Veterans Affairs Secretary Wilkie on Presidents 2020 Budget Request Mar 26 2019



affairs committee to order and welcome everybody to the committee today and thank secretary Wilkie Wilkie in particular and all the members of the VA staff for being here today you're gonna get a lot of questions on Owen hopefully give us a lot of good answers and then we'll hopefully get some good results at the end of the year and be moving in the right direction but we had a the committee and the VA had a good year to get last year we got a lot of squared away that hadn't been had been needed to be addressed for some time we got some lost past y'all waiting for some time said you needed for some time and we wanted we gave them to you and we're gonna look for the results this year and that's what we're gonna be reviewing is making sure we're making progress with results not just promises and and I think we will be able to do that this is an important meeting today this is our annual review of the budget the President's budget came out a few days ago the VA budget is is a significant one and significantly increased we have a unique situation we get more money than anybody in increases every year as a percentage they are you only calculated money is not our problem now I know there's some people this room so yes it is I need this much more I could do this but we've been we've looked out for our vets veterans we know we're paying for benefits they've earned and we know we got a finance man I'm proud the President's budget is up nine point nine point one there are nine point five and two hundred and twenty billion dollars right and that's it that's a huge budget but what I wanted to do this morning in my over March ready just focus a little bit on this year and then how we did came to where we are first thing I want to do is thank the VSOs I changed the way we do this meeting used to they came in with a second panel first panel was the secretary second panel was all the VSOs that took a lot of time it diminished the value of each person's testimony and we've just finished with meetings with all the VSOs almost all with all the BS those over the last five weeks anyway so the important thing I asked to be Essos do was submit their testimony in writing and submit the questions they want specifically to have answered in writing and then we get those and they they submitted some terrific questions and prompted a great thought on my part and other members part is we went over those and review those questions and they'll be sent for answers to the secretary and the secretary I'm going to expect an answer on all of them and I want to thank the VA for the time to be yes those the time we put into it and make sure you know that just because I didn't include you in terms of verbal testimony at this meeting and not because we didn't want to hear from you I want to say that what we heard from you actually got done so I ask you to submit in writing and we'll submit that to the VA and then we'll follow up on it rather than having lost somewhere in the ether system once you've said it here and it's gone wherever it goes the second thing I want to do today is talk about two million we have coming up that I'm insist I promise members I try and keep my promises I've we've done amazingly well on that and it's because we had cooperation by all the community particularly ranking member of boot number one senator Manchin that asked for a discussion on burn pits and toxic exposure excited we're gonna have a meeting on toxic exposure it will come later in the year after we have begun to swallow the blue water Navy my understanding is that the Truman sector will key that the blue water Navy to see leak court decision is not being challenged as that right that would be my recommendation from VA yeah and VA has recommended that which I appreciate it I have I've offered that opinion as well and I think that's what's gonna end up happening and if that happens we're gonna be in the process of the game to swallow a big bite and chew it and dissolve it and get it I'm happy to learn from the secretary that 51 people have already been treated there would have been eligible that that benefit blue board Navy benefit anyways that's correct fifty one thousand three one thousand and I please appreciate a secretary in the VA doing such a good thorough job as far as blue water Navy is concerned in anticipation of what this committee and the other committee in the house did on blue water Navy so hopefully that will continue the other is access standards and the big fella student my right has made it clear to me that access to enters are a big thing within well they're a big thing with me too if you really think about it if the recently published for comment rules and standards for access of community care once those are finished and then in Alaska and in Kansas and in North Dakota South Dakota Georgia and Montana everywhere are more rural veterans in more rural areas how it's working for them to get them the care they need as quickly as we can get a system that works so doctors want to be a part of it a third party administrator working to make sure that they've got a good repertoire of doctors available chosen from to meet the standards it's just terrific so I'm gonna focus on access standards at our next meeting which you have in April the 10th is that right and we want to focus on access standards I want to encourage everybody to be there because if we do one thing this year we can get that working that's the part of choice that was hard that's the part of choice that had the most problems and we can get it working right for the VA and by the veteran and right for us and we're gonna take care of our single biggest problem in terms of operations out there on a daily basis and there's a veteran's benefits so with that said I'll in my opening remark and turn to I guess I should about welcome to the Secretariat I'm a work I'll let you have your opening round they're not welcome Secretary John tester good thank you thank you much mr. chairman I don't want to beat you the punch but I want to welcome secretary Wilkie and dr. Lawrence and dr. stone I think you just did mr. Reggie aus key to the hearing today I look forward to learning from you today and and I want to thank your team and thank you for what you guys do every day the Chairman talked about access standards and access standards will be talked about a lot today we've talked about privatization nobody around this table I don't believe any of you want to see that happen but it's something I'm very concerned about because the big boss talks about it all the time and in the end we need to make sure that as the via the VSO is told us a couple weeks ago during joint House and Veterans Affairs Committee they prefer the carrot that you guys provide that's that's a good thing okay I think that's a very good thing that means you guys are doing some things right okay and we'll talk about a few things you might not be doing so right today and I'll apologize ahead of time but the truth is is that these are folks that have served our country and we need to make sure we live up the promises as you well know mr. secretary the promises we made to them look over the past few years this committees heard from the VA about what it needs to be successful we've engaged with VSOs as we did for the last couple weeks to see what they wanted in their VA and I will tell you this committee listened and we acted leading the way on a number of monumental reforms that quite frankly a lot of people didn't think we could ever get done but we did last Congress on behalf of our nation's veterans this is important part of our job providing you the VA with the tools that you need to do your job equally critically though is your job is deciding how the new authorities and the resources are executing utilized and that is where as I've said already my concern tend to lie in my view the level of commitment from Congress to address health care vacancies and critical infrastructure needs that the VA needs to be matched by the department I've talked about my parochial interest in Montana and I'm going to talk about it again today Fort Harrison by the way if you run back about 15 years it was one of the top VA facilities in the country Fort Harrison today has one primary care physician a part-time doctor who sees a handful of patients I've got see box in Montana as you know mr. secretary with no primary care doctors no advanced primary care clinicians and where that care is only provided through telehealth now I'm going to tell you tell the house a great innovation and it does some great things with folks that have mental health issues but it cannot replace all types of health care so you get the frustration that VA primary focus seems to be expanding eligibility and investments in the community care and I don't want it to be at the expense of capacity building initiatives I'm gonna say that again I don't want our investments of Community Care to be at the expense of capacity building initiatives as you and I have discussed there's certainly a role for the private sector especially in a rural state like Montana I'm sure said senator Sullivan would agree in Alaska and other states too but I think we've got to be careful we don't take the Department down to dangerous paths when it comes to veterans you can outsource the care but you can't outsource the responsibility and when they're sent in the community care without first knowing get that care can be provided in a timely manner and if it's quality care we're gonna pay the price for that later because quite frankly the veterans going to come back and say why so I think we need to hold our VA providers through one set of standards and community cared care providers to that same set of standards after all notice want a flood of veterans going to Community Care if it has lower and less lower quality and less timely and we certainly can't head down a path without a firm grasp on how much it's going to cost the American taxpayer for example we received multiple estimates from the Department on how much it would cost to implement access standards in the month leading up to the budget request none of those estimates match the number that finally appeared in the budget request and as we go forth I'd like you to clarify that if you could why that is so it's not clear how that estimate came about it's also not clear whether the technology you need to implement this program such as a decision support tool will be ready in time from implementation I've been receiving conflicting reports about the readiness of this tool I'm frustrating we continue here about IT solutions that may not be executed properly there's a huge chunk of money in this budget for IT if it's not spent properly if we've wasted taxpayer dollars and we haven't delivered the services or veterans that they've earned as you know the VA has struggled for many years in the field of IT earning a place on the GAO high-risk list this year again I recently had a great meeting with Jim correr but there's no OIT representation from the department here today and so I hope that's not a reflection of how this issue is being prioritized I know the tables short so you have to pick and choose but we have seen how flawed IT rollouts impact veterans and the progress of VA is making on replacing an antiquated system that can't afford to be plagued with short cuts by the way we are here today with the mission program as a direct result of IT failures in Arizona so this is a big thing we need that we need to we need to work you've got a great team around you mr. secretary I've said it before I'll say it again I think you're a great guy I think you're the right guy for this job and I'm glad you're there but we need to find out the details of this budget and as we move forward I certainly do not want to see VA care dollars transferred to Community Care because we ran out of money in the community care budget so with that I would just say thank you all for being here Thank You mr. chair with the opportunity to visit to speak and I look forward to this hearing Thank You senator tester for everybody's benefit here I think I heard without exception at our hearings of the VSO is we ain't gonna privatize said a hundred times I didn't have a single person to write me call me trip me up throw me down the steps or anything else willing to privatize the VA and I have no interested in doing so well let's just put that sign behind the bathroom door out of the front door let's talk about making the VA the best VA we can make it and be what our veterans want it to be which John's right they like it their VA and that's why they call it my VA they just won't be a little bit better than us we want to make a little bit better at better in its accountability and better its results and that's what we'll be talking about with that said talking about better we have the best guy you could ever have in terms of Secretary of the VA Robert Wilkie's I did not know Mr Wilkie until he was appointed I guess that's the first time we met I learned quite quickly he's got a good bedside manner he's really easy to talk to he just resonant voice he's very easygoing know some great jokes they're all clean he's just a terrific guy all the way around but the good thing about it is he doesn't he doesn't just have a good personality and a good demeanor he likes to get the job done and he talks in measures that are accountable hold that hold himself count accountable and I appreciate that and I think with his type of persona we already are seeing improvements in results with the VA we got a long way to go they do a lot of things well and we're proud of those things we want to do the things we don't do well better and take some of our problems we've been hanging on with us for a long time and do and get those problem solved and I think Robert whew he's the man to do it and I'm really pleased to work with him in John tester and the there's my committee and Senate two-seater we finished the job and we'll never finish the job but continue the job of improving the Veterans Administration for the benefit our vets well that's it I could go over your military background your fact that you're a good southern boy and all those good things Robert but instead I'll just say we have a great Secretary of the Veterans Administration I'm proud to work with Robert Wilkie appreciate what he does and I'm proud to introduce him for as much time as he might consume except remind him that how much he does consummate consider how much we enjoy what he has to say so don't take too much of it well introduce your other yes sir well thank first of all thank you for the courtesy and thank you for the kindness that you've you've shown me I'm gonna take a point of personal privilege and and thank you and Senator tester for all the support that you've given me as you know I came to this having been the Undersecretary of defense for personnel and readiness I've was raised in the in the military world my service compared to my ancestors is incredibly modest but it is service nonetheless and I have been privileged to see the military life from from many angles so there is no higher honor than to be sitting here before you I'm pleased to have with me and I'll start on the left side John Witkowski who is our budget guru our assistant secretary for management and our chief financial officer on the dr. Richard stone who is our executive in charge of VHA and our most recent Award winner who has just received an award for being the government government's best senior executive and that is dr. Paul Lawrence our undersecretary for benefits and I thank them for coming when I last reported to this committee mr. chairman in December I said that the state of VA is better I believe from the statements that you've made and from the statement senator testers made that you believe that as well I count that to the support of this committee earlier this morning I address that the house doctors caucus and I said the changes made were not driven by the executive branch the changes made in the VA came from the two authorizing committees I argue that it is the most transformative period in the history of this department going all the way back to Omar Bradley's day and I don't believe that we are any longer on the cusp of transformation we are actually in the middle of it but but before I talk about that I do want to talk about the trajectory that VA is on in the last month we've had last few months we've had some excellent news in most of my career in and out of government VA has always been rated 16 of 17 or 17 out of 17 in terms of the best places in government to work well the partnership for public service for the first time said we're no longer there we're in the top third and we're actually moving in a higher direction so if we have customer service amongst ourselves we will provide good customer service to those that we are honored to serve the annals of internal medicine said as senator tester implied that the medical care that VA gives is good or better than any medical care in any region to the country we're proud of that and last the Journal of the American Medical Association said that our wait times and the four most important categories of medical care or as good or better than any in the private sector that is an indication as to where we are headed in our department the major driver of transformation is the omission act as you know it simplifies and consolidates VA 7 community care programs into a single streamlined simple to use program it extends the choice program expands the caregiver program and provides a new Urgent Care benefit as well as other access improvements regulations setting new access standards ensuring greater choice for veterans will be completed in June we have proposed a 30 minute average drive time standard for primary care and mental health and a 60 minute average drive time standard for specialty care we have also proposed an appointment wait time standards of 20 days for primary care and mental health care and 28 days for specialty care from the date of request with certain exceptions and I I want to also begin to address the privatization argument obviously I come from the conservative Republican side of the aisle the issue that that has been raised many times about privatization is just not borne out by our budget by the directions of this committee and I am here to say as Senator tester said that the care in the private sector nine times out of ten is probably not as good as care and VA give you an example one of your colleagues gave an interview in a in one of his state's newspapers saying that he was disappointed in the the wait times for certain services at VA in one of his major metropolitan areas the wait time was 12 days for VA in the major metropolitan area it was 78 days so that also is an indication that we are moving in the direction that you have pointed to appointed for us and the direction that veterans deserve things are not always greener on the other side of the hill at the same time we are trying to move out in making VA a modern 21st century health care administration no longer will we have an ad hoc supply chain we are tying in with the Department of Defense and their computerized systems for medical supplies the days where VA doctors at the DC VA have to run across the parking lot to MedStar to find equipment have to be over if we are going to continue the road of improvement the other part of our major transformation is the electronic health record where we tie in with the DoD DoD the minute that young American walks into the military entrance processing station so that we have a complete picture of that health the Chairman mentioned burn pits for the first time when this is online VA doctors will be able to see everything that had happened in that soldier's life from exposures to too toxic so Versys from exposures to toxins in the continental United States and we will then know better how to serve that veteran I have been asked to lead the national suicide prevention task force that is one of three areas that VA is moving out on in response to this committee for Senator Manchin it's the opioid epidemic and how we begin to change the way we treat our veterans when it comes to the use of opioids homelessness is another area and then finally suicide prevention in the last year we have hired over 3900 mental health professionals we now provide same-day mental health service for veterans in need as part of the continued transformation we are also engaging in the creation of a modern HR system right now there are 140 HR offices across VA we are consolidating those down to 18 and for the first time bringing in HR professionals to create a modern modern human resource capability that will send doctors nurses and health care professionals to those parts of the country's country where they are most needed as for the budget the Chairman is Right 220 billion dollar budget that's a nine point five percent increase over what VA had last year that's ninety seven billion dollars in discretionary spending a 1 123 point two billion dollars in mandatory spending and funding for 393 full-time employees which is an increase in 13,000 for those working at VA that means that for the mission Act 19% of the funding will go to community care but 81 percent for VA care 1.6 billion to the electronic health record 184 million for a modern integrated financial acquisition management system and 36 million for us to continue to adopt the defense medical logistics standards support system 8.1 million to continue the improvement in customer service the prime directive for those in VA 547 million for women's health and 1.6 billion dollar dollars for capital investment the last item on my list is to continue my pledge to you that we be an open department we are joined at the hip with this committee and with the Committees of the House of Representatives we all have the same mission in mind and again I thank you for your your courtesy thank you for allowing me the honor of serving in this capacity and I look forward to your questions thank you much very much mr. secretary we appreciate it I appreciate your acknowledgment of what I had said earlier about the amount of money we were talking about we're not here complaining about we have to spend it on work looking for answers to spend it better and see our veterans get better services and we work out there all along but we've got a good budget to work with we're not begging for more we're looking for results and which brings me my first question that I'll ask the private sector today in health care the whole answer to most the quote whatever the question is the answer is outcomes their meds trying to measure outcomes for everything from reimbursement to being in networks to anything else are you when you refer to the improvements that you've referred to how do you measure your outcomes in the VAD you take them from the senior person in charge or you take them from evaluations or you take them randomly how do you gauge your outcomes for the services you provide drive veterans a combination mr. chairman I really look to the veterans first I have been very aggressive in the eight months that I've been in this chair and reaching out to veterans in terms of surveys in terms of of interviews what I have seen is that our customer satisfaction rates are are moving in an upward direction where we have I think an 89 percent customer satisfaction rate amongst veterans in terms of other metrics opioids is the outstanding example how are we changing the way that we approach this national tragedy and we change we approach it in changing the way that we treat our veterans by providing things that would have been an asset but somebody like my father 30 or 40 years ago with alternative medicines Tai Chi acupuncture yoga we are on the cutting edge both of alternative treatments to our veterans we are on the cutting edge of telehealth as Senator tester said and we are on the cutting edge in terms of tackling the national epidemic of suicide and homelessness so the answer is it's a combination of things but for me the most important is listening to what our veterans say on that answer let me say this in your in the budget recommendations you have includes funding for a retiring to IT systems that currently exist within the VA you and I've talked about this before but it seems like say the VA is a place where you collect software and systems and where people have bought things over the years they've piled up they don't talk to each other they don't work together and we're not getting good bang for our buck you obviously are trying to clean that up and I would like for you to talk about those two recommendations in terms of retiring those programs and the overall picture in terms of VA is IT system getting accrued getting better well I told you eight months ago that the overall condition of EA's IT system was bad as a result of that this committee is looking at as senator tester said a massive increase in our budget 4.2 billion dollars I believe but that money in the past has been spent on redundant systems going down the same road that led to the failure in the forever GI Bill as well as other systems so what we are doing and you I believe will have the CIO up here for testimony in the next few weeks is we are beginning to migrate our legacy systems out and bring the VA in line with the rest of America through the through the cloud we now have 8,000 employees who are dedicated simply to that transition we will ask for a bit of patience on some of these but the migration to the cloud is the wave of the future and it is the way that we will maintain I think the trajectory that VA has has undergone in terms of its overall customer service but you are absolutely right the reason the forever GI Bill crashed and burned and that the directions from this committee were placed on a 40 year old IT system it was bound to fail which is one of the reasons why I stopped us going down that same old road and and pivoted just so we can make sure that our veterans got their checks well let me say one thing I'm not gonna ask another question but I'll make a statement I'll make an admission to the state of Georgia brought me in when they lost their super dean of schools in the middle of a election cycle to take over the Board of Education in Georgia and the Department of Education going through y2k now I had a pretty good company in terms of being with technology and stuff like that I've learned that you buy read you buy every trick in the book when the salespeople come in and start talking to you they got an advantage they know what their doormat you don't know and you don't understand if you're as old as I am you don't really understand digits and clouds and all the other piles I want to find that damn cloud on these days – I want to see where that thing is if I always says it's the solution well I think it may be the problem I just can't find it anywhere but anyway my point is this so many times when we go clean up a system of technology information we had a buying more stuff to clean up the mess and we have a beer messes when it's over than we had before and we haven't solved the main problem which is the workability and the interoperability of the IT systems we had so let me just encourage you to make sure we got the right people who know what they're talking about making the decisions or the recommendations to unit in the final decision good understand technology of what it can and cannot do and don't buy every bid and promise that comes through the front door because that gets expensive and can cause you lots of problems and if we've got such a the VA is so big the number employees are so large the budget is so big you're talking about any little problem in the VA is a big cost particularly if it's the IT system so I encourage you to what you're doing I appreciate what you're doing on that mr. just around sorry Thank You mr. chairman and secretary thank you for being here and I don't I have a medicine a veteran yet in my state and you know we have a high percentage of veterans who want the VA to be privatized and I haven't heard that from any of y'all and I don't think you do either but here's the the troubling thing that we have your request is 44 percent decrease in funding levels for construction programs that was in the budget that you that you all submitted I know that we are investing heavily in Community Care we're leaving our current B facilities let me give you a few examples and our in rural states such as mine in West Virginia our rural mobile unit in Clarksburg is totally inoperable totally inoperable our via our medical centers haven't had any update and gree crease or increase in residential rehab centers since the 50s and 60s most of our facilities require basic maintenance deferred maintenance as we call for roofs uu HVAC all the above I'm worried that even though our intent and the verbal agreement that we have that we don't want to privatize because of starving some of the things people are going to say well I'd rather not go to that because it doesn't have proper services they don't have updated equipment and it leads me right into another question is is that there are over 40,000 vacancies at any time in any moment in the VA this morning there were 130 positions posted on USAJOBS in my state 138 I've got pulmonologist cardiologists in Huntington psychology and beckley practitioners in Martinsburg we're hurting all over the board so even though the intent might not be there it looks like the signs we're moving in that direction because of demand from our veterans if our veterans aren't getting the care they're going to say I just need better care I'm not getting it and the facility is not worth even going to because it's not in good enough shape so you can see the concern mr. secretary of what we have and what we have to answer to they're still totally overwhelmingly supportive of the VA well let me let me take your comments and seriatim first I would be lying to you if I told you that we are anywhere near turning the corner on capital investment my estimate is that we need sixty billion dollars over the next five years to come up to speed that is an incredible number but let me tell you what else we're dealing with more than half of the buildings that I'm responsible for age and ranged from over 50 years to a hundred years but this committee has provided the way forward we are now engaged and I believe it was senator Moran's idea with market assessments of our national infrastructure and our human resource needs that will then inform when they are done what this committee told us to create and that is the asset Infrastructure Review Commission to bring our facilities up to speed where the veterans are again this is a monumental problem my first job is to do as much as I can to ensure that the basic health needs of the veterans are taken care of and unfortunately their cost-benefit analyses that have to be made and I can't come to you and say give me 60 billion dollars to repair all of those facilities as for the human resource side you're absolutely right but let me tell you where we have been and where we are headed my first week in office I had two senior leaders give me two different numbers as to how many employees we had now that's outrageous and I asked a military question where's your Manning document a Manning document in the military is one where you have your requirements and you have the people to match them we never had one so finally we now have a modern HR team HR team in place that has come on in the last few months at my direction I've consolidated in the process of consolidating a hundred and forty individual HR offices into 18 so that we have an even distribution of resources across the enterprise we have asked for the resources to hire 13,000 people as senator tester knows my emphasis as the head of VA has been for rural America rural America and Native America those two sections of the country that provide the highest per capita number of men and women in uniform and for the native populations the the population that provides the highest number of holders of the metal medals of Honor and combat decorations so it is a complex problem as I said I would be lying to you if I think we're anywhere near turning the corner but I understand it let me just say and I'm saying my times that but I just want to make this comment I I speak to veterans all over my state and anywhere I can and I tell them I said I do not believe that we intend to build brand-new VA facilities but they say can't you at least take care of what we have that's the biggest concern they might have and I would hope that you all would understand that they are scared to death that they're being set up that this thing is going to go private because a demand will switch the man will switch if the facilities are not adequate enough to give them the service they need so mr. chairman let me say ask your indulgence one that means we have to be much more creative and Senator Tillis is here and he has one of the fastest growing veterans population in the country in Fayetteville my hometown which sits underneath Fort Bragg two massive VA facilities the new one is leased the VA center director doesn't have to worry about HVAC doesn't have to worry about the lawn concentrates on taking care of veterans we have to be more creative in terms of two things one how we manage our infrastructure which mission Act tells us to do better and to giving more incentives and I want to come to this committee and talk about it I have some since something like a Veterans Peace Corps to get medical professionals out into areas like rural West Virginia Western North Carolina and and provide the means to serve those veterans in communities that are hard to reach yet provide the highest percentage of service of anyone in the country thank you sorry mr. I use it I mentioned senator Cramer Thank You mr. chairman and thank you mr. secretary for for being here thank you for a previous discussion and into all of those are with you I'll ask my question specifically to you and you can defer them to others if it's more appropriate but you mentioned you've talked a fair bit in your testimony about alternatives to pain management I'll turn to certainly 200 people to opioids and you talked about some things like acupuncture and other types of care but you didn't mention hyperbaric oxygen treatment chamber treatment and particularly for pain we've found it to be quite effective I think in other types of treatments particularly post-traumatic stress brain injuries things common to veterans and athletes and others but just wonder why and what do you think the potential is for for that well it certainly wasn't for lack of appreciation of the of the treatment and I pledge to you that I will be out in in Fargo to look at the headquarters of one of America's largest hyperbaric chambers no we have to be more creative particularly as as treatments become more complex for more complex injuries particularly the injuries of the brain I think we're not we're not even at the Sputnik stage when it comes to exploring the brain and how it responds to trauma how it recovers and dr. stone is probably the better expert when it comes to the actual medical conditions that that treatment addresses certainly as a practitioner who spent much of my career doing wound management the hyperbaric oxygen is something we've worked with for a long time but using hyperbaric oxygen to actually heal the brain or to do some of the work that you've been discussing is work that's been studied for at least a decade in both the DoD as well as in VA what we know is that hyperbaric oxygen has a chambers have a dramatic effect in improvement of of individuals with both PTSD as well as brain injuries what we don't understand is what the addition of oxygen to the presence in that chamber does and so there's been multiple studies done by all three uniformed services as well as by the VA demonstrating that and we look forward to further research on it brain rest remains one of the mainstays at this time and certainly going into a chamber where there are silence has as great value whether the addition of oxygen under pressure remains in debate that would be interesting to see carried out because my understanding is that you know the presence of more oxygen could have the alternative impact because of course it's stimulated I would guess senator I agree with you and as a practitioner who's done wound management in the presence of yeah trying to penetrate oxygen into wounds that's exactly correct well we'd love to help you with that experimentation in Fargo but we can talk further about that later the other thing I wanted to mention cuz you've mentioned it both in your testimony and then your answer to Senator Manchin you talked about 13,000 more people and we're in the people business you're you it requires practitioners to do the work that you do and they do it very well and by the way they do it really well in Fargo we're very pleased and proud of the service they provided our veterans but it's getting harder to find good people and to attract them to keep them and particularly in an economy like North Dakota has is you're aware it's even it's even really elevated there the challenges is amplified I think in a in an economy and in a region like ours by like other world world states that said can you can you elaborate a little bit on specific programs whether it's loan repayment so what are some of the tools that you have available or that we could you know help you with to attract and maintain and keep good people well I will say the chairman and the ranking member inserted into the mission Act that really the first monumental step in addressing the needs of rural veterans by giving us the authority extra authorities on relocation pay reimbursement the the ability to pay off medical school loans up to two hundred thousand dollars those are absolutely needed my goal though is to try to even to try to create even a more robust relationship with our universities and also with the Armed Services General Bradley's goal was to have at least half of the doctors and nurses coming off of active duty coming into VA general Madison I spoke a great deal about that we are now telling doctors that when they decide to leave active service come to VA to continue your your service to those who have worn the uniform I want to go back to the future on that but this committee has given us a start particularly when it comes to rural America Thank You Denver for all those games it must work something to him he's pretty good quarterback I just heard that I don't know that's true or not sound good mr. Moran thanks mr. chairman I hesitate to interrupt senator Moran but I will thanks mr. chairman Thank You senator Moran Thank You secretary Wilkie and your team for being here today I want to congratulate and thank you on your announced decision that you would not be appealing the ruling of the court in the Bluewater Navy okay well I think your recommendation will be key it is instrumental I would perhaps with all due respect mr. chairman express on my behalf and I hope on behalf of the Committee on Veterans Affairs that that recommendation be adopted and endorsed heartily to bring fairness and justice to our blue water Navy veterans it would culminate a crusade that has been bipartisan involving almost everyone on this committee it's been a team effort and I'm grateful to you for making that recommendation I also want to submit for your consideration the Agent Orange exposure Fairness Act which would extend the basic principles of that Court decision and suggest also that there are other toxic chemicals and poisons on today's battlefield that are worth the research and attention that the VA should give them in deciding what kinds of benefits and disability compensation our veterans deserve the potential for poisons on the battlefield is one of the great challenges of our time one of the areas of unknown consequences who are heroes in uniform and as the father of two veterans who have fought in recent Wars and a friend of many I hope that we can carry forward the spirit of that court decision and of your support for it I want to move to the Veterans Affairs health care system most especially in particular the VA facility in West Haven I think you are familiar with my letters to you on this topic I understand that sterilization processes there essentially have them installed so that the operating facilities are at one-third of capacity to put it very bluntly 2/3 of the veterans who need surgery at the West Haven facility are either sent elsewhere or their surgeries are alert delayed or possibly denied and that is because the sterilization capacity is limited the surgical facilities were closed for about three months because of flooding their back open now but the tools and equipment used in those surgeries cannot be properly sterilized a mobile trailer is planned for a year from now that's way too long a permanent facility five years from now much too long I'd like to know what the plans are mr. secretary for expediting the availability of that surgical capacity in other words the sterilization process facilitating I know how important West Haven is and dr. stone is supervising that I do want to step back though and I agree with you and some of your earlier statements about the burn pits we don't want to go through what we went through with Agent Orange I certainly saw that and my family work for Senator Tillis on the burn pit registry legislation that he and senator Klobuchar introduced and had passed a few years ago so it's important to me and I'll let dr. stone talk about West Haven Thank You senator we appreciate your role and your activism and in this in the recovery of West Haven clearly this goes back to the fact that this is an older facility we've got a steam line running underneath the sterilization area and as we've worked to recover that facility let me reassure you that the surgery being performed in that facility today is safe and sterilization is a safe process I don't doubt that it's safe and I want to emphasize that the docs physicians staff are doing their best they have one top and tied behind their back in no way are they compromising the safety or effectiveness of the surgeries they do they're to be commended but I think the VA here is failing them by failing to expedite the sterilization processes which limits their capacity so my understanding is that the mobile trailers that will bring the ionized water and the sterilization materials in will be installed by June of this year and that the major holdup was because of utility issues on that that area as well as the building of the trailer the actual funding of a new sterilization facility will take three to five years that said my expectation is that as soon as that mobile unit is installed this June we will begin to recover the surgery that needs to be done at that facility will it go to a hundred percent that's my intention absolutely can you make that commitment I have absolutely thank you I'll make it Thank You mr. secretary and I'd like to continue our conversation my time is expired I thank the chairman about the possibility of expediting a more permanent facility but I appreciate your commitment today Sherman thank you thank you and Senator tester for conducting this hearing mr. secretary thank you for being here I joined both the ranking member and the chairman and expressing my gratitude for your continued service to those in uniform and I appreciate the job that you're doing at the Department of Veterans Affairs I'll have a chance in senator Bozeman's appropriations subcommittee here in a few days to have more conversations about the spending and the budget recommendations I have a couple of things that I think are timely that I want to ask you today while I have this chance first of all I'd like to highlight for you in 2014 we authored legislation we're now working with Senator Brown of Ohio and furthering this legislation but the National Academy of Medicine was required to do a toxic exposure analysis to determine if there's any medical and scientific evidence related to or whether there needs to be further study on this topic of the relationship between affliction problems now challenges that following generations of the the serviceman or woman now face as a result of that toxic exposure and we look forward to continuing to find the answer to that question there may be a whole nother generation I'm it saddens me because I can't imagine anyone serve their country thinking they may harm their children or their grandchildren by their service but that very well may be the case and we're working to get the medical and scientific evidence to demonstrate that I also want to highlight a piece of legislation that Senator tester led and I joined him in introducing related to mental health and suicide prevention and I look forward to getting input from all my colleagues with with Senator testers leadership on that stuff that's the that's the reserve and guard she's actually there's two of them that's that is one of them and in addition to that the commander john scott hammond Hannon veterans medic mental health and suicide prevention act John Scott Hennen being a veteran who lived in the state of Montana for my two questions on the timeliness of this hearing staff of this the House committee and the staff of our individual senators on the committees met with your staff in regard to the veterans hearing aid access and assistance Act for as poorly as senator tester cannot get along this is another one that he and I sponsored it was passed into law in December of 2016 and the takeaway from that meeting well first of all I should indicate that that that legislation in 2016 the law mandates that the Department of Veterans Affairs determine criteria for her hearing aid specialists then with the goal of integrating them into the care of veterans that the VA serves but the unfortunate circumstance is that since 2016 we can find no evidence of the VA taking any steps to implement that mandate and the meetings that I think I would describe the takeaway as little interest in in meeting that mandate and I highlight and the reason it's timely is that we asked for a response from VA officials by today's hearing knowing that you would be here and we've received none to date perhaps dr. stone he appears to be interested in talking about this conversation senator thank you I appreciate it and I was unaware or the letter if if we have not responded you have my apologies we will correct that today I had intended to send a letter we didn't send a letter it was a conversation with officials at the VA saying okay but the secretary is going to be here on Tuesday could you please get back to us by then otherwise we need to raise this topic with the secretary you happen to be looking at a hearing compromised veteran from my combat service so I'm deeply appreciative of what the VA is brought to me and my family as we've sought care for by hearing loss due to combat so I'm well aware of the issues that you bring up and let me say to you that we last year performed over a million visits for hearing compromised veterans with our audiologists and our technicians we have continued to grow that we refer out about 38,000 visits a year and we appreciate the legislation on hearing aid specialists but the question is do we need to move into the specialist area clearly you and I may have a different understanding of the role of the specialist today I have enough audiologists and and enough technicians in order to provide that vast vast majority of the care that's needed including less than a 10-day waiting period in order for veterans to come in for care or for their appliances in addition we have an under two-week waiting period in order to take outside prescriptions and fill them on behalf of the veterans let me suggest this dr. stone that may be with Senator tester a nice staff we could have this conversation in the z-row seconds I have less mr. secretary I'm in Emporia Kansas on Saturday four days from now Emporia has a CBOC thus EVOC has two days of service rarely has a physician has a mid-level practitioner the the department the eastern division in Kansas has announced the closure of that CBOC one would expect me to be angry about the closure of that CBOC I am hopeful that with the closure of the CBOC and conversations with the VA that the mission act now provides additional opportunities for care for veterans because we go from a two-day CBOC with virtually with with often no physician and one mid-level to an opportunity for a multitude of community resources being available to those veterans in that area I'm gonna meet with your your folks in Kansas or joining me in Emporia on Saturday what message would you like for me to deliver about the opportunities that mission or the VA now can provide mission act is about veteran centric care it's not about protecting the institution or guarding the status quo it is about giving that veteran the option to be the guardian of his own or her own future and for rural America offering the widest aperture possible on access to medical care is is meeting the attention of this committee and as long as we keep the veterans health at the center of everything that we do then the system will work I will convey that to those veterans who join me on Saturday its chairman thank you in keeping with our bipartisan committee commitment I'm gonna excuse myself just a minute turned over to Senator tester to continue here and it's also his turn to ask questions so I'll be back in just a second Senate twice Despero Thank You mr. chairman I assume that means I can just expand the time that I used it means you have to say oh I have to thank you all for being here once again I hesitate to talk history with somebody who probably knows history far better than I do especially military history but nonetheless this is pretty Elementary in the 1930s this country did not want to go to war President Roosevelt turned our car factories into airplane manufacturing and prepared for war and then came the bombing of Pearl Harbor and we were ready for war pretty simple pretty ingenious everybody on this committee I believe has said no privatization and all the vyas those who said no privatization the president has said something different you have said no privatization and your staff has also said that but as the questions are asked here today and I've talked about our vacancies in Montana Manchin talked about his vacancies his facilities that needed improved improvement Blumenthal talked about West Haven that was one-third capacity even senator Moran even though he's not mad about it is talking about a sea balk that's going to be closed because of lack of staffing everything that I'm hearing and everything I'm seeing says something different and then I look at the budget and the budget and you had said earlier that you needed sixty billion dollars in capital investments and the budget request for major and minor construction wasn't decreased by forty three percent for major construction and fifty percent for minor construction and and we're talking about the needs that are out there by the way we can go down the list in Montana it's pretty pretty reflective and I was at the meeting six days ago and you guys said you can't get the money out the door but nonetheless you talked about 60 billion dollars in capital expenditures and we're reducing those accounts by 40 and 50% putting all that together how how how can we justify that so senator tester I could probably shed some light on that first let me say is a department CFO I feel dirty not asking for more money to be honest but well I'm not asking for more money I don't care if you ask for my money but if you got sixty billion dollars in needs over the next five years and we're reducing those same accounts that will meet those capital expenditures something doesn't jive that's all so let me explain and so I was that was being a little bit facetious the fact of the matter is we do have a requirement there's no question we have older facilities and we have a substantial facility requirement as you know we had a substantial plus up in eighteen and nineteen the fact of the matter is that we sort of very quickly executed our shovel-ready projects and they are in the works and we are at a point now when you sort of divide the amount of money we have in the works by the number of facilities we have about 19 to 20 projects per facility going and they have limited capacity and in a lot of areas of moving clinics around moving people around and we're now hearing from a number of facilities they have actually some shovel-ready projects they just can't execute because it's too disruptive we're going to end up carrying some of that money forward from 19 into 20 we're going to carry about a billion dollars of the plus up in NRM we're also going to carry some minor construction money forward so so I'm gonna do some quick math for you that you don't know this already you divide 60 by five it's 12 billion dollars a year and and if that need is out there and we can't execute the amount of money we've got so far how do we not privatize the VA well we don't privatize the VA because we still have the largest healthcare system in the country hundred and seventy hospitals and our veterans are voting with their feet let me let me just say this is not a libertarian VA if it were I would be giving myself a card that says veteran and I go out in the private sector and get anything I want that's not that is not happening and again I fall back not on anecdote but on the stats our veterans are happy they're going where people speak their language and their culture I support that and and this committee supports mr. secretary and I agree with you but I go back to the example of history if if we're short on manpower if our facilities are short and substandard if we're not making the HVAC additions that we need to do eventually those veterans are going to the VA are gonna say nope not anymore well I you gave me this committee gave me the answer and that is the market assessments yes and then the asset infrastructure review committee which does exactly what you says said and I think I'm going to come to you and ask to accelerate the beginning of that commission of their act yes so that it moves more rapidly than the timeline that this committee has given it and really quick just and I don't have a problem with that can you give me an idea and how quick here because it's set to go into effect 2021 or 2022 okay and and I would like to do that earlier because our market assessments are already underway I would love to visit with you about that moving forward okay thank you very much and we do appreciate you and Senator Isakson we can be very proud that the 2019 Appropriations because of your twos leadership and the committee was significantly increased and I think again we're going to see that going into the next fiscal year so we appreciate your leadership secretary Wilkie in your team especially in grappling with the forever GI Bill and getting that under control I know that was a hard thing to do also your work with the veteran suicide I think that we're coming up with a method now that is going to have significant results so we really do appreciate that appreciate that in your leadership style again with your team one thing I'd like to understand I was in Arkansas last week in a lot of our smaller communities and that will be impacted by the mission act and I guess what I'd like to understand is that there's a little bit confusion as to what's going to happen in June so we'll have the rules and regulations in place going forward for the veteran in Mountain Home Arkansas as meet all these ineligible for a choice because of the nearby location of the CBOC even though it doesn't provide the medical servicing needs what what's going to happen to him in June if anything will he be able to talk to the end June 6 to get authorized for care from a private hospital or what what's the what's the process the process is that the veteran will continue to talk to his provider or his scheduler in order to really authorize care and make the best decision on behalf of the veteran it frankly June 6 should almost be a non-event for the veteran today we authorize well today we will do over three hundred thousand visits in our direct care system we will authorize about 50,000 visits in the community care system that is all done on a manual basis by our providers and schedulers On June 6th it is our hope to have something called a decision support tool that will automate that process should we fail with the decision support tool it will look just exactly like it does today now there will be an enhanced number of veterans are eligible to make a decision of whether they want to go out to they for care or not but the system will look very similar to what it does today as far as a veteran sitting in front of a provider or a scheduler or on the phone making a decision on whether they stay or they go out for care so for those that are eligible on June 6 for theoretically for enhanced care in the sense that you know that they're gonna fall into the new parameters if they call will they be told do this and this or will they be said well because we're phasing this in callback or senator this will will be they will be told what they need to do for care there should be no increase in wait times there should be no increase in wait for care now our problem is and in most areas of America the commercial healthcare system is not as responsive as we are please remember of those 300,000 visits were going to conduct today over 22% are same day visits so the in the commercial space it is not as responsive as the Secretary has said previously in an urban area in the southeast it was found that the wait time for the commercial space was dramatically higher than ours I'd like to talk and again mine mine was more in context of the travel time versus the wait time but but we'll talk about that the veteran says the collaboration with these groups that seemed to be doing a good job the secretary and I were in a meeting earlier this morning and one of the congressmen talked about a program that they'd had a 70% reduction side as a result of can you talk about the efforts of the collaboration so that we can get these public-private partnerships going that seemed to seem to work well again we need to make sure the metrics are there and all of those things yes sir so the the budget calls for 222 million for suicide prevention programs I have just been named as the chair of the National Task Force on suicide prevention you know that the terrible statistics 20 veterans a day take their lives 14 of those are outside of our VA I think the most important part of the task force other than a whole health approach to suicide prevention is the opening of the window for monies to flow into the states and localities to help us find those veterans example I was in Alaska with Senator Sullivan more than half of the veterans in Alaska are not in the VA system I asked the Alaska Federation of natives to double the number of VA tribal representatives that they have to go out into the hinterland of Alaska and help us find those veterans who not in their system it sounds simple sometimes simple solutions are the better solutions the states and localities know better than we do in many of these instances where where veterans are and where they are in need a couple of things I'm not going to give you a metric saying that we're going to achieve zero suicides the majority of veterans who take their own lives have our vietnam-era my father's generation some of these Americans have problems that began building when Lyndon Johnson was president we're not going to be able to cure all of that but we can and and the chair chair will indulge me as the former Undersecretary of defense for personnel general mattis and I both began a system of education throughout and into vigils military career that focused on mental health wellness and and taught a soldier sailor Airman marine z' to look for the signs of danger so that for the first time in our military history we actually have people coming out of the service who at least have had some educational grounding throughout their term of service in what to look for when to ask for help not only for themselves but for others so the deepening of the relationship between VA and DOD is absolutely essential so we never again have those numbers that we have now that began to build in Southeast Asia fifty years ago thank you Thank You mr. chairman mr. secretary thank you for recommending that the blue water decision not be appealed at this point appealing that decision is not what we should be using our resources for so use your persuasive powers to make sure that that happens there was an article recently oh by the way I understand that the Chairman is going to have a hearing later on the your proposed access standards that's good because a lot of us have expressed concerns about how those standards were developed and the fact that we heard from many VSOs that they were not consulted during that process so that will be happening in April I understand a few weeks ago mr. secretary the New York Times published a story with the heading quote a quote treated like a piece of meat and female veterans into your Harris Minh at the VA have you read that article so it paints a pretty dire picture of the kind of experiences and harassment that the women veterans to go to the VA sandor so what is the what we are going to do to make sure women veterans are respected by the VA staff and other patients I realize that there needs to be some kind of a cultural change but I don't know posting sighs whatever you need to do so that this is not the horrendous experience where the women veterans as described in this article and I want to know whether the VA is conducting any research into the best practices or models of care that increase rim of veterans utilization of the satisfaction of VA services and your testimony you mentions that 91 percent VA is community based outpatient clinics have a women's health primary care provider and when can we expect that number to be a hundred percent because you're almost there well that's certainly the goal and in our Center in our previous relationship from my former capacity as the Undersecretary of Defense you and I discussed that the first thing that I had to do is the Under Secretary was promulgate the first DoD regulations on sexual harassment and equal opportunity which we did so that tells you my commitment you hit on it it's a cultural change I don't believe that what was in the New York Times story is apparent in all of our VA facilities I'm not going to be able to tell you with a straight face that I can change the attitudes of every person who works in VA but we are changing the culture we're putting in women's health centers in all of our VA hospitals one of my goals is to make sure that there is an actual privacy barrier separate entrances that in the case of this New York Times story those things will probably less likely occur just by changing the way we bring our women veterans into the system I can say that we now we had 500,000 appointments last year for women's veterans that is a sea change I will also say that the culture that you talked about is now beginning to change within DoD I think the longer that that goes on the less likely you will see an end product such as you described in VA but I think we are we're on the right path one would think that when you make those cultural changes that you may not need to expend resources on separate facilities but obviously that is something that the women veterans are very clearly want at this point I want to get to the the lack of progress that I've heard on various VA healthcare projects for example they're vastly word outpatient healthcare access the aloha project in Hawaii on Oahu was scheduled for a lease award early calendar year 2018 2018 but has been delayed a number of times and at least has still not been awarded and the project was scheduled to be completed originally by fiscal year 2020 and I know that these kinds of outpatient clinics are really helpful because they're usually closer to where the veterans live and in Hawaii the the Tripler Hospital is very crowded and you can hardly get any parking and it's a pain and the Equality as we say in Hawaii so you know can you commit to seeing that the law project is completed on time with no further additional delays senator as you know I spent a great deal of time in Hawaii last year I talked with the governor about this lease I will get you more information my understanding was that they were contractual problems with those responsible for for improving the facility that was when I discussed back in December in Honolulu but I will I will get you more information now thank you because I'd like to see this in other sea walks come through Thank You mr. chairman Thank You senator Ono Senate vibrant Thank You mr. chairman and I want to thank you all for for being here in secretary will Kia thank you for the time you've spent with me prior to this to talk about the needs that some of our veterans in in Tennessee have and to look at how we fulfill that promise of providing for them and for their health care health care I want to start with the EHRs and your deployment the modern is a you were doing there is we've talked many of our folks would like very much to be able to under the Mission Act seek that care at home because they are a good distance away from a facility and as we've talked before interoperability is an imperative in making this work and I want to know where you are what control measures you have that have been implemented to ensure that you are going to meet your milestones as you go through this deployment as that begins to take place senator we will go live in March of next year you know in the Pacific Northwest to reach our initial operating sites that is unscheduled there are issues that we need to work our way through these are old facilities we need to rebuild our communication closets and that's going to go on this summer we also need to work our way through all of the internet of medical devices and make sure that they are ok let me ask you this as you were doing that are you working on a plan so that when someone enlists day one they began a cloud-based encrypted record that will follow them the rest of their life yes that that is the goal I used my father's I use my father as an example the days of somebody carrying around an 800 page paper record right but I think it would be instructive and helpful to us if you could provide us with your timeline of when you're going to achieve this now in help committee today they are doing a hearing on the EHRs and we know that whatever you do that you have to have a strategy so that this is going to be interoperable with commercial best practices and do you have that in place yes we do and obviously you mentioned the goal is to begin building that record the minute that young American walks into a military entrance processing station and then there is a handoff I expect and I don't know when there will be new changes in leadership at the Department of Defense that I will continue the relationship that I had with general mattis I expect to come to this committee with the announcement of a joint program office which will be the first I believe the first joint program office between two departments so that we combine the resources of both departments to build this record it will be interoperable I didn't I would have never approved it if it could not be interoperable with the private sector okay telehealth I was recently in Gallatin Tennessee to open a veteran's clinic there and it's one of the whole of life clinics and the day after that was over at the Nashville VA for the new mental health center we were walking through that and I think that those are important components to have because the telehealth helps to bring those services to them especially in behavioral health and I want to know how you are what is your strategy and your timeline on moving more facilities so they're functioning with telehealth and have that whole of life approach to the clinic we've got a lot of clinics people cannot get to health care long waiting the list and this helps to speed the process you're exactly correct about three-quarters of million veterans consumed telehealth visits last year that's about 13% of the veterans that are enrolled with us this year's budget will move that to 20% we believe that in order to keep veterans in their homes especially at risk veterans instead of hospitalization expanding telehealth services is absolutely essential so we will move to 20% under this budget and I would say this committee has given us authority that no other healthcare system in the country has and it allows our doctors to practice across state lines this is the front line of our attack on the problems of mental health as you mentioned with behavioral health it provides our veterans with the opportunity to stay at home stay in a comforting surrounding and stay with people who look after them their friends their families without forcing them to go into a larger facility I I appreciate that I know my time is expired I just want to say listening to you all and as you talk about the budget and you talk about urgent needs things should never have gotten into this shake never and it comes from mismanagement and my hope is as you set these timelines for implementing technologies that are going to enable greater access that you also are utilizing technology to make certain that there is not the gross mismanagement that has taken place in times past senator Murray thank you very much mr. chairman and thank you secretary Wilkie and your team for being here let me start with the fact caregivers I'm sure you're shocked on going there but the October 1st deadline that the caregivers IT system was to be certified and begin the expansion process is quickly approaching and the VA still has a lot of work to do before then we have now heard rumors in the press and in briefings that the VA might not make that deadline and I do really appreciate your personal understanding of the challenges caregivers face I know you can appreciate how much our prior era caregivers and veterans need this support but for the record will you meet the October 1st deadline to certify the IT system and begin expanding eligibility for the care his program if I don't I will be back up here but let me take a step back the reason that I made the decision not to remove anyone from the caregiver program was because of not only your your work and your insistence but because this process has been mismanaged in the past so that was the right thing to do and that's why I made that decision based on your recommendation the date is October 1st the statute says that I have to certify that the system is working if I do not certify that no one will be removed we will continue to manually process the checks right now there are 24,000 stipends that go out it is manually done but as long as those checks get to our veterans that is fine with me we do we do have a new commercial off-the-shelf technology and if you have not been briefed I will get you someone to brief it that we brought on board on February 22nd that is the template that we'll be using hopefully to be ready on October 1st the the other side of this is that we have increased the budget primarily because of your work to about 720 million dollars I expect that to go up in the next few years but we're also using that money to hire professionals to staff out our caregiver program this is a manual program today and there are over 24,000 families receiving benefits their checks are manually written every day as we move to this commercial off-the-shelf software system what we will need to do is to migrate all of the data over and then assure that we can then on an automated basis write the checks every month before we're ready to expand and although we've made a decision on the software system the migration of that we have not recommended a certification date yet on the software system and the expansion I'm not going to do it unless it's right okay III appreciate that and at first glance your request for caregivers looks strong and appears comprehensive however several components of the program are in need of resources you mentioned staffing the IT system the planned expansion of support services provided to caregivers all of those will need increase during expansion and your budget requests 150 million for expansion of the caregivers program leaving 555 million for the needs of the existing program and as I have made clear in previous settings I want to be sure this request is not individually underfunding expansion or the needs of the existing program so I wanted to ask you how will this funding especially for the expansion be allocated to end which areas of need so the basic management structure of this program was done at individual medical centers resulting in dramatically different criteria for inclusion and removal from the program the first thing you'll see is a stand up of a regionalised management system to look at who's eligible and who will be removed and no one will be removed until we can assure you that we're doing this in a clear manner that is transparent to America's veterans and to the American people as we stand up that regionalised process that will occur under the chief medical officer of each of ism we will move from the individual caregiver being the gatekeeper of this program to a regional eyes board process and then institute an appeal process at the VA central office so the entire management structure in order to do this to the secretary standards and the standards that you expect needs to be stood up and put together we've introduced this concept to the vision leadership last week and have begun talking to the chief medical officers about the hiring and stand up of this system now mommy let me the last thing I'll say senator I've used your time we are retraining our clinical staff across the country with the most modern techniques and information on how to deal with families and caregivers I I would say that I think VA is really the only health care system in the country that's concentrated on this is the son of a Vietnam soldier it's it's vital to me so ok I appreciate in this I know you this is something you personally care about too as you know I'm gonna stay absolutely on top of this we wanted to implement it we want to implement it correctly we do not want to deny people this care that they have been waiting for this helping the support and appreciate response today but we'll stay in close touch I just thank you very much I do have other questions mr. chairman I will submit for the record I guess in a marine is another Tillis Thank You mr. chair gentlemen welcome secretary Wilkie it's great to see you first off I want to thank you all for in your budget request funds to expand the CBOC down in Jacksonville how do you see that well first off for people who would suggest that there is a trend in the VA or members of Congress to privatize it seems like budget requests for the expansion of the CBOC the opening of a million square feet in three different health care centers in North Carolina with a different model that you mentioned earlier when I was here seems to suggest that you believe the brick and mortar VA presence is a very very important part of the future so I wouldn't I'd like for you to maybe touch on that but tell me how that CBOC expansion and Jacksonville in combination with the the pact teams are going to help improve care there and then how do you leverage the pact model for the rest of the veterans across the country well senator let me let me talk about business processes that have led us to that stage as I mentioned earlier we are in the process of doing market assessments across the country to lead into the asset infrastructure Review Commission the demographic changes that I see for veterans and changes that mirror those in the rest of the country by 2027 North Carolina will have the fourth highest number of veterans in the country it will be begin to nip at the heels of California and it will be the eighth largest state yes for those like senator Brown just came in Ohio remains in the top ten because of the the large populations and those stand Georgia's in the top 10 so as far as we can see in the future we have to be more creative we have to not only combine the brick-and-mortar facilities that we have we have to manage them more efficiently but we also have to create an environment where our teams can reach rural areas of our states and and be more creative when it comes to things like telehealth but we are moving our resources to where the veterans are and I think dr. stone has your pack answer so the packs will continue to expand across the nation as we hire Montana alone we have 38 primary care providers we've got offers out to eight additional primary care providers that will come in and expand that rural area the secretary is exactly correct that we're seeing growth in north Florida we're seeing growth in South Georgia we're seeing growth in your state sir and will continue to expand us now let me talk about brick-and-mortar veterans are no different than the rest of Americans our parents generation stayed in the same house on a generational basis we don't and our children don't they move we must be able to move from place to place in in order to follow where the veterans go therefore lease authorities are incredibly important to and enhanced police authorities that would allow us not just to provide housing but to also be able to provide ambulatory medical facilities that we can move every five to ten years and to follow where America's veterans are much of the non-recurring maintenance that you hear about and the cost of our infrastructure is for our inpatient facilities our inpatient facilities in many cases are aged and need substantial improvements but our ambulatory facilities more than a thousand of them need to be able to be mobile when the veteran moves each decade thank you I want to talk a little bit about access standards and the Mission Act I think I could have infer at least from some comments from some of my colleagues that it's almost like we're giving some of our veterans too much choice in some states I think you have a hundred percent access to choice if you want it and there may be a variety of reasons why you need that my colleague just came in from Alaska he's got a very diverse population over a geography that almost spans the United States from tip to toe and so I can see why you have to have a different solution for different states but what would happen what would be the negative consequence if Congress succeeded in rolling back the access standards that you're putting in place now and combination with a Mission Act senator it would no longer be a veteran century patient centric approach to health care that was the clear mandate of the mission act not institutional prerogative but the health care of a veteran so let let me beg the chairs indulgence and describe what this isn't and I mentioned it earlier this is not a libertarian VA this is not giving doctor stone or me a card and saying thank you very much go out and find whatever doctor you want and take care of you for the rest of your life what this says is that if we cannot provide a service then you have the option to seek that service in the private sector give you an example if there's no rheumatologist I don't there probably is in Fayetteville and you meet the criteria for that service then we tell you that you have the option to go to Duke or to Chapel Hill or to Cape Fear Valley in my own town to get that to get that service but it is based on the needs of the veteran and veterans come first if we can't do what the veteran needs then we will provide him the opportunity to seek that but they I think it's very important mr. chair just to close out my questions that's why I think a broader understanding of what you're trying to accomplish with the patient aligned care teams it's not like you're giving them a card and sending them on their way I mean you're gonna spend a lot of time making sure that the outcomes are going in the right direction that they're getting their appointments filled when they need to and you'll always have that brick and mortar presence if necessary but I for one think the access standards we need to continue to move forward and the work that you're layering to provide a better standard of care for the veterans and I thank you for your work thank you you said tell us senator Brown thank thank mr. secretary Wilkie thanks for your letter back to me regarding the VA history Center at the VA in Dayton Ohio we're excited to get the next phase of this project up and running my staff and I look forward to a briefing on how this project is progressing we will be in touch with you about that I'll be brief I have a number of questions senators tester and Bozeman and I have been working for years to push VA to track and report an overpayment and veteran debt I've had constituents who have reported a change in status or a dependency to VA and VA didn't take action leading to an overpayment in debt were able to get some provisions through last year as you know last week we introduced our updated bill to clearly outlined the reporting process for veterans and their families to foster better interagency coordination reduce overpayments I'd like your commitment that VA will continue to work with the three of us yes sir okay thank you um over the past month and this is a bit of a follow-up to Senator Moran's some comments in question about about toxic exposure over the years you and I have discussed this issue whether it's Agent Orange or burn pits it took this country far too long to come to terms with or with Agent Orange so each veteran didn't have to apply individually and go through that pain we I appreciate the decision not to appeal on the Bluewater Navy that's really important that that's my recommendation so I don't know what other departments are doing that's your recommendation okay I'd like to my question is this I'd like to know when VA intends to make a decision regarding the National Academies recommendations on Agent Orange bladder cancer hyperthyroidism hypertension and Parkinson's like syndromes yeah we're working our way through that right now and it would be my hope within the next 90 days that we'll have some decisions made okay and then you make the decision it quickly is ratified by secretary Wilkie as well sir I would not presume when the secretary is living right next to you might ask yeah thank you thank you okay secretary thank you for that you said that Congress put unreal expectations on an outdated IT system for the forever GI bill respectfully served v a's IT and programmatic offices should be able to flag these issues for leadership and leadership should respond accordingly in update Congress I if I said that I probably misspoke I should have said that the VA systems were not capable of handling the changes that Congress mandated but they will be they will be yes VA went through similar issues with care t for care givers expansion why did that take six to seven months as well that I can't tell you based on my tenure here what I just my short tenure what I got what I can tell you is that once again because we were not ready to implement the programs required to support our caregivers I made a command decision based on my discussions with Senator Murray to make sure that no one was removed from the program that the checks the stipends that went out to 24,000 caregiver families were done manually even but they were done and I do expect to come to this Congress by the deadline on October 1st hopefully certifying that the commercial off-the-shelf technology that we purchased to support caregivers is in place but I will say I'm not going to certify anything that doesn't work we've been down that road before that led to the problems with the forever GI bill that led to the problems with caregiver so you have my commitment that nothing moves unless we're convinced that it helps veterans yeah thank you I want to reiterate what the chairman said about the legacy IT systems getting them to work together to work for all of our veterans that is so important well one more comment than one last question the comment is well the question is when can we expect nominees for deputy secretary and undersecretary for health when's that going to happen hopefully soon we've made the recommendations and I hope there will be an announcement from the White House shortly I will thank the committee for for approving the nominees for the office of whistleblower protection and CIO I do want to say one thing though there is an added layer of approval for the undersecretary for health the law unlike for any other position in federal government requires the convening of a commission a commission to meet deal with candidates deliberate and then pass a recommendation on to me that was the reason for the delay in the eight months that I was here because the Commission had to be convened my last comment I heard your Thank You mr. chairman for your forbearance I I heard your senator or your junior senator from North Carolina his laying out choice and privatization and I know how he stands on that I've been disappointed that you aren't quite as opposed to privatization as I thought you were during the process I just asked you I'm not asking a question particularly but just ask you to listen to the veteran service organizations and what they think about this president's philosophical commitment to privatization that I hope the VA doesn't follow I will say senator with your permission mr. Chairman I think I've been very clear about where I stand and where I think the department is heading I think the legislation was right on target when it said that the veteran is at the center of everything that we do I also think that the veterans voting with his feet or her feet our customer satisfaction rates are at an all-time high I look at that as the gauge as to how well we are doing I also believe and I'm not one to use a lot of anecdotes but I can say as someone who has spent an entire life in and amongst the military that our veterans no matter what age they are will go primarily to someplace where people speak the language and understand the culture because there's nothing like it in the United States and I stand by what I have done in the last eight months and that that the way that Congress appropriates or withholds money can have a lot to do with people voting with their feet and I hope you'll keep that in mind Thank You mr. chairman Sullivan Thank You mr. chairman and mr. secretary in your team thank you for being here I also mentioned in the nominees you know for undersecretary very important so we need to get those out the door I also want to mention to my Democratic colleagues they also need not delay the nominees once they're on the floor there's been very very unprecedented obstruction of very basic nominees for their confirmation so we get them out the door and we'll have guys like Senator Brown move them quickly as opposed to delaying them because that's that's not helping at all so wasn't a nice try it's actually really see issues so they need to help they can't just say give us nominees and then delay him for 10 months right it's ridiculous and that's what's gonna happen let me mention first of all congratulations on these national awards I think that what you're talking about for your team it's should be commended and you know sometimes you guys come here you get the wrath of the Congress and we rarely recognize when there's been improvement so I'm gonna recognize it and I appreciate it so keep up the good work on these things you may have also noticed the Alaska VA health care system was also awarded with the most improved inpatient experience for the entire country in 2018 so I want to thank all of you for that you know dr. Ballard is one of the best dr. Ballard does a great job but it's helped from the top you know the VA out in the mat-su Valley a huge veteran population finally has not just one not just two but three doctors it only took five years but now we have some doctors so thank you for that and mr. secretary I also want to thank you it's not exactly in your purview but you may have seen my Alaska Native Vietnam veterans equity allotment Act was recently signed into law and when the president cited the broader bill was in he highlighted this very important bill for Alaska that helped our Vietnam veterans overcome a huge injustice and the act that the president highlighted that in a signing ceremony made me I will I will add to that Senator I mentioned that the caregiver legislation closes one of the last loops of the Vietnam era sadly it's been 44 years since the fall of Saigon I think the Alaska allotment issue was one that sadly took almost as long and I think that also closed particularly for a state that has the highest per capita number of veterans in the country well I appreciate that mr. secretary and you you weighing in on that former secretary Zinke weighing in on that again previous administration remarkably they were opposed to it so you guys at the cabinet level weighing in really helped make it happen so thank you for that I wanted to talk about the the Veterans Benefits Administration is working on and I know it's a big issue for you identifying off the VA grid veterans who have yet to make contact with the VBA and its services I know you're looking at possibly doing a case study in Alaska you know we've been you've been out there so thank you I look forward to your visit and dr. Stone's visit here soon again but can you just talk a little bit about that whether it's the pilot program in Alaska we do have enormous challenges on this issue but also how you work in it in other rural communities throughout the country certainly you may recall that a confirmation time when I visited with you you spoke about your efforts to engage your constituents and so after I was confirmed I didn't forget that conversation I said in motion to try to figure out how we actually do that our presence augmented by our relationship with the county and state VSOs as well as tribal and communities to better understand how that network should be set up so that if you can't touch us you can touch somebody who can touch us and that's we're trying and we're using Alaska by engaging those groups to figure out exactly how the workings of that take place and what we can do in terms of the ways we communicate and the effectiveness by way we're able to do that so we're trying to use that as understanding how do we mobilize all the resources that are in the veteran community VSOs included to figure out how we do those touches and engage folks effectively how about the pilot program you're looking at in Alaska on this it's just it's just going happy to come briefed in some of the details we're just getting started in terms of how that all work okay well I appreciate you guys focus on that miss secretary you know I know you've been asked earlier by Senator Bozeman and others on how are you feeling with regard to the mission act launch date you know Alaska's been carved out its own region region five there's been some concerns that you know we're behind the power curve there a little bit relative to the rest of the country can you just give me a quick update on that how you're feeling about that launch actually because of the uniqueness of the geography and the dispersion of the population I worry about it a lot we're on schedule though for the the getting out the contract and so when I say that the bid should be out I think it's this fall what can we do to ameliorate your concerns and worries I share them I think just a continuing dialogue with your staff and yourself I'm looking forward to my visit up there where we can dialogue and really walk our way through it but it is a unique area with geographical challenges and you are exactly correct in our previous conversations it should be handled locally and I will add if you go down the list and I've said this to folks in Alaska the Federation of natives I've said it on Alaska television if you go down the list and look what we are prototyping in VA my philosophy on electronic health on logistics on on VBA and and here with mission is if we can make it work in Alaska it won't work anywhere because of the unique challenges that Alaska presents by its massive size but also because of the impact that veterans have on the population of the state it's a unique unique situation thank you well we look forward to you getting back up there mr. secretary and dr. stone your visit as well thank you thank you mr. chairman thank Sullivan senator Moran had one additional question so if you don't mind the secretary and I'll have one very short statement after this question unfortunately the Chairman almost tells the truth I have to it's when developed while I was waiting to ask the one we better hurry yes sir I wanted to go back to the hearing aid specialist just for a moment and this really is to you mr. sec I understood what dr. stone said that the V Aiden may have reached the conclusion doesn't believe that additional professionals in this arena is are necessary but I want to highlight a complaint I've had with the Department of Veterans Affairs for as long as I which is now 23 years that I've been on a committee on Veterans Affairs is can we get the department to abide by the congressional law the mandate that you have and the issue of whether or not the specialists are necessary at the VA that's a different issue than abiding by the law that requires you to determine what the qualifications would be for that profession at the VA this I don't want to diminish this issue it's important to many people and it's important to many people who are hearing specialists who want to provide those services who want to serve our veterans it's important to veterans that they have the care necessary but I just knowing you mr. secretary I want to highlight about the importance of just the folks who work for you not making an independent decision whether or not they get to abide by the law the mandate that Congress gave them to act in any particular way yes sir I didn't know that that was occurring that that's my honest answer and you know my background so they will be told to abide by congressional will I think it's true when you were confirmed it's true as I recall in every confirmation hearing for secretary they if the VA that my question has been will you make certain that the people who work for you work with Congress provide the information that we need answer our letters and of course given is abide by the law and so I I just want to highlight for you the importance of that we raised the issue of toxic exposure and I told you about a study that was completed by the National Academy of Medicine in November 2018 that law that created that study requires you mr. secretary to determine based upon that report within 90 days if there's a trigger in that law and requires you to make a determination about now how to proceed and I just learned that mate marks the 22nd which is just a day ago you have you sent a letter to the committee you're now you weren't in compliance I don't know if the 90 days but you're in here in compliance by responding I appreciate that you now have a responsibility that I want to work with you to make certain that there is action taken and again we're talking about the generational consequences the met the National Academy determined there is no medical research that determines the relationship between toxic exposure and the next generation of the veteran there is a great opportunity and a necessary opportunity for you and the Department of Defense to proceed in determining that relationship but also getting the facts in place so that we can determine who those veterans are and you are a perfect person with your relationship and history at the Department of Defense to accomplish this goal I'll I'll digest your March 22nd letter in a more timely fashion but this is something I want to highlight for you thank you Thank You chairman you're welcome senator Sullivan was inspired to ask one more question I want to grant him that privilege Thank You mr. chairman and I it will just be one mr. secretary this goes to the issue of infrastructure improvements streamlining expansion where you see the populations that are growing in certain areas of the country and States populations that are declining and again in your I know that broadly the VA is repurposed or disposed of 175 of 430 vacant or mostly vacant buildings since June 2017 I think that makes a lot of sense but you've also talked to me about you know areas if you see if the VA is looking at expansion with regard to leases or even facilities I know you were struck by some of what was going on in Alaskan that way given that you you mentioned not only more vets per capita the size but also I think we're one of the few states that does not have a full-service VA hospital not even one so can you just give me an update on what you're thinking with right the VA is prioritize ation of leases that are in the budget requests we have in Fairbanks we're looking at the possibility of a new campus and also outside of J bear you may have remember that kind of big parking lot area that we were talking about after our tour the simplest answer is that we are going where the veterans are and this is only the first step the legislation requires market assessments to be done throughout the country we are in the process of doing that that develops a knowledge base on population trends the services available in those those areas to inform an asset infrastructure review commission I mentioned earlier that I expect to come to this committee to ask for an accelerated date of the for the beginning of the deliberations on the asset infrastructure Review Commission because we have to go where the veterans are I also mentioned earlier that what you said is only the beginning of many different processes more than half of our buildings 57% are between the age of 50 and a hundred and thirty years old because of that the leasing option and co-locating and I'm not going to say that we we're going to we're in the process of doing this but I saw a number of facilities in Alaska that present us with an opportunity to be more creative about co-locating with entities outside of the federal structure thank you thank you thank you so let me conclude by thanking the secretary and staff and each of the department has for their being here today and for your thorough out answers I appreciate what y'all we're all doing with our beds we all have the vets apart that's in mind and that's in Solem we're gonna see through their take here as best as possible I want to thank the VSOs for not being offended by my request for them not to testify but rather submit questions and statements mr. few any days I said to the back of room just taking copious notes and I'm sure he's gonna make sure that I keep every promise I've made just like they're gonna keep every promise that they made but I want the VSOs to be sure and remember that I've asked you to submit the questions you won't answer the secretary I'm gonna I'm not gonna give you a deadline because I that doesn't do any good I don't think but I want to give you a encouragement as quickly as possible to answer those questions and copy the those wasn't the committee staff were the same the answers to those they're very good they're very thoughtful particularly on the priorities of the budget and what some of the statements and your statements have meant when I saw as they materialize will mean so it's very important this works well I think we'll get better responses because we consume so much time we have too many witnesses we don't get two points we really need to get to as demonstrated about mr. Sullivan and mr. Moran who's had instant thoughts toward the end they were both very good and appreciate I wanna thank you for being here I thank all our veterans for the service they provide to all of us wish all of you a very nice day and I very happy week and I look forward to seeing you soon and recognize the record will stay open for five days on submissions to the committee for this hearing and the Secretary will respond as quickly as possible the question is if you'll get those questions to the committee right they will make sure that it gets to the secretary and then we have a copy trailer so we can do it thank you very much thank you sir thank you

Author Since: Mar 11, 2019

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