Transcripts For CSPAN3 VA Secretary Shulkin Testifies On FY 2018 Budget 20170615

Before i call the meeting to order let me apologize fob being a little late i got called on a couple things coming down the hall. Were going to stand at ease thats a military term i learned a long time ago in the air force for just one minute while i talked to my trusted friend the Ranking Member and then well open the meeting. Call this meeting the Senate Veterans Affairs Committee together i apologize for being a little bit late but i wanted to make sure we were on the right track and i didnt mess anything up. I want to welcome secretary shulkin whos had a great start. I dont think anybody started out with a better unanimous vote than he, you cant do any better than unanimous when you get affirmed. I think the vote last week on accountability was extraordinary. And the way we got to the decision working together hand in hand was extraordinary and i commend the Ranking Member on his help in doing the same. Weve got some other things to do today to Start Talking about budget wise and well have some other decisions to make, but we can keep the same tempo and discipline to make sure we all know what each other knows before what happens rather than after the fact and well be better off. But i welcome dr. Shulkin and the staff thats here today. And i appreciate what theyve done to explain where were doing with the Veterans Administration which is upward and outward and further ahead all along. Im going not make a long statement at all except to say a couple things and i dont want to make this david sthul kin day but one other thing i have to brag about, the certainer decision in getting our medical records solved after years of unwillingness to address it is extraordinary. And i think, from what i have heard, theyre already signed saying people are coming together in the past hadnt been together to make sure this happens and works efficiently for our veterans and for the department of defense and the department of Veterans Affairs at the same time. It was sillily to have two different agencies in the same department serving the same government that had two medical systems that were not inner operable one to the other and where our veterans who fought for us with literally fall in a hole leaving from active duty to department of defense to vat transaffairs. I think this move is going to prove to be a tremendous move economically for the va and benefit wise for our veterans and theres no possible way do any better than that so i commend on you that decision as well. With that, instead of getting into details im going to turn for an Opening Statement to the Ranking Member jon tester. Thank you, mr. Chairman and thanks for having this hearing. I think its important to say that our thoughts are with the colleagues who were with the victims this morning. We wish you a speedy recovery for congressman scalise and everybody else who was injured. And a big, big thank you to the Capitol Police officers who work every day to make sure this place is a safe place. And our thoughts are with them. Now, secretary shulkin i want to thank you for being here and being here with your va team. We spoke last week at some length about the future of the Choice Program and i hope i made my perspective clear the Choice Program was intended to supplement care, provided directly by the va, not replace it not now and not into the future. I worry that the budget proposed by this Administration Starts us down a path of unfettered choice that will hollow out the va in doing it so it proposes to cut income by a third white proposing that the vas own hospitals receive ann crease that is less than half the medical inflation rate, not much. Further the budget does nothing to address vas aging infrastructure. If were starving the funding for staff and care for velt rans 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 va hospitals staffed by quality providers and it will become nothing more than to send veterans into the private sector to hunt for a doctor who has the time and capacity and knowledge to treat them. That is not what our set transneed and want to have happen and for a rural state like minnesoontana, it would be disaster. More and more hospitals are at the risk of closingand finance there are rollbacks to recent medicare expansions its likely these close yours would accelerate. We cant assume the private care will work where there are no providersed in the first place or where they dont have suffer net works. We know the vast majority of slet velt transusing choice over the past two years are eligible due to long wait lines not because they live too far from a va facility. It shows that rural veterans arent using choice as much but they do depend on va care. But now based on your quest yesterday we may have to shift additional funds around and out of va care accounts to get Choice Program through the fiscal year. For months weve been asking about the choice to spend rate and the amount of funds and the amount of remaining funds. We were never provided with those answers we need to make informed decisions and now were in a difficult spot. Mr. Secretary, no one wants delay and care for veterans, no run, and we will act appropriately 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 its compound by a budget that cuts services that veterans rely on, makes cost education oversight, makes cuts to i. T. Which impacts every business line and department operates. Im most concerned that it appears these cuts are being made in order to pay for certain veterans to get private care. The new policies propose this budgeting to pay for private care are simply untenable. It would, without warning stopped earned benefits payments to the most severely disabled vets is not proper. To get the individual unemployment benefit payment it must be determined that a vat trens unable 10 to gauge in substantial work as a direct result of service to their country. Appears that the budget proposes that we stop paying these veterans at a time when more americans are having to work longer to make 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 work with my colleagues 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 va. And finally i would like to wish the u. S. Army a happy birthday. With that, thank you, mr. Chairman, i look forward to your testimony. Secretary shulkin. Secretary, welcome and let me introduce those you brought with you to back you up and acup along the way. Edward murray thank you for being here, richard chandler, Department Assistant secretary resource management, marc you, james man ker, acting principle pal deputy, mr. Michael sullivan director secretary of defense and planning, mr. Shulkin, the floor is yours. Thank you, Ranking Member tester and other members of the committee. As you can see i brought a big team with me because i know youre going to have lots of questions and in particular with the Opening Statements i really do look forward to having a meaningful discussion and getting to some solutions and some closure on some of these issues. I also did want to echo the Ranking Members concern that this is a sad day for the nation where Public Servants who work as hard as i know all of you do have to worry about their personal safety and our thoughts and prayers are with the congressman and the staff and the Capitol Police as well. So 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 proegs appropriations. And all of this is in showing support to veterans and we appreciate the leling e leg slailgs slags thats recently been passed. 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 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. This is really allowed us to make Real Progress for veterans and were, again, grateful for that support. Ive 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. 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. 0 billion in the choice account. Less than a month and a half later when the president signed the choice extension act into law, our choice account was at 1. 5 billion. Today that aket is at 821 million. As we nope, 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 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 mutting more putting more through choice. Two years ago im sooul sewer sure youll remember we had too little money in our community accounts within the va which we solved with your help by accessing unused us 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 legislative authority to replenish funds into the choice account. 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 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, and obviously its not a science, its an art and 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 four last week will solve this recurring problem permanently by modernizing and consolidating all of the Community Care accounts including choice. The president s budget in 2018 and 19 provides additional funds for choice and the resources necessary to continue the ongoing modernization of the v. A. Requests whun 86 billion for v. A. , whun 4. 3 bund u funding in mandatory funding and 1. 83 billion in discretionary funding for a total of 6. 3 over 2017. 2 provides 2. 9 billion in mandatory funding to continue the Choice Program in 18 34rus 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 as 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, providing greater choice for veterans, modernizing our systems, focusing our resources towards whats most important for veterans, improving the timeliness 6 our systems, 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 announced a waste Prevention Advisory Committee which will be set up and running this summer. I directed the v. A. Office remain under a hiring freeze, those are 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 and Mental Health at all of our Medical Centers. Veterans can access wait time data for local vas using online easy to use tool to understand access and quality. No other Health System in the country has this type of transparency. Weve made it easier for them to fill out online Healthcare Applications so much easier in fact that since last summer weve received eight times as many online applications than the year before. 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 problem deucing decision ready claims nationally september 1st. At our regional offices well be completely paperless for claims by mid2018. A few months ago the Veterans Crisis line had a call rollover rate of more than 30 . Today that right is less than 1 . Weve launched a new Predictive Modeling tool allowing va to provide proactive support for veterans who are at higher risk for suicide. Were also lawn offing a new initiative this summer getting to zero to hips end veterans suicide. This is my top priority. But to keep moving forward were going to need your help. Weve identified over 1,000 facilities that are either vacant or underutilize and were work 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 date at in one shared system enabling seamless care between the v. A. And d. O. D. Without manual and reconciliation of data between separate systems. We also need congress to authorize an overhaul of broken and failing claims appeals process. Weve worked closely with vso easy and other stakeholders to draft a proposal and modernize the system and we we are pleased to see the house unite behind the bill last month now we just need the senate to act. Most of all we need congress to ensure the continued success of choice for veterans. Veterans are responding to our modernization efforts by choosing va more than before. To keep up with those choices we need to fully fund choice and help us modernize and consolidate va Community Care through the Veterans Care Program the program will coordinate care so they get the right care at the right time with the right provider whether in a va facility or from a highperforming va Community Care provider. We just need your help to make it happen return colluding funding to keep up with veterans as they choose va. Thank you and we look forward to your questions today. Thank you, dr. Shulkin we appreciate your attendance today. I want to start off with my questions on the appeals process. I have consistently said that any change in the process to improve it must include an acceleration of and dealing with a 470,000 veterans choez whose claims are pending today at the va. Would you agree with that . I would like to see that happen. Im going to give you a second question was a chance to make a commitment on that. If both appeals reform and budget request are adopted in this budget, would va be able to begin accelerating decisions for those 470,000 appeals that are pending . The appeals that are in the board of 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 law passes in moving forward. Youre asking about the legacy claims. Right. And appeals. We do not have a plan to make 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 mange contract mental 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, is that we will give current veterans who are in the appeals process the option of opting in to 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 this is my hope to be able to accelerate the backlog to encourage veterans to 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 had expected anything else. But its easy for a Department Head sometimes to talk to department ease and we think we ladder one thing and we heard Something Else. But what i heard you say in effect as far as those legacy appeals are concerned, this really is not going to do much even if its adopted to take those legacy claims and move them forward, which means well still have 470,000 veterans claimed out there that one of them is 25 years old, thats the oldest. At least, yes. And eventually weal hell die and well get that one solved but weve got 369,999 more to get to. And im going to quote now what ive heard sect secondhand and ill say up front this is secondhand. But ive been told that the va recently told the Congressional Budget Office that vas plan is to, quote, very gradually, end quote, address the 470,000 legacy appeals if appeals reform is passed. Is that the case and i heard your answer being yes, its going to be very gradual and it would be 2026 before we got to it . Yes. And let me just add because we share that frustration. I find it really difficult to tell people who have submitted into the appeals process 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 by how much if was. I want to know. Around 800 million. Senator sander, senator tester, senator boozman, senator moran, everything we do as a committee, senator manchin, will pale in comparison to the hake were going to catch if its going to take 800 million to handle those claims before 2026. The appeals were going to clean up appeals prospectively in the future with what this budget proposes but for the legacy appeals that sit out there, theyre going to still be out there. Yes. The angers going to get louder and the frustration deeper. You need to know the number, 800,000 will do it, and we need to be prepared to find someway to do that. Because all thats going to happen is there are a lot of people that are going to get more and more anguish, less and less service and its going to cause us more problems with the programs we try to bring in place. Thank you for being candid with that i want all of us members of this committee to be aware of whats going upon and we tro make the hard decisions and one of them is to get those legacy claims done and not let them build up in the future. Because when you put your new program in and solve all of the new ones, it sure as hell better because if we clear it up and get the backlog done and it doesnt were going to be madder than a wet hornet. When a veteran an american citizen signs up in the United States military and commits themselves to a period of service, carries out that service and it meets the qualification necessary for them to be qualified for va healthcare in their retirement or when they leave the service, then we are we are obligated as a nation to pay for those benefits, is that not correct . That is correct. Does anybody up here disagree with that . This is not a trick by the way, im just trying to get everybody engaged. We did choice, when senator sanders and mccain did a great job of leadership 36 months ago on that. We did choice to address the backlog, the waiting time periods and things of that nature. We did some good things and it brought about some problems, which we have eliminated and then begun to solve. Were now in a situation, and you alluded to if 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 budget to the other. I just want to make sure im right on this. You have seven accounts that Fund Healthcare benefits, is that correct . Community care. Community care. But theres seven accounts . Yes. One of those is choice, one of those is Community Care, care in the community. So when youre asked to move that money to so you have enough money, youre not asking for new money to be given to you by appropriators or by the congress, youre asking them to move existing appropriated money under one stove pipe in the va to another stove pipe to achieve balance but its no new appropriation, am i correct . Thats correct. We have enough money to be able to make sure that all veterans will get the care that they need. We 23450need your help to figur best solution to figure out 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, but i want to get to that point also but we get bogged down sometimes . Legispeak, this acronym and that acronym. When tl its all for the veterans, tls its not any new money were just trying to meet our obligation to our veterans, so we need to find out way do that and not just a stop gap matter but permanent. And one of those ways might be to see to it that all the Veterans Benefits for healthcare are paid out of one account and its under the secretary of the va, is that not correct . That would make sense to me, mr. Chairman. Senator tester. Thank you, mr. Chairman. Thank you again for being here, dr. Shulkin. You talked about and i want to follow up on the chairmans questions put 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, i dont know what you want to cowl it, whats it called . Directive. Directive, thats better, a few days ago that 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 day or two later you rescinded that, thank you for the breakfast yesterday we had a great breakfast and we talked yesterday about potentially doing a fix lek legislatively. I was told today that another directive was put out today that reinstated that rule to go back to the initial. No. Is that correct . Let me try to be accurate about about what happened. We noticed that there was an imbalance in our two checking accounts. Yes. On friday we sent out a directive saying stop spending from this account. Right. Okay, start spending 23r this account. Correct. Were afraid after seeing that directive that we were going to confuse the field. Bingo. And so we rescinded that memo. Thats correct, right. The field, once we rescind the memo said, okay, we get it, youre rescinding the memo but 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 check accounts. And did those four principles i dont have a problem here. Yeah. All i wants 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 to use choice for the appropriate use of choice, which is clearly as you leg slated which is 40 miles 40 days and to use Community Care for the original use they consider using it for. So with all due respect, the directive was putback in place. And 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 when we fix this this will be no again. And so thats all i ask. In that that uncertainty, by the way, and i woent wont speak for everybody on this committee but i got a notion it will be this way for everybody on the committee does not add confidence to the va moving forward, ill just tell you. So do you get my drift . Absolutely. Let me just say, listen. Yes. I would not disagree or argue with you. The Choice Program has been difficult to administer, difficult to understanding, and very complex. We the first memo was rescind and remains rescinded because what it said is do not go to choice. We do not mean that. What we tried to do is provide guidance to say, you can use choice and we want to you use choice appropriately, but we have Community Care funds we want you to use those. We 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 and the breakfast we had yesterday was very, very important. I think everybody that was at that breakfast would agree and 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 dont want to micromanage the va its your baby and it would hang me out to dry if i tried to do so and rightfully so but we need predictability, thats all. We, this committee but more importantly the people sitting behind you need that predictability otherwise things are going to going upside down pretty quick. Ive got a bunch more questions but ill refer to the next person in line. Okay. 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. Yes. When we visited about the first member the Third Party Administrators would have no role to play and they could go away and lie dormant. Exactly. The second mem mope says choice is alive and well. Absolutely. And its to be use dollars in these circumstances which are the ones that were defined by the original choice act. Right. I dont actually know what why thats different than how it was being used how is choice being used different than 40 miles in 30 days . Because we were also putting everything that we could through choice rers specially services that werent being offered at the va. So senator moran, have you it correct that was what we tried do during the first and second, senator testers pointing out that we have some work to do in getting our communications better. Thats the part i was going to agree with. A debris with him too. Because on that point would make the dais case on behalf of senator tester that we had a hearing on wednesday on choice. Yes. Your first memo goes out on thursday or friday. Friday. And this conversation never occurred with people who care a lot about choice but care a lot about veterans. I will say, everything that both of you have said is accurate and i will tell you and i hope that you politician i must confess. Yeah. You about 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. Yes, 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 because if choice isnt being used then our intermediaries arent be paid, the network thats been established under choice goes away, and you have Community Care but no choice and no network, no thirdparty intermediary. So its not just 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 accepts . Yes. And weve worked very hard do that and i agree with you we want to keep that in place. A part of this that im still confused about because your response 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 having for any new money. Right. My understanding is that you have about 2 billion in the Community Care account. Is that an accurate number. Unobligated, yes. Unobligated. So at some point in time, and i dont know how soon that is and mabt va does, that money becomes scarce. So the fix can only last so long before both the choice account and the Community Care account are insufficient to meet the community the healthcare 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 to 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 fq 18 budget requesting is not needed until fy 18 . Im going to defer to my cfo but i would have said yes. Yes, sir, thats a requirement thats for next year. The one caveat is in the budget we assumed we were going to carry over 26 million of this yearss choice money into next year our actual requirement is 3. 85. So we are going to consume that now before the end of this year so we will have a hole next year of about 600 million. And that hole exists in 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 . Yes, sir. That true . Unless we were to find some other offset. I guess my take away is assuming that your budget numbers are right 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 ib put of money as long as there can be a transfer of, i suppose a Discretionary Spending into the mandatory account. Yeah. That true . The last part that you said is true, but if there is no action at all by 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 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 to you spend money that you have, although it certainly sounds like it creates a likelihood of fiscal shortfall, dollar shortfall in fy 18 even if we appropriate the 2. 9 well dollars in the president s request. I think everything you said is correct and as he said, we are not seeking the additional monies. If we needed to we will identify the offset to the 600 million for 18. The chairman has his finger on the no. I think that ive had my fair shot. We may have another chance. Thank you. Thats very helpful i apologize im going to take one minute to clarify a couple of points. Dr. Shulkin, im a veteran, serve in the military in afghanistan, serve my years to necessarily make me eligible for va healthcare, im a veteran, im in va healthcare. If i go to the va hospital for a latent for a medical need related to my service or to just regular healthcare, youre obligated as head of the va to pay for it and deliver that healthcare to me in the best possible way, right . Yes. Its mandatory, you dont have the discretion as head of the director of the va to not provide me with healthcare because you didnt get enough money . Correct. You have an obligation to manage the money that you have and if you need more come get more money, is that correct . Yes. Thats why when we talk about mandatory and discretion, its not a matter of discretion vaet veterans healthcare is at risk if we dont have the money and its mandatory we provide that money. I would agree. What youre talking about in transfer ability is after we decide to put x number of dollars in however many accounts that 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 that veteran without having to go to a secondary step within the va to get money moved by somebody else because somethings named mandatory or named discretionary, is that correct . Correct. Yes. I wanted to make sure i had that right im not sure i said it right. You said it perfectly. Its clear to me now, clear as mud. Senator sanders. Thank you very much mr. Chairman, dr. Shulkin, great to see you. On page three of your testimony you point out i think what most veterans organizations and veterans know, that by and large the va has a pretty good Healthcare System. And you quote a study published by the journal of the American Medical Association where researchers compared hospitallevel quality care on 129 va hospitals with over 4,000 nonva hospitals and you found that that the you had Better Outcomes in the va on six of nine Patient Safety indicators and the other three were about the same. Thats a pretty good that speaks pretty well for the system that youre rung 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 a few years ago on the help committee talking about prevent able deaths in american hospitals. According to im look at an article right now in 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 varks a doing compared to nonva hospitals on that issue. As the article in jama suggested, the va is 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 that senator test rubbermaid a moment ago. And that is what we hear every time there is a hearing with t veterans, they like va healthcare. And what senator tefrt and many of us dont 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, 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 traditional va. Other question, you mention on page nine what is obvious, you say that the vha is the largest Healthcare System in the u. S. And in an industry where theres a National Shortage of healthcare providers. We a major doctors price sis, primary health relief, psychiatry and 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. And what that does essentially, mr. Chairman, is what it does is help, as you know, medical schools now outrageously experiencesive so i talked to young doctors who are 300,000, 400,000 in debt. Theyre not going working in the va, theyre going working where the money is. I would like to see that program expanded. What it does is provide Debt Forgiveness. You want to work for the va for x number of years, we will forgive the debt that you have incurred in medical school. Is that an argument 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 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 viceversa. Wed like to see that aprila ture open so that we could actually take money that was in the budget for sending veterans out and reinvesting more of it into the va. We think thats very important, it should be done at the local level when every local visit makes its decision on what strengthens it. Couldnt agree with you more on the education. The program that you were helpful in crafting was a great success. Is it working well . It is. It is. And we need to did more of it. We are 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 of Public Health service the national Health Service corps. Afterwards they would give five years back to the va. So mr. Chairman this san issue where i think we can go a long way in attracting physicians and nurses perhaps into the va by expanding the Debt Forgiveness program which i already understand is 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 crit kat cal source of healthcare for veterans approximately 175 million veterans have medicaid as a srs of coverage. If the republican Healthcare 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 that a lot more veterans are going to be flocking into the va. Am i correct on that zbli would think so. We are a Safety Net Organization and we tend to have veterans without other 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 we would need to do that. If veterans lost their medicaid, theres a reasonable possibility many of them would turn to the va for care. I believe so. And you would need additional help to accommodate that large number of veterans . Yes. Thank you very much. Thank you, senator sanders. Thank you, mr. Chairman. Mr. Secretary, last week we had a rather i guess id call it a spirited about the Emergency Care fairness act. Under the fiscal year, a budget line to pay for Emergency Care lacking, the vso independent budget has included recommendation of 1 billion for 2018. My question, sir, what is the status, which is the appeal on the Emergency Care fairness act the way that its being interpreted. And at what point with the va formerly request the necessary funds to pay for Emergency Care for veterans. First of all, senator, i appreciated the interchange that you and i had. I think that you were making excellent points and you were actually on the right side of this issue. We have done two things since weve talked last, first we have completed all 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 part is complete. So thats moving forward. Thats good news. The second thing is that after considering what you said and also, i think, senator blumblum bloomen that will, i have mumen i think what that means is that, 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. We still have to go through the rule making process, thats why we transmitted those rules to o and b and they needed to go through the process. I dont want to set time expectations. Were moving in that direction to adhere to the judges ruling on this. Thats very positive development. For those 370,000 individuals, this is great news. Any possibility of expediting the rulemaking process . We did. We got the rules over there fast. What happened 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 va is focus on what the veterans need and what the veterans care should be and then when we make a promise, we honor that promise. I think thats what veterans are expecting from the va and i think this is a major first step in that and thank you very very much for your work on it, your attention to this. And i think that will paint dividends for the entire organization for years to come. Mr. Chairman, i will yield back time. Thank you, sir, thats great news. Thank you senator. You announce youll be scrapping and developing the same system that based in st. Louis. Well, im certainly in favor of making it easier on veterans transitioning from dod to da. The speed of this decision will have second and third and order effects that could be detrimental and here is where they are. Are you concerned theyll be increased risk at having one company manage all of these records. What becomes the health net of Electronic Health 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 this the expense that will be required and our lack of ability will maintain qualified Software Developers within va, the risk of doing nothing was worse. Theres always risk especially when you transfer system. I have to two, by wading the bidding process, how are you guaranteed of what we will consider a little bit of a ride. We have not committed to any funding, we have not how will you know prices is competitive if theres nothing to compared to it. Well, we certainly know the price that dod paid. We know the price that were currently paying to maintain our systems. We are going to be seeking the best way to do this for taxpayers. Now most of the cost of a transfer of system is actually in internal change management. I was going to say, how are you going to observe the cost. Well 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. While im showing the records transfer, its important to ensure records transfer and their operability between nonva. While its a decision to move forward with a common platform, this will not be the dod system. Vas needs are much different we have to be interoperable with our community partners. Theyre not necessarily on a platform. Were going to have to create a system that does several things the dod did. Were not going to be scrapping this stuff. Well have to connect into and mainta maintain. How are you undertaking this without those positions. We look forward do you feel like you had 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 opiod epidemic, which is the number one problem i have in my state, not just with the general population, but my va and veteran community. Im looking for assurances that when we do new provider agreements on any contract with nonva care providers, were good at making sure they understand more or less we have a lot of mills and they get these people hooked and they keep them hooked. How are you going to ensure whats your oversight, are you prepared for this . Well, i dont think were doing good enough job in this. I think the country needs to do a lot better. We have challenges within the va ourselves. A lot more needs to be done. You had very little control when you were out at the private sector. I think weve made Good Progress in the va. Weve seen the 33 reduction in opioid use in 2010. I have the concern about going out to the community. What im saying is the contrast you write, if im a provider. If im nonva provider, the new act lets that person come to me. I contract with these people. Is there conditions on that if i prescribe if i follow a prescription guidelines, are you going to be monitoring that as far as opioid prescription guidelines. I think this is a really good area for us to come back to you. Mr. Chairman. Mr. Secretary, thank you for being here. Glad to have you here. 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. So we proposed a part of the process that would revise the individual unemploy ability benefit. The budget is a process. This is part of a menu of opportunities that we had for thinking how we could make the budget process better. As i began to listen veterans and their concerns and bsos in particular. It became clear that this would be hurting some veterans and 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 i am not going to support policies that hurt veterans 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 we have to hit. We should not be doing things that are going to hurt veterans that cant afford. We have 300,000, jamie there are 300,000 in receipt of iu. About 210,000 of those are over the age of 60 and therefore would have been effected. Would have been. Yeah. Correct. It would have been retroe active . It would have been point forward. To include all veterans, so when you say retroe active, i dont believe well pull any benefits that weve distributed back. No. Im saying if you had the benefit, you could lose the benefit . Yes. Yes. Thats correct. That was the proposal and but we do look forward to working with you to figure out how to do this better. I appreciate your concern. Do you know what the average is per veteran on this and what the average intake is . The average payment . Yeah. Its roughly 1,600. Roughly 1,600. Yes, sir. You have to be rated between 60 to 100 and it takes you to temporary 100 . 60 is roughly 1,600. So you can understand the financial burden that may pose for an individual, that 1,600 and what im more concerned about, the longterm retirement. They may have not prepared or been prepared if in believing that that 1,600 may 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 would not 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 for 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 and make sure i understood this correctly. Did you say you had a decisionready claim in three days. Weve had 12 of them so far, yes. Thats big news. Thats big news. And im glad. To think you can actually turn one around in three days. Its pretty incredible. Were pouting in saint paul right now and, again, with a couple of our bsos. If it brings in the claim ready to be decided. No further development and we decide a claim. We had previous secretary said. Were about 90,000. As of this morning. 94,000. Yeah, thats about what i have. Thats about 1,200 of them in nevada. Yeah. And i think our goal, jamie is by the end of we wont start rolling them out until september, that will begin to dwindle that down and we hope in two years to be down below below half of where we are now. Thank you for the time. Thank you, senator. Senator murray. Thank you, mr. Chairman. And thank you all for being here. Secretary, in last years budget request, the va estimated it would need 725 million in fiscal year 2017 and 840 million in 2018 for the veteran caregiver program. In the first budget of the Trump Administration, you plan to only use 521,000,604 in 2018. Those are cuts of about 30 . Im hearing from so many of my constituents, caregivers being dropped from the program with no explanation and investigation by npr found that charleston medical senator dropped 94 of the caregivers, 83 in press donald trump cpresscot. Its balancing the budget on the backs of veterans in need, how do you explain those numbers. Revocation of caregiver and benefits unacceptable. Thats why we suspended the program. Today there are no relocations until we get guidelines better understood and belter shape. Thats the freeze youre talking about. Right. Right. Thats only a temporary measure. Its a temporary measure until we revise policy. I will not accept. On the right amount of money to request. Was in the budget. Budget funding for next year. They requested 600 million. Our hope as you know, youve been tireless advocate for this is to expand caregiver benefits 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, that we have find that thats going to be cost effective. Because we remember we pay for longterm care. So my plan is to be responsible to taxpayers. The Ranking Member i wrote to you a couple of months ago suggesting series, those issues havent been addressed and i would like to see the freeze extended until all of those issues were discussed, can you do that. Yeah. Do you happen to have the date of the letter, if not, ill find it. Two months ago. Of course. Absolutely. Let me go to the shortfall and the Choice Program. I know that you wrote to try west and health net telling them to return referrals for care including for veterans that are waiting for care. How many veterans are going to be effected by that . When they cant appoint an appointment. 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 its a big . Well, this is actually speeding up care, rather than letting a veteran state out there in the program. They return them to the va and the Community Care program goes out and tries to find an appointment. It seems to be two different stories here. Transfer authority is what im hearing from this year, correct . Well, if you transferred money from this year, then what youre doing is impact gs what you thought was going to be carry over from next year. What you wont you need additional money from 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 programming to a single Community Care account. Look, were doing to these guys are going to help make the best predictions possible, so mr. , yao is going to help us understand the right amount of money to trance for over. It will impact 18. You know, we need real numbers here. We cant do our job if we dont know what the costs are. So you know im hearing from veterans in my state about the delays and theyre seeing as a result of this, i had veterans in walala who are being told theyll have to drive 8 hours round trip just for some simple imaging tests as a result of this. Im hearing a lot more and happy to get those to you, this is having an impact. I want you to know that and we want to know where this money is coming from and so we will follow up with you on that. But i think this committee needs to be aware of that. I am deeply concerned about that. This reminds me of the question i had yesterday, somebody asked my wife and i what we attributed, we never had a joint checking account. Thank you senator. Thank you for being here and we appreciate our veterans advocates that are going to testify shortly for being here. Also senator sanders talked to you about the problem with the fact of providers. So many people are at the age now where big group of baby boomers, you know, that are aging out. They practiced because they like and, you know, medicine has gotten more 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 and this is a huge problem here. And. And 8. 4 billion. And, you know, put it done at work. Weve targeted the highest. And given full and putting your skills to work and Behavioral Health and expanding. And and thats essential for veterans and for the country, that the va provides and turned her and secretary, they really would be lost. So these are services and stress. And across Behavioral Health Care Services and clearly foundational as well. Environmental exposures. I dont want to leave out a group. But these are you will not find easily accept in specialized geographies. Its important you keep those strong. You talk about Community Care and how doctors will make decisions on providing care in these facilities versus in the community. How do you make sure that, you know, with we had an institution we have a bureaucra 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. We need to get rid of the administrative rules and third parties in between, thats what we saw. What weve learned is delayier the process. You know, the tell tmonitors. Let the doctor of the patient and make the decision together whats best for them. Thats the decision were trying to decide now. Thank you, mr. Chairman. Senator, thank you mr. Chair. Im going to be married 30 years, two weeks from today. We have a slightly different approach. We have a joint account. I dont have access to it. That works also. Im not even 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 that senator doll is heading up and its critically important. I want to spend time talking about it here. One thing that was striking is 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 a way to provide support over time. I understand that in order for us to do that, that we have to talk about the resources and make sure were not shifting our attention away from so many other pressing things. Its something i look forward to talking about. I want to know how were doing. You know, some of the estimating, some of the uncertainty with respect to accounts and how much we need and one of the other one thing with 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 your i understand the cio nominee i think is withdrawn their name from consideration. How are we doing on trying to get that administration. Were attracting a good viewing audience. We need help we need people to want to come. Its going to be pretty important to get in some of the Financial Planning and order and get your planning processes in order. Yes. I think youve touched on something important. You need somebody thats highly skilled. Weve got to get the positions filled. Im not going to spend much more time im going to get back to the other committee. Im going to echo again what i said in the last committee. Im sure there are various factors that led to the shortfall. There are other things we need to do to make sure were facilitating the process and not giving additional distractions or uncertainty as we go through the Financial Planning. Speak candidly to make sure when there are things that we can do or should not do that are getting in the way of you giving us answers so you want to reiterate make several good points. I think shes right. The sooner you articulate what your funding levels are the better. Thank you mr. Chairman. Thank you, chairman first of all i want to express my appreciation on the richard style versus mcdonald i joined my colleague senator rounds in expressing consideration for your decision to withdraw the appeal and also withdraw which i know you will do. On the employment, as you know, it provides career counseling. Training and educational institutions. Ive been told by connecticut universities that there are delays in vocational rehab housing and education payments for service. They have used those delays to lack of vocational at the hartford regional benefit and the purported goal of ratio of rehab counsel to client is one counselor per 125 veterans. The average ratio in july 2015, is one counselor to 139 veterans, despite the payment delays and the vas inability to meet the ratio. The fy 18. Is 13. 8 million. Youre probably more familiar with these numbers than i am. I apologize for you 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 under funding and id like to know whether you plan to delay to address the delays and your view of the apparent under funding of this very valuable program. We see a 1. 5 million increase for these programs. There are some staffing issues and delays that we do want to get improved and we want to fix. We think this is an important program. If you have different numbers and were wrong youll want to address that. I think the overriding issue here is not necessarily even the numbers because even if there is a slight increase, this is small this program is so valuable, it ought to be a major increase, certainly not a reduction. This is not a criticism of the va, in fact, on the contrary its saying were doing great work. And we see these delays in hartford and we would like your help in solving them. I dont know whether its been asked about, but i wonder if i could where you see Real Progress and reducing the claims backlog im guessing someone has asked about it already and i apologize for it. Thats not a problem. Whats your prognosis . Were at 94,000 night. We hope by the end of the year to be approximately 70,000 and then a year following that or two years from now below about half the level. So 45,000. Those claims have to be all of the information is ready and we give a decision in three d s days. The progress youre making is the result of a different. The budget stays flat so its not necessarily therefore you can distribute the workload across the country evenly. Its enhanced and increased the productivity stands for the people who work in bba and theyre doing a terrific job. We have great work who are up. As we know, this is say, problem has continued to over many years and im glad that youre making those process changes and there may be some break through changes in the foreseeable future, thank you. Ive been in public life long enough to know if you want to know where things are headed, you follow the money. The fact that we have 1. 2 increase and 33 for outside medical care is disturbing. Moving forward, ive got a notion theyre going to talk about care and theyll talk about other possibilities they can fix it. I would say that. Number two, this is an authorization committee. Electron cal it funding youve got 200 million in this budget. You should be asking this committee to plus that budget up. You need to do it so it represents the money youre going to be dumping out for the dod, electron cal platform i think its important that were honest with ourselves, ill tell you why, i happen to be on both committees, i dont want to get na nailed. And john rowan up here in a second and i want to thank those guys for their service. We had said early we need to take our direction. Im not going to be able to be here. Ill try to get back before the end and we do need to take it. I think its critically important, thank you all. Senator, thank you and, you know, the one thing is were always clear on where you stand and appreciate that. I do want to try to work with you and your staff. 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 to 1 , would help us a great deal. Thats something well continue to work with you on. I will just say, well work with you on that, too, johnny and i both agreed to that. As i have said to you, you can out source care, but you cant out source responsibility. Theyre criticized for over dependents on opoids. Can you say a word about how the va can lead this country away from opioid although obviously theyre 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 four or five months ago in the journal of the American Medical Association about the vas approach. I think it is a National Example that others can learn from. We started this work in 2010 where we identified problems before the rest of america did. We zoo ak. We have our patients signing informed consent so theyre part of the process when they get opioid. We participate in the programs thats mandatory that our providers do that. Were providing alternatives such, as you said, complimentary care. The best practice for us in the country, i dont know if you know this, is actually white river junction. We have the complementary medicine. Acupuncture, yoga. I mean, you know mind body, type of techniques and so were trying to get others to be as good as were doing white river junction. Were working in a number of these areas and were trying to work on research with the fda on nonaddictive narcotics as well. We think thats important. Thank you very much. Thank you. Let me thank the secretary and his staff for testimony and support and continued response to committee and were grateful for that. Let me welcome our second panel and ill begin with the introductions, mr. Carl blake associated executive director and paralyzed veterans of america. Mr. Leroy, assistant National Service director, disabled service veterans. Mr. Carlos, director of National Legislative Services Vietnam veterans of foreign wars. Mr. John rowan Vietnam Veterans of america. Thank you for the opportunity to testify with your approval and committees approval. Well like to submit budget report into the official hearing record. Thank you. I think i like to spend my time talking about what weve heard here today rather than the recommendations that are included in our budget report. Lets recap. I appreciate senator or senator heller bringing up the question of iu. All i would say, its not ready apparent that the va has said for sure they want to drop that proposal altogether, sounds like theyre willing to discuss further and see where this goes from here. I appreciate senator mansion and tester for bringing up the question for ehr modernization. Senator rouchbds continues roun rounds continues to beat the drum. About holes that seem to be appearing in the budget. I appreciate that the secretary has made the commitment he has as relates to the ehr modernization, doing the right thing on the ruling and trying to address issues like the caregiver expansion. Its not an easy job, i dont envy the position hes placed in. Lets forget him, for a minute. Lets set aside the fact, sounded like to me we may be stairing a budget shortfall right in the face for this current fiscal year based on the transfer ability problem, moving money between Community Care and choice, all of those things in historically shortfall there. Lets look at fiscal year 2018. I think thats the good way to snapshot the bigger hole the va has to deal with. Going to fund a large majority of choice Going Forward and perpetuity as it were, at least 2. 2 billion. If we assume thats 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 mansion and they mentioned discern or decision. I think on policies thats probably the right decision to make for va and for dod. But i read an article, recently, that said the department of defenses obligation is something on the order of 9 billion, i think, is the life cycle of that program. It also said that vas obligation will be at least 3 to 4 times that great. How does the vas budget rationalize that point, im sure it doesnt. Senator rounds mentioned, its the right thing to do what the secretary says. I think he knows it and acts upon that. I was amused he said they expedited the rule making process. I think he said it went to omb, thats where the expedited process goes to die. He said. The average is 1 billion, 1. 1, 1. 08, something in that range. Where is that money at . Its not in the va budget either. We have a 3. 2 billion hold of choice. We have an approximately 1 billion hold. And then we have this issue. And we dont know what that hold looks like. The choice plan has it at exactly the same approximately at 3. 5 billion. Are we going to decrease it. I think we all at this table know thats not going to happen. Right now the va could be stairing at a huge hold in its budget for 2018. Weve expressed this to the appropriators because of the time. Theyve moved forward on the house side. Theyre going to mark up their bill tomorrow and none of these questions are answered. The va has 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. I appreciate the opportunity to testify and be happy to answer any questions you may have. Mr. Chairman, members of the committee. Coauthor of the independent budget, pleased to present our views regarding funding requirements for Veterans Benefits program. Today ill focus on critical funding news for the compensation service, vocational rehabilitation and employment and the veterans appeals. Also to unacceptable Administration Proposals to scale back veterans disability compensation. Mr. Chairman, they recognize theyve made the va has made significant process in reducing the disability claims backlog. Workload continues to rise. To manage current and future workload, they recommend an additional 1,750 fte for service which will require an increase of 183 million. Program participation has increased and based on historical trends. It will increase by another 5 in fy 2018. Over they recommend total funding be increased by 278 million, 10 increase and over to fund the two staffing increases and maintain Current Service levels. Unfortunately, the administration is recommended an out right cut of 12 million. And that recommended. Recommending funding levels to continue the progress in delivering to veterans their families and survivors. Mr. Chairman, theyve made significant progress on the claims back law, one consequence has been an alarming increase in the backlog of appeals for denying claims. Today, there are over 450,000 appeals pending either the board. And it takes almost six years on average for decision by the board. Fortunately, they have been part of stake holder work group to develop of comprehensive reform of the appeals process. Thats 1024. The improvement and modernization act of 2017 is built upon the framework and has received broad bipartisan support. Well pass this legislation, the house has passed similar legislation earlier this year. Enactment of this legislation would lead to a more modern response of inflexible appeal system, one that will provide with quicker decisions on appeals while fully protecting veterans due process rights. Even when passage of appeals reform, however, the board will continue to acquire resources with commensurate workload. Last Year Congress authorized the board to increase by 242 to an authorized staffing level of 922 fte. The board has yet has not yet filled all of those positions. For fy 2018 expects the board to continue all authorized positions. We do not recommend further staffing increases while this legislation has been approved and implemented. Moving forward, the board and Congress Must carefully monitor the appeal system to ensure it remains adequate. Finally, mr. Chairman, enthusiastically opposed two legislative proposals in the administration budget. First, we strongly oppose to round down for ten years which will hurt our nation and their families and survivors. Were the entire congress the sound rejected. Furthermore, we objected cut off eligibility for employment or and theyre determined unable to work. This is also that result from a total disability rating. Commissary and in many cases, state benefits such as property tax exempt shuns that will be harmful to disable veterans. That concludes my testimony and ill be happy to respond to any questions of you or any that they may have. Theyre glad the administration has proposed the increase. We certainly support the continued focus on expanding access to health care, expanding expediting decisions on benefits, claims and appeals, increased focus on combatting veteran suicide and addressing the stigma associated to health. Ensuring vas ready and able to care for Women Veterans who are the Fastest Growing in veteran population. However we would like to make it clear efforts to call back benefits from the most disabled veterans to pay for such improvements. In the past week, nearly 40,000 letters and emails from members and supporters have been sent to members of congress opposing the administrations proposal to revoke individual unemploy blt for veterans unable to work the vfw opposes the proposal and the other measures to balance the budget on the backs of our nations veterans. Permanent program which could lead to the Va Health Care system. The continued failure by congress to eliminate sequestration that has forced the Administration Proposed cuts to veterans programs in order to expand the Choice Program under mandatory spending instead of including it in discretionary Community Care counts. Sequestration and spending caps limit our nations ability to provide Service Members veterans and their families and care and benefits they have earned. They call on this committee to join our campaign and finally and sequestration and do away with federal budget processes based on our budget caps. In partnership with our independent budget coauthors, i would like to focus some of our remarks on the construction and National Budget request that under funding thaz allowed the infrastructu infrastructure. We continue to believe that this need for space and chronic under funding of Major Construction projects could force to ration care. Vas budget request says that improving the conditions of the facilities through Major Construction projects account for the largest resource need to keep pace with the growing demand for operation care. Yet the administration Major Construction arrest only funds Major Construction project. They believe that requested an adequate amount for fiscal year 2018 Major Medical leases needs, however, Congress Must find a way to quickly authorize leasing projects. There are now major facilities leases awaiting congressional 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 to veterans. The 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 ineligible family members. And theyre glad to see the for ncas higher than our recommendation which may be one of the only ones. We commend v. A. This concludes my testimony. Happy to answer any questions you and the committee may have. Thank you. We appreciate it. Mr. Rowan. Thank you. Nice to see you, senator, good to see you back. I missed you when i had my annual testimony this year. I missed you more than you might think. Im glad to be vertical again. I was coming out of the hospital when you were going in. Anyway, i would like to first of all thank you for the accountability act. Its an issue weve been dealing with since we started dda 35 years ago. Calling on congress to take full accountability and hopefully this will work and we support that bill. Iu, as was noticed, has got to be rescinded. That whole proposal is a classic budgeteer proposal that has no impact to people. It is a dollar amount from somebody in omb and the effects are beyond what everyone understood which is the whole nonsense that Social Security was going to pick up the amount of money in iu, not talking about the effects of the family members, the loss of dental chair and champ v. A. And loss of local benefits as was mentioned earlier, tax abatements in new york city. We gt the expansion for real estate. That would be cut significantly by that. So this has got to be one of the things we are calling upon. Since the secretary has alluded to the fact that they may agree with the fact that this should be shelved we would love to see a joint effort between the v. A. And the leadership in the house and Senate Veterans Affairs Committee publicly denouncing this idea and saying we are not going the pass it so we can tell all those scared people out there who have been sending me emails and letters about the horrors they are concerned about they have nothing to worry about. We have got to bring these people down about 10 notches because they are climbing the walls. That is something that i hope the committees both in the senate and the house and the v. A. Would take into consideration so they can publicly acknowledge that this was one bad idea. The Choice Program is not a choice, its a false choice and i think we need to understand how its done. I just came back from idaho where i met with my council in north sand point, idaho and northern idaho. Choice program because they are hundreds of miles away but they can tell me the problems with choice and the doctors who will take choice, who will take the v. A. s money, who will even sign on because of problems. We know they are 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 live in new york city. My dermatologist that i had in my private medical program just retired on me and i managed to outlive him. So that was great. Hes retired. Im still sick and have to go see the doctor. I called up Emblem Health which is one of the largest in the country and they couldnt find me a dermatologist that i could talk to at the earliest in august and really they were talking about october. That is a false choice. That is dermatology, which i think i could throw a stick out of my window and hit a dermatologist but in new york city but theyre not there because they dont sign up to the v. A. They wont take the v. A. s payments. Just like weve seen in medicare and medicaid with doctors not signing on. So we are concerned about that. It needs to be rethought significantly. Because the private sector is not ready, whatsoever to take on the v. A. Patients. No way. A couple things i want to point also the r d budget has been cut. It shouldnt be cut but increased. We need more r d. For all of the programs that we have. We need more evidencebased programs and testing on ptsd and how do we really handle it. I cant tell you all the different programs telling me what a great panacea they have for ptsd. It sounds great. I love my dogs and yes, they are helpful and help some veterans but without counseling that doesnt end their problem. And we need to get more evidencebased actions, research into these programs. Im also concerned we passed a bill last year that would look into the effects of toxic exposure of children of Vietnam Veterans, where is that money going to come from if the r d budget is cut in we got a nice bill passed. Where is the money . We need the money. If the v. A. s budget isnt there how are we going to get that done . Let me say about the appeals process. It would go a lot quicker if the v. A. Took outside doctors opinions and didnt have to redo everything that someone came in with an outside doctorss opinion. That would be nice. And the other thing is, if we need to blow up the board of veterans appeals. It doesnt function. Nobody should lose 70 of the time, which the v. A. Does. I have been in this position for 12 years and in 12 years, every year, our vsos, 70 of the time get a remand or an appeal from the board of appeals. 70 we win, v. A. Loses, year after year after year and i guarantee thats the same with the rest of the gentlemen at this table. Thats ridiculous. The other problem is no precedence. Karl can put in a claim and i can put in a claim for the exact same thing. He gets judge a. I get judge b. We get two opinions, we both go down, he wins, i lose, too bad. His opinion doesnt count for anybody to follow after them. And neither does mine. The denial doesnt either. It just keeps regurgitating the same programs over and over again. The same problems over and over again. We need to get the issue of precedence and we now understand the court of veterans appeals is going to be doing class action lawsuits in the court of veterans appeals. I will be happy to answer questions that anybody may have. Thank you. Thank you for your testimony. I dont have a question but i have a proposition for you, though. Id like to find a time and id like my staff to listen to this. You and i have to have lunch in the next three weeks or a month. You piqued the interest in my mind. Your comments about the iu recommendation which is a nonstarter for you. Its not hard to pass benefits. And once you passed them youre not going to take them back or if you do you lose more than you get. But i also heard the comment mr. Acosta referred to about the c. O. L. A. Run down. There are a lot of things out there that over a period of years of the Veterans Administration and its existence and benefit existence and health care where times have changed, things have changed. We probably ought to look at everything that we got out there. There may be some pearls of wisdom and some benefits in the scheme of things that would apply different today than when they were passed. We need folks who have no agenda rather than helping our veterans than go to court. Ill call you and go that lunch. Im not avoiding the others but you made the comment that piqued the interest. I think if we open oneonone dialogue there may be some things that we bring up because the omb brings it up, you are in the benefit of looking at the best interests of your organization and i appreciate that. But i served the taxpayers and other people. We ought to start having some meetings. Talk some of this stuff through. We may find no Common Ground anywhere but we might find pearls of wisdom somewhere. Well try to set that up. Senator sanders . Thanks, mr. Chairman. I should have known but i thought we got rid of this round down thing finally. Been hearing about it from my first day in congression. I was chairman, we got rid of it. The idea of nickel and diming veterans didnt seem a lot. What youre telling me is its back again . Yes, sir. Thank you for your leadership when you were chairman of this committee and really eliminating that k. O. C. O. L. A. Round down and that practice. Now that the president s proposal is laid out, proposed to reinstate the c. O. L. A. Round down as a way to pay for extax of the Choice Program. Taking money away from the v. A. Benefits. If this was implemented, how much would it cost veterans . The accumulated effect of this proposed tax would cost close to 2. 7 billion over ten years. I dont think we should be nickel and diming veterans. I thought we got rid of it. Its sad to see its coming back. Let me ask what i think is the elephant in the room and that is the concern and the numbers seem to be disputed and not quite the clarity wed like. But the increase in appropriations for the Choice Program and the very, very modest increase for traditional v. A. Care. Who wants to comment . Is that a concern of you guys . Mr. Blake . Start with you. One of the concerns is and the secretary addressed it. There were talks about marriages and checkbooks i think the bottom line is that we believe all the Community Care should be stream lines under one authority, one account and manage it that way. I understand why they put choice on the mandatory side like discretionary caps and spending that place that at risk. But from the independent budget perspective we believe they are shorting the larger discretionary pot. The differences for construction in particular which are tremendous, and you take into account that outside of the health care 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. I would like to add this whole notion of having a mandatory program and discretionary and not being able to transfer and as carl said having one checkbook. But ultimately you are right, senator. We cannot forget the need to invest in v. A. s ability to thrive and hire and expand facilities. That is the preferred choice for veterans and we need to continue that. I have studied privatization and worked as the city manager and last two in the councilors office. Looking at all of those kinds of programs. I watched them privatize. That never worked. 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 is going to be administered by someone who is making 2 billion a year. And thank god our v. A. People arent being paid that much. Maybe they should be as i will tell you in the hospital where i got my care. Let me ask you very brief thoughts on a crisis thats impacting, vermont, that is this opioid epidemic. And my impression is that the v. A. Is trying to do the right thing. What are your thoughts on that . Who wants to jump in there . It certainly an epidemic that must be addressed. We hear about anecdotes where veterans are being overmedicated. One of our concerns would be the reverse as well. What we have heard is veterans cutting off veterans without proper alternatives and we dont want that either. Other thoughts . Okay. Thanks. Mr. Chairman, thanks very much. Thank you, senator sanders. I want to thank our vso members for coming. I want to comment the secretary of staying through both hearings we appreciate it. Your words are heard. We appreciate your input. We look forward to working with you towards providing the benefits that are earned and deserved by our veterans and doing it in the most efficient way possible as a taxpayer. We thank you for your attendance today. And this Committee Meeting stands adjourned. Environmental Protection Agency director scott pruitt testifies live at 11 00 a. M. Eastern on cspan3. You can also watch that at www. Cspan. Org and listen on the cspan radio app. Sunday night on after words, mike lee talks about forgotten historical figures who fought against Big Government in his book written out of history. Senator lee is interviewed by neil paciel. They come to you gradually. I asked friends from other people i knew who they thought should get more credit than they get. And this was an iroquois indian chief who understood the principal of federalism because they lived it for centuries before we were other our own country. Because its not a name that most americans know anything ant. And yet he had a profound impact on our system of government because hes the guy who enabled benjamin frankly to learn about federalism and he was the conduit through which it flowed to the founders. And made its way to the constitution. Watch after words on cspan 2s book tv. 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. Senate arm Services Chair john mccain was critical of the Trump Administration for not having a comprehensive strategy for the ongoing war in afghanistan. Defense secretary james mattis and joe took questions about the 2018 budget request. Well, good morning, Senate Armed Services Committee Meets this morning and receives testimony on the department of defenses fiscal year 2018 budget request. We welcome you and thank you for your many years of distinguished service and leadership of our men and women in uniform. Before we begin we all want to acknowledge the service and sacrifice of Sergeant Eric houck, Sergeant William beas, they were soldiers killed this weekend in afghanistan. The thoughts and prayers of this committee are with their loved ones. The sacrifice of these showers a painful reminder that america is still a nation at war. This is still true in afghanistan where after 15 years of war, we face a stalemate and need an increase in resources if we are to turn the situation