watched them privatize lots of thing that is never work. Once you go outside and privatize, you are adding layers of cost. You are not going give it you are not going to a doctor, you are going to a plan. The plan is going to be administrated by somebody making 2 million a year. Thank god our v. A. People dont pay that much, though they should be. But, thats not what we should be doing. Let me ask you your brief thoughts on a crisis thats impacting vermont, new hampshire, the whole bloody country. This is the opioid epidemic. My impression is the v. A. Is trying to do the right thing. What are your thoughts on that . Who wants to jump in there . Its certainly epidemic that must be addressed. We, you know, hear about anecdotes and veterans being overmedicated. A concern is the reverse as well. What we have heard is veterans cutting off veterans without proper alternatives and we dont want that either. We dont want an overcorrection but eliminate overmedication. Other thoughts . Okay, mr. Chairman, thanks very much. Thank you senator sanders. I want to thank all the members for coming. When you go after the big guy and testify and then everybody is gone and you are stuck with me and the secretary. I want to comment secretary for the hearing, we appreciate it. Your words are heard. We appreciate your input, look forward to working with you toward providing benefits earned and desirerved by our veterans. That is our goal as a committee. We thank you for your tenants. The record will stay open for ten days. This meeting stands adjourned. This weekend, on American History tv, on cspan3, saturday at 8 00 a. M. Eastern on real america general secretary gorbachev, if you seek peace, if you seek prosperity for the soviet union in eastern europe, if you seek liberalization come here to this gate. Mr. Gorbachev, open this gate. [ applause ] mr. Gorbachev, tear down this wall. President Ronald Reagans 1987 trip to berlin. Then at 8 00 p. M. On lectures and history, Hillsdale College professor on how the baby boom, suburbanization and teen culture changed world war ii society. To get a separate Youth Culture, advertisers are looking at this, young people begin to adopt their styles of dress, the kind of music they listen to is different. Theres a segregation, a separation of Youth Culture from mainstream culture. Sunday at 8 00 p. M. Eastern, on the presidency. On the 45th anniversary of the watergate break in, joan halderman has a view of the watergate scandal that led to her husband serving an 18month prison sentence. The white house phone rings and i assume its the dreaded call from nixon. The conversation is surprisingly brief. The president wants john and me to chopper up to meet him at camp david at 1 30 today. When the white house phone rings again, i fight to stay composed. That was ron zeigler, press secretary. Bob says hes at camp david, too. The president now feels very strongly that john and i should volunteer to resign. For the complete American History schedule, go to cspan. Org. Sunday on q a barack is committed to presenting his story. I think thats different from history. Part one with our interview with Pulitzer Prize interviewer, rising star the making of barack obama, which covers his life up to winning the presidency. I think baracks political aspirations and sense of destiny lead him to push yeager aside. During that time, there was a well known political figure in chicago, hugely respected man, senator dick newhouse, who everyone in black chicago believed could never go higher because he was married to a white woman. So, it is in the political tradition of black chicago, in the late 1980s, the early 1990s, that for a black man to aspire to represent black chicago, it is necessary to have a black spouse. Sunday night at 8 00 eastern on cspans q a. Cspan, where history unfolds daily. In 1979, cspan was created as a Public Service by americas Cable Television companies and is brought to you today by your cable or satellite provider. This week, defense secretary, james mattis and the chair of joint chiefs of staff, joseph dunnford testified on the pentagon budget. They talked about the various defense programs. This hearing of the House Armed Services committee is four hours. Come to order