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-- in providing timely high-quality care towards nation's veterans. i rep is into rural state and during my time as a member of the house of representatives i rep center the congressional district for proximally the size and state of illinois. there was no and is no va hospital in that geographic territory and so i bring this perspective of long distance and long amounts of time for veterans to access care. farawam v.a. facilities about those challenges. in the absence of community care, these veterans would not be able to use the benefits they earn. the same could be said for veterans who face long wait times at the v.a., veterans who provide a service the local v.a. does not offer or veterans who have unique needs that are best

served through community care. this was created so the v.a. could more seamlessly care for those veterans. seven years after the act was signed into law, it is still not fully living up to its promise. i've heard from veterans nationwide suffered as a result of the last year as v.a. acted to discourage and restrict the use of community care. some of those veterans who have suffered the most are those with mental health conditions and addiction. this morning we will hear from veterans and family members, veterans and advocates about how they overcome barriers which limited access to potentially life-saving care and put their lives at risk. one of those veterans will testify today but waiting more than a year to a counselor after passing -- asking the v.a. further help in the midst of a personal crisis. another one of those veterans is

-- page will testify how her and charlie to request for indication in patient care denied by the v.a. after charlie attempted suicide in a parking lot of the v.a. clinic. v.a. leaders and advocates have repeatedly said suicide prevention is one of the top v.a. priorities. if that is indeed true, stories like the one arrogant and page will share in the countless others that this committee has heard from, veterans and their loved ones should definitely as chair of this committee i am committed to making certain that they do not. that is why am introducing legislation with my counterpart in the house to strengthen and give veterans an improved pathway to care and the v.a.'s direct care system and in the community. i hope this will be a bipartisan effort. the health care system is a valuable resource for veterans,

but it will only remain so if it stops failing those who need it the most. with that i yield to the ranking member. senator blumenthal for his opening words part sen. blumenthal: thank you mr. chairman. this cause must be bipartisan and it must be immediate. there is no question about the need to speak, streamline and safeguard access to community care and referrals to the kind of providers that are necessary to prevent the tragedies or near tragedies as in the case of your husband charlie suffered. i believe strongly that these two systems, private and va must be complementary, not competitive. overriding all of this debate is the need for more providers, more doctors and nurses, more

psychiatrists. and social workers who can provide the kind of care that our veterans need and obviously the v.a. should not be in competition with communities for the numbers of scarce providers, skilled professionals who are necessary to provide this care. but we are here on a morning when all these programs are in severe and urgent jeopardy. the trump administration has announced illegally it will freeze federal aid for programs that are immensely important to veterans. this freeze will hurt veterans by causing funding for critical programs but millions of americans -- veterans and their families rely on. we are talking about homeless

veterans, funding for veterans, nursing homes across the country, suicide prevention programs, many of the programs that we will be discussing today and the efforts to streamline, speed and safeguard access to communing programs, reimbursement for those providers who need it to make community care work. frozen. we are deterring and discouraging that kind of community care right now in real time. i urge all the members of the committee, my colleagues, to oppose this measure, to make their views known. i call on veterans and their organizations across the country to make their views known because these funds must be freed immediately or else veterans will be betrayed.

there is nothing woke or marxist about working to end veteran suicide or delivering our federal and the benefit they have earned and deserve and i will put in the record later today a list of programs, it is going to be probably about two pages long that will be adversely impacted by this freeze on funding. it is also, by the way, unsustainable legally. it violates -- these funds have been lawfully appropriated under bills passed by the congress and signed by the president and no member of the executive branch, including a president has the lawful power to simply stop them. i am concerned also about the action to dismiss the inspector

general. i will be circulating a letter to my colleagues that would in fact protest to the president the firing of the v.a. inspector general who has worked for many years under both republican and democratic administrations to stop -- call it and stop waste fraud and abuse. he's done it in a nonpolitical way, aggressively and effectively and the question for all of us is why this measure of firing the inspector general of the v.a. was done at this moment when in fact he has been forward against waste, fraud and abuse as had the inspector general across the executive branch. i believe strongly that the private sector health care

system and the v.a. are complementary and one group's care should not, of the expense of another. i fear that's what's happening today, of the erosion is a real threat. if it happened gradually, not all of a sudden but if it happens it may well be irreparable. i am hopeful that we will restore the inspector general, that we will make sure the funding for the v.a. system and other programs will be unfrozen and that we will work together in a bipartisan way to speed and assure the referral system under the kind of legislation that the chairman has proposed that was

in for last session and i supported it, to legislate in this area. i am hopeful that his measure is one that we can all support. the veterans health act, i assume this measure is similar to it, ranking member tester offered the care work for veterans act. i feel some combination of these measures is viable and achievable and i am helpful -- hopeful that we can reach a bipartisan effort. chair moran: i wouldn't get a couple of things for all of the members. it's my understanding the department of veterans affairs leadership is meeting later this morning with omb to learn details of this issue of impounding or holding funding. i would say in both instances, one of the best things that we can do is get congress when

collins confirmed and in position to represent but a barman of veterans affairs in these matters. that is apparently taking place this week. i will call on our witness panel, a navy veteran and an advocate for mental health and suicide prevention for veterans and first responders. page marg, a veteran spouse with first-hand experience navigating. jim lorrain, president and chief executive officer of america's warrior partnership. naomi mathes, the assistant national ledge litter director for disabled american veterans. and john eaton, vice president for complex care for the wounded warrior project. thank you all for being here this morning and thank you for all you do and your care and concern for your loved ones.

mr. gomez we will recognize you and your recognize for five minutes. >> chairman moran, ranking member lee blumenthal and distinct members of the committee, thank you for the opportunity to testify on prickle issues of improving access to care for the v.a. community care program. i am a u.s. navy veteran and i've dedicated my life to support you health and well-being of veterans and first responders. the v.a. is an essential resource for veterans. community care is meant to complement not replace v.a. services pride assuring veterans receive the right care at the right time. i will begin by sharing a personal story to show you why this is so important. after leaving the military, i sought mental health care through v.a.. i was fortunate to see a psychiatrist relatively quick, but it took over a year to see a therapist. the lack of therapy meant i was only addressing part of the problem. this came to a head over the

holidays a few years ago and without the support of friends and fellow veterans, i may not be here today. for someone with a mental health or substance use disorder, the window to intervene is often just days. for veterans, timely access to this care is a matter of life and death. my experience reflects the barriers many veterans face in accessing timely care. that is what inspired me to cofound forge health. we address urgent mental health and substance use needs for veterans and first responders. working with the v.a. to help those who could not find adequate care. the collaboration showcase the potential for how these relationships could work with the community but also highlighted challenges. some the amcs and visits fostered strong partnerships but inconsistent implementation across the system resulted in delays highlighting the need for clear, standardized practices to ensure veterans receive timely and consistent care.

while the mission act has expanded options for veterans, many do not know about these options. unclear eligibility requirements often lead to delays. even for those who meet the access. one veteran after being told he could not continue care that he developed a therapy relationship told me i am done, i give up. before this year i had been through four clinicians in less than six months. when transitioning from v.a. to community care, many veterans face disruptions caused by court export medication. for example, a marine veteran i worked with struggling with severe post-traumatic stress was referred to community care but waited months due to administrative delays. his commission -- condition worsened and he attempted suicide with a firearm. some hesitate to refer veterans or community care feeling it could negatively impact their budgets.

this can create barriers between systemic concerns and urgent care needs. the mission act was designed to ensure timely high-quality care whether at the v.a., veterans and not funding structures should remain top priority for the care of that's. to address these challenges the v.a. should enhance its efforts to educate veterans about their options. clear coming occasions for active outreach campaigns and partnerships contributors about the rights and choices. the approval process should be streamlined, simple find and automating these procedures can alleviate administer it of burdens and help veterans access care more efficiently. this includes ensuring that community providers and visions are all in transparent and constant munication. for rural and underserved areas,

community care should act as a force multiplier and not a replacement for v.a. sources. helping the v.a. fill and address critical service gaps. telehealth is also a powerful tool for bridging the service gaps in these underserved areas. challenges such as limited broadband access can make this difficult. it's also crucial for some veterans to have the option to see an in person provider especially for the process of trauma. chairman moran, ranking member blumenthal and members of the committee, of the v.a. has made progress in improving care for veterans but to give again challenges remain. by building on the foundation we can ensure all veterans receive timely high-quality care they deserve. it is our responsibility to ensure no veteran is left behind, by fostering collaboration and prioritizing veterans needs we can fill the promise. every delay risks of veterans

well-being and their life. as one veteran told me, shouldn't fight this -- should not have to fight this hard to get help. i look forward to your questions and working together. chair moran: thank you for your testimony and your service . >> good morning chairman moran, ranking number blumenthal and members of the committee. thank you for the invitation to speak at this meeting. i am the wife of trials marg. i am not here to talk about the life of my husband in the past tense. better? my name is paige marg and i'm the wife of charles marg. i'm here to tell you how charlie was saved. countless times the v.a. and community care program provided

impactful mental health counseling, resources and residential treatment but failed again and again. i met my husband 27 years ago. we've been married for 23 years. in this time i've seen my husband changed dramatically from a pivotal deployment he went on. in october of 2012 he deployed from germany to guantanamo bay, cuba for eight months. to this day i am not sure what happened on that deployment but whatever did happen permanently and profoundly changed my husband. in august of 2013 while still on active duty, charlie attempted suicide and was hospitalized. it was then that he disclosed he attempted suicide twice on deployment. his doctors told us he could not have ptsd because he was not deployed to a combat zone. he was diagnosed with major depressive disorder and anxiety and was medically retired in july of 2015. we moved back to san antonio and

he was connected to a v.a. psychiatrist only supported, counseling is not part of these quarterly appointments. charlie has repeatedly requested counseling referrals from the v.a. psychiatrist and the cycle includes the community care program failed charlie again and again. he had to wait six to eight weeks to see a community care provider. in each of the nine times that he went through this process, he has never been granted more than 12 visits with a counselor even when he needed more. and in each cycle he saw a different provider and spent time retailing. in february of 2023 charlie disease v.a. psychiatrist as he was in crisis. we were told to go outside of the v.a. to seek care and were given a list of local providers. the earliest point and we could find was 30 days out.

on march 1, 2023, my husband sat in his desk in the parking lot and attempt to overdose on his medication. i found him in his truck drenched in sweat, crying and incoherent. he was transported to a local hospital. when he was released he was referred to the v.a. community care system for counseling and was seen for 12 visits before he was released from care again. his medication was adjusted multiple times over the next six months. towards the end of this time, charlie went missing and was found by the police in the eer waiting room at audie murphy hospital. he was held on emergency detention order and admitted for 36 hours. for several reasons i asked if he could be sent to a residential program and was told that no option like that existed through the v.a.. at his follow-up appointment i explained the last few years of navigating fragmented community care counseling and at least 12

session appointments were not accurate support in the longer-term solution was needed for him. i again requested that he needed to be put in a residential treatment program. a referral was submitted for residential treatment to the community care program. charlie's psychiatrist called and told him the referral was denied and suggested he reach out to try care, wounded warrior project or another veterans service organization. to get the care covered bring wounded warrior project complex care coordination program assigned case manager and within three days paid for his flight to tucson, arizona, secured a bed for him at sierra tucson and paid for six weeks of residential treatment. sierra tucson is in the v.a. community care network and the v.a. should have covered this expense. but failed to support charlie again. while he was there all of his medications were changed and reset, he received intensive

counseling, treatment for nightmares and is diagnosed with ptsd. since he returned home charlie has avoided the v.a. for mental health support because he did not want to go through the familiar cycle fragmented care again. instead he is sought outside support through local nonprofits. charlie is currently attending counseling appointments to the local center in san antonio. the wounded warrior project saved his life by getting him connected to care he desperately needed for years. that over and over again the v.a. -- it's heartbreaking to see your spouse become a shell of a person, to repeatedly ask for help, to maintain prescript and compliancy for more than a decade and not miss appointments only to be discarded from the entity that should be providing treatment and care that he earned through his military service and sacrifice. the obtuse heartless interactions with the v.a. over and over or why veterans do not seek care. it is why veterans suffer in

silence. how many veterans need to commit suicide for the v.a. to prioritize long-term mental health care? how long do veterans have to wait for mental health care? how many veterans are getting lost in the community care system that do not have someone to advocate and fight for them. we need the v.a. to be better. thank you for the opportunity to share charlie's story. chair moran: thank you for your must -- must be difficult testimony but very valuable to me and the members of the committee. mr. lorraine. >> members of the committee, i am honored to testify today regarding veteran access to health care specifically care in the community. the ability to make our own decisions as a foundational american freedom. i've told my army serving son but a successful career should give him choices throughout life.

and i remained the military through retirement because i love service. but i also did it to ensure i had choices, especially managing my health care, something that my father never had the option for print awp believes veterans have a choice in managing health care they have earned providing veterans with health care choices of where, when and most importantly the continuity of care they seek is not only the right thing to do, but it is also affordable and effective. awp operates at a community level by building proactive relationships with veterans. our mission is to partner with communities to holistically improve the quality of life of their veterans and families. thereby reducing veteran suicide. community care is vital for veterans, particularly those who do not trust the v.a. and don't utilize the v.a. facilities due to the factors like distance,

time and continuity. while we recognize the v.a. crucial role in veteran care, we always side with the veteran. we have supported empowering veterans to make their own health care decisions and community care is one of the most popular and in demand options. the mission act and community care enable veterans the opportunity to access outside v.a. facilities as a result it has been overwhelming. community care helps veterans regain the trust in the system especially given little staff of the 17 point 6 million veterans in the united states are unknown to the v.a.. atawp nearly 9000 veterans contacted us, over 4000 needing assistance. most often related to health care. these 4000 plus represented 6000 cases issues. 300 92 related to mental health.

of those, 320 nine had suicidal ideation's within 30 days of contacting us. the most common theme we see is a struggle to access care. even for veterans familiar with the system navigating the v.a. can be frustrating. confusion and long wait times and canceled appointments erodes trust in the system. though it is popular, full implementation of the mission act has yet to be realized. in the past years the v.a. has continued to deny community care referrals, continue to expand v.a. hospitals and hired more employees, often competing with providers for talented medical professionals in the community. we must get this right. as you said during the confirmation, america's national security is dependent on our all volunteer military force in the v.a. that is successful in helping service members thrive as veterans is key to bolstering

recruitment and keeping the nation safe. we agree 100%. we feel the v.a. is not a social service department, it's a national security entity. despite some opposition and clear data, veterans are voting with their feet to seek outside care of the v.a.. the department should trust in the power veterans by allowing them to choose their care providers. after all, who knows what's best for the veteran, the government or the veteran. in my experience, both my wife who is a veteran, service-connected disabled veteran and challenges after years of frustration we see that care. because it provides us with so many other choices. immunity care is essential. veterans should be able to choose their providers needs the best. awp put forward several options

for care. they should codify the existing access standards for the community to ensure that veterans have access to timely health care. limited the referrals for veteran health substance abuse and tbi care. i add that because it is essential. we need these services as often urgent. and referrals delay needed help. further assessment and care have been neglected because of the similarities to post-traumatic stress disorder symptoms. and must include tbi services when discussing mental health and substance abuse. we also feel that edge -- we need to educate veterans on community care options and allow them the preference for community care and allow them to utilize select. community care is essential to improving access to health care. we must improve the system by empowering veterans, not restricting them. together, we can do that.

thank you sir. chair moran: thank you sir. miss mathes. ms. mathis: over the past decade, due to increased demand for services, ba's reliance on purchased medical care services has risen significant. all the use of community care has grown many veterans have encountered barriers to accessing that care. dab supported the mission act, which aimed to improve veteran'' access to high-quality and veteran-focused care. importantly, this support was based on maintaining a fundamental set of principles. unfortunately, there are reports from some veterans indicating that they have been denied eligibility and access to the veteran community care program. the access standards enacted in the mission act are clear. mva is responsible for educating its employees on the law and veterans rights to access community care when v.a. cannot

provide needed care in a timely manner or due to distance from a v.a. facility. in cases where it is determined to be in the best medical interest of the veteran. we also continue to hear about delays in scheduling community care appointments once a referral has been made. due to the lack of an interoperable health records system v.a. struggles with transmitting records to community providers and integrating those records into the patients' electronic health record. additionally community providers for complications with transmitting health care information and test results back to v.a. there were also complaints from veterans regarding billing issues associated with referrals to community care. v.a. must find an effective solution to ensure that patient records are transferred in a timely manner and provide the tools and procedures for transferring records back to bha

-- vha. finally, vha must ensure veterans are not burdened with resolving billing issues related to community referrals. a bipartisan issue and v.a.'s top clinical priority is suicide prevention, yet it does not mandate community care providers to meet the same quality standards as v.a. direct care providers. dav recommends v.a. amend its contracts with these providers and require -- require clinicians to be trained in military culture, suicide prevention, lethal means safety counseling, and trauma-informed care. accessing mental health and substance use disorder care is essential in preventing veteran suicide, and we made recommendations in our testimony to ensure quality services are provided to veterans refer to

the community. women veterans are also significant users of community care. they are referred to the community for all maternity care and often times for other basic gender-specific or productive health services. although we want to see fixes to improve access to services in the community we strongly believe that investing in v.a.'s veteran-focused evidence-based care model is likely to produce better health outcomes for veteran patients and ensure quality of care. it is essential to maintain v.a. as the primary provider and coordinator of utterance health care. a bipartisan position supported by current and past v.a. secretaries and under secretaries of health. a robust v.a. health care system also provides vital research, a central clinical provider training, and emergency preparedness for veterans and the nation.

the failure to adequately fund, maintain, and expand v.a.'s care infrastructure and increase staffing levels to meet rising specialty care demand has led to unsustainable growth in community care, threatening the long-term viability of the entire v.a. health care system. likewise, an improperly-managed veteran community care program has resulted in some veterans receiving substandard care. in closing, congress and v.a. must work to resolve existing issues impacting veterans' health care. improvements need to be made expeditiously to ensure veteran patients receive quality, timely care. most important is to maintain a veteran-focused health-care system for service-disabled veterans who rely exclusively on vha for their health care needs. ensuring v.a. specialized care

and services remain available as part of honoring the commitment to those who serve during mr. chairman, we look forward to working with you and the committee. this concludes my formal statement. chair moran: thank you for your testimony and dav's continued presence before members of this committee. thank you for your testimony. mr. eaton. mr. eaton: thank you, chairman, ranking member, and committee members for this opportunity. since 2000 and three wounded warrior project has been working to transform the way america's injured post 9/11 veterans are powered, employed, and engaged in their communities. over the past 20 years our programs and services have matured to a point where we can engage with each individual based on their unique needs. part of our process is learning more about their journey to wounded warrior project and some of these veterans have used v.a. for mental health care. others have not. using v.a. is not a prerequisite to accessing our programs and services, nor is it a

requirement to keep engaging with us. but as a majority use v.a. and nearly half are using v.a. for mental health care we often learn about what that care looks like for those who come seeking mental health care and support from us. for some wait times are still an issue, despite efforts to expedite access. many warriors have reported way times of several weeks to months before being provided with a mental health appointment. this is typically when a veteran or their family reaches out to organizations like ours for help. we have a relationship with direct care providers and can triage veterans into care sooner in many cases. while the v.a. has its network for a similar purpose we have learned that some warriors still wait for care well beyond 20 days after being referred to a community provider. for some of these same warriors we hear frustration with provider turnover. it can take time to develop the trust and rapport with a counselor that is critical to effective care. when providers leave the v.a. health system their patients are left to start over.

this can be an agonizing process for some, particularly those who struggle to tell their story. even as some veterans are referred to the community an enduring relationship with a community-based provider is not always possible as workloads adjust and observations lapse after a course of treatment. while the stores are not, the challenge we have seen firsthand his accessing care through v.a.'s mental health, residential rehabilitation treatment programs. v.a.'s mental health programs provide rehabilitative and clinical care to eligible veterans who have a wide range of symptoms, illness, or rehabilitative care needs. to be clear the v.a. provides inpatient stabilization for veterans in crisis who are suffering from mental illness. our ot p's serve as a step down and more intense treatment option for those in need of substance abuse, ptsd care, and dual-diagnosis treatment in a residential setting. they serve a small but high need

, high-risk population of veterans. a contrast, nearly 2 million veterans received individual or group mental health treatment in a v.a. over that same period. despite the logical source -- association between rotp and mental health care the standards more realized in the coda figure -- federal regulations do not extend to substance use disorder care provided in a residential setting. this becomes a problem when we are working with high-risk warriors for placement at the v.a. or in the community. stated simply, we having crown -- encountered v.a. providers who have stopped the care -- stopped referrals to rotp care. you will pay for that faster connection to community-based care paid by donor dollars. and with almost no opportunity to secure any reimbursement from the v.a..

we are proud to step in, but we see only a small percentage of the veterans seeking this critical level of care. many veterans are not accidents -- accessing the care they need when they are ready to receive it. delays in finding care in a timely matter -- manner not only capitalize on the veterans desire to change their circumstances but in some cases cause damage to the mental and physical health, declines in their family and social relationships, and even involvement with the justice system. to mitigate the risk and ensure consistent v.a. help throughout the enterprise we believe the mission act access standards must apply to the delivery of residential programs. we want and need to be successful. simply put, the v.a. is our most critical partner in connecting veterans to the rehabilitative care they need. we thank the community and its distinguished members for this opportunity to share our perspective on community care. we are eager to support your efforts and keep our promise to our nation's veterans and i look

forward to your questions. chair moran: in so many instances that you do. ms. marg, i want to highlight the testimony between you and mr. eaton. you indicated that on numerous occasions the care your husband needed was denied by the v.a. and the suggestion was that you seek care through tricare or through a private organization. ms. marg: that is correct. chair moran: and that is despite the fact that charlie had a service-connected disability from the v.a.? ms. marg: correct. his rating has actually increased, so he is 70%, but he is rated as iu for individual employability. he is actually at 100% right now. chair moran: what was the reason

the v.a. made that recommendation that you seek care elsewhere? how did they explain that? ms. marg: at his follow-up visit after his second suicide attempt the nurse practitioner told us that the v.a. did not do long-term mental health well, and she turned around her computer screen and pulled up psychologytoday.com and told us to search and filter for which providers take tricare and to connect to a provider like that. the only explanation was, they just don't do long-term mental health well. chair moran: is it true, mr. eaton, that the v.a. could refer charlie to the same place that tricare would be paying for? mr. eaton: yes sir. the location ms. marg

highlighted is a member of the network and would be eligible for a referral. chair moran: that caught my attention, where you have helped find a place for ms. marg's husband, charlie, is also eligible for the v.a. to refer to community care? mr. eaton: yes sir. chair moran: how do you explain that? mr. eaton: without clearly-defined access standards the v.a. is left to other alternatives to find that level of care. he goes back to education, but also really clear whenever a veteran is met with ambiguity in this critical time you can imagine different barriers they have to face. so, we need clear standards that are dispersed across the entire v.a. that outline what veteran'' options are and what their rights are in this case. ms. marg: can i add something to his statement? when my husband went to tucson they have a program just for veterans. it is a wet -- red, white, and

blue program. my husband was housed with veterans. the veterans had the v.a. paid for their care there. so, it really seems very hit or miss as to what the provider understands and knows what the process is, as to what kind of care they get connected with. chair moran: that is really a partial answer to my follow-up question with you again. it is, you know of other veterans, other veteran families that have experienced similar circumstances? or are you just a one-case circumstance? ms. marg: no sir. there is other veteran families. chair moran: mr. golnick, you were nodding your head? mr. golnick: we saw this a lot at forge, where -- what is the old saying, you have seen one v.a., you have seen one v.a.? unfortunately like i mentioned, some v.a. mc's head grade

educational community care. others didn't. when that ambiguity came in that is where people started, unfortunately what happened with your husband, you're getting into those things and it is not necessarily something that is standardized across the system. that is the bigger issue. chair moran: my impression is that often the treatment at the v.a., if you remain there for the kind of treatment you need for the circumstances that charlie and mr. golnick needed, is often opioid prescription. is that true? mr. golnick: senator, in some cases, right? in some cases it is. a lot of it can be severely persistent mental illness. but, yes, that is a lot of times the case. chair moran: i don't know whether i have made my question clear. there are programs that do not involve opioid treatment, that

the v.a.'s tendency is to utilize opioids as a treatment. is that true? mr. golnick: in a lot of cases, yes. chair moran: maybe you answered my question, but i wasn't sure. anybody want to add anything to what i asked? if not we are going to send it to the ranking member. >> thank you, sir. the ability to do case coordination at a national level, wwp has figured it out and they have people that do complex case coordination. we work with them, but i think that is the absence. there is care out there, it is just a matter of, if you know about you know about it, but you have to know somebody and you need somebody that can navigate the system that way. chair moran: mr. blumenthal. sen. blumenthal: thanks, mr. chairman. what i hear is a common theme. veterans should have choices. care should be timely and it should be high-quality. the most skilled professionals

in the world ought to be available right away. especially in cases of mental health crisis, such as you experienced and your husband, ms. marg. in the best laws in the world demand accountability. the v.a. must be held accountable. one of the best means of holding it accountable as an effective inspector general. would you agree, mr. eaton? mr. eaton: yes sir. sen. blumenthal: finding an inspector general sends a message. it should be accountability not only for the v.a., but also for dollars spent on community care. would you agree with that, mr. eaton? mr. eaton:mr. eaton: i believe sir -- i believe so, yes sir. sen. blumenthal: right now the inspector is far from that kind of accountability when dollars are spent in community care. and they are scarce dollars.

we cannot afford to waste them. whatever we think about the v.a., at least there are means of tracking and record-keeping there that often is unavailable when dollars are spent on community care. we spend a lot of time talking about v.a. facilities. wait times, for example. that data is transparent. it can be recorded, tracked, and acted upon, but that is not true in the private sector. mr. eaton, would you agree that there needs to be accountability in both the front -- the private sector and v.a.? mr. eaton: i think when you consider access standards what we have heard from veterans is even if they receive a community care network referral they could be waiting longer than they would within the v.a. system. i think there are certainly opportunities to identify how we could ensure streamlined care throughout v.a.'s integrated

system, which includes the network. sen. blumenthal: that point is critical. the wait times may be longer in some instances and we need to guarantee the two systems have to be complementary, not competitive that veterans are not delayed in the care they received because care delay can be care denied as charlie's example shows so dramatically and graphically. and i want to thank you, by the way, for being here. i know it is not an easy task to be here. thank you for telling us, being the voice of charlie's story. i want to talk about the hiring freeze. the hiring freeze was going to apparently deny positions being filled in v.a. facilities across the country.

doctors, nurses, tendons, technicians. the people who provide direct care. the administration may have walked back that hiring freeze so far as v.a. facilities are concerned. we are still unsure and clearly the hiring freeze still applies to a, core functions the v.a. provides. and i'm going to ask you again, mr. eaton, because your organization was so instrumental in providing care for charlie and your organization and ms. mathis provides services for veterans, thousands of them across the country. isn't this hiring freeze having a detrimental effect on the v.a.? mr. eaton: thank you, senator. looking at the exemptions we note that critical roles such as social worker, marriage, family therapist, and licensed health are listed as exemptions. we are going to continue to work closely with warriors to hear

their experience throughout the system so we can step in if and win their's area for us to support. sen. blumenthal: but if there are insufficient exemptions it will have a deleterious effect, i assume you would agree? mr. eaton: the capacity to care is tied to capacity. sen. blumenthal: and freezing for suicide prevention programs? just give you one example, suicide prevention -- grant program provides grants to suicide prevention resources to meet the needs of veterans. you are familiar with it? including easter seals, for example in new london? that program now is frozen. in terms of funding. that is a bad decision, would you agree? mr. lorraine: i think it freezes our ability. we connect to three and 35

veterans a week. that is 235 veterans i cannot connect to. sen. blumenthal: my time has expired. i have quite a few more questions, and i hope the chairman will give us a second round. chair moran: senator cassidy. sen. cassidy: mr. golnick, maybe three years ago we had testimony that v.a. was giving people ipads and allowing tele-mental health and setting up satellite offices in a rural area in the back of a walmart. we would be as if you are going to a pharmacy but instead you are not going to the psychologist with a stigma, but instead very discreet. reading your testimony i did not see any reference to that. i will start with you. what about this mental health program? are you familiar with it? mr. golnick: i am, senator.

i think there are lots of good options getting out there. again, i'm not anti-telehealth. i think veterans should have the opportunity to have the choice between seeing an in person provider versus a telemedicine care. sen. cassidy: i only mention that because the rural aspect of it -- this is obviously a way to -- so someone doesn't have to drive an hour to get in and miss the appointment. i'm a physician. by the way, ms. marg, does anybody else have experience with the telehealth and is it effective? one issue here is the lack of providers. this is pretrade as a way extra providers across the country would be able to provide services someplace else and therefore give continuity of care and address that need. yes ma'am? ms. marg: yes sir. we agree telehealth is an excellent option. i think when it comes to license

portability there becomes an issue. sen. cassidy: for the v.a. am told -- ms. marg: for the v.a. it is not an issue. sen. cassidy: but if you are specific to the v.a. right now? ms. marg: telehealth is an option, complementary with in person. sen. cassidy: is that being fully used or is it fully effective? a lot of what we have here is a shortage of providers, and therefore requiring long wait times and/or referral. yes ma'am? ms. mathis: my husband has utilized telehealth before. personally for him he would choose to see somebody in person, given the opportunity, especially when he is talking about his mental health struggles. sen. cassidy: again, i am a physician. when there is so much turn and veteran has been a feature of the discussions about mental

health and the v.a. for some time it is telling me something is wrong. he could be that the salaries are less. but then why would you take the job in the first place? or it could be that the administration is so frustrating that people just don't want to spend the rest of their life in this sort of situation. you are on the outside looking in, perhaps, but you may have special insights. any idea as regards why there is so much churn among providers? >> in terms of them getting into the v.a.? sen. cassidy: the providers, one of the things i read said the providers face this constant turnover. when you are trying to get that report and six months later you have somebody else and six months later you have somebody else. we have seen previous statistics in which there is a lot of hiring but there is a lot of departures. there is a pattern there, and it is disruptive of the patient-physician relationship. do we have any insight as to

what might be causing that churn? >> yes sir. one of the things we see is not just a turnabout leaving the v.a., it is moving within the v.a. also. i think continuity -- and i mentioned it in my testimony. continuity is critical. i think when we talk about telehealth seeing a patient face-to-face as a provider myself, seeing a patient face to face cannot be replaced. it can be augmented and enhanced by telemedicine. sen. cassidy: i accept that. mr. lorraine: in terms of the churn, you are moving within an enormous system. it is not just leaving the system, it is leaving the facility you are in. sen. cassidy: they may go from des moines to new orleans? mr. lorraine: four within the facility, moving to another area. sen. cassidy: theoretically you have systems that would minute that? -- limit that? mr. lorraine: but you lose your continuity to churn. sen. cassidy: ok.

no, i think you all for your testimony. >> thank you, mr. chairman. thank you for your service to our country, whether by direct service or a family member. testimony -- failing our veterans. personally my experience is when i first got back from the war i tried to go right to my v.a. and ask for services for ptsd, was rejected because my paperwork had not caught up, then continue to get help, as well as many of my other guys, and actually avoided therapy for almost 12 years after that. and luckily was now in and have been. but a lot of us missed some opportunities, i think, to put ourselves on the right path because of v.a. bureaucracy back

in the day. this is 2005. as i say, this is very personal to me. and even now i still talk to my brothers in arms who are now also going through different levels of therapy and/or rehabilitation. so, thank you for the testimony you guys are providing. this is obviously important. as well as also disappointed that we did not get someone from the v.a. to talk because they could have brought us a very good first-hand experience about what effective contracting looks like, as well as asking the government accountability office about their assessment of the program last year. i think that would have been a very good perspective because we need to look at this holistically. and for us veterans who use services, get ptsd services or other services, you know the best to deal with anything is holistically. mr. golnick, think you for sharing your experience seeking mental health care through the v.a. and the work you are doing

with forge health. did i say that correctly? wish is my second language so sometimes i mess up thanks. i also have the experience of seeking care and dealing with the trauma of being told you cannot get help. it is too, and of a story among us veterans. it is our responsibility to ensure that veterans have access to timely, high-quality health care. in your testimony you said that. the man that was able to help catch in the first months of trauma were the ones able to recuperate and put out a good path. you mentioned the collaboration between forge health and v.a. showcased community partnerships, but also how some of these ongoing challenges. could you speak more specifically about what you saw in terms of inconsistent implementation and what solutions you would recommend be implemented to address these issues in particular? mr. golnick: yes. thank you for your question. going back to what i had mentioned, there are some v.a.

mc's that are collaborative and work well within the system. if there is delays, and there are somewhere they were basically told not to refer out, no matter what the case was. i think the standard, how we fix this in my personal opinion is to figure out a way to standardize those standards across the system to wear, ok, every v.a. mc has the same exact standards on how they are going to refer out. the number of people they are going to refer out. i understand community care costs money, but again, when we have a veteran and you don't catch them in time and they end up going to the emergency room it becomes way more expensive, right? how do we go upstream to prevent that? i think that standardize practice across the v.a. mc really is an important piece. sen. gallego: some of that is text, but some of it is sop. matter what unit you were you

did an sop so you didn't have to have massive retraining and there was uniformity? mr. golnick: we saw it from the v.a. mc, where the providers are referring out saying, i'm trying to refer, i understand this veteran needs that care, but the visit is telling us now. sen. gallego: got it. naomi -- did i say that correctly? really great organization. they helped me get my disability rating. so, thank you so much. i wanted to follow-up on that. i totally lost my train of thought. are there any standards in place to ensure that community care providers are adequately trained to treat these types of conditions? also, have you seen any specific instances where the lack of veteran-specific training standards have negatively impacted the quality of veteran care? at least from people, constituents of the organizations?

ms. mathis: thank you for that question, senator. there is a lack of training in community care currently. community care providers are only required to have opioid abuse treatment training and as far as compared to direct care. there is a difference between what the direct care providers are required to have and the community care providers. so, this is why we believe that if you strengthen the v.a. direct care, you know, direct care that then you would have that are health outcomes. sen. gallego: so community care, sometimes there may be a veteran that goes and ends up getting treatment for opioids, but not, for example, deep trauma or anything else of that nature.

there is probably a mismatch at that point. what you're saying is there is a better investment in direct care or potentially also doing community care? hyping up community care, making them more accessible to traditional ptsd? ms. mathis: where they would understand military culture, right? that is really where that opportunity is missed. you might have a veteran that presents before a community care provider and they don't understand military culture and they are missing the key was where this patient might actually be suicidal. chair moran: senator tuberville. sen. tuberville: thank you, mr. chairman. i apologize for what has happened to your husband. i had a couple of friends that went through the same situation. terrible outcome. even some were arrested at the v.a. for not having an appointment. and run off of property. it is a terrible mess. how do you communicate with

other servicemembers or family that come to you and ask you about your husband's problem? what is that conversation like? ms. marg: i will tell them that any story they have heard about the v.a. is true. when i have heard other people's stories -- when i first heard them i was surprised and shocked that -- like, this must be a one-off situation. my husband has been medically retired since 2015. and it seems like every step along the way it is such a struggle and there has been many times my husband has just felt that he is done. and i tell him he is not. and we just keep fighting. and sometimes it takes going to an outside entity to get help, which i'm incredibly thankful

that it exists, but that is ridiculous. sen. tuberville: ms. mathis, i heard you say something in your opening statement. we still having problems getting information from the dod? ms. mathis: yes sir. there is no interoperable. sen. tuberville: and we have spent billions of dollars doing that? billions. not millions, but billions. i wonder why we need a new ig? i wonder why we need to freeze the funds and find out what is going on. it is embarrassing. i mean, the biggest health care system in the world and second-largest budget in our country and we can't figure out how to get information from one entity to another. but i have talked to people who said they could not do it. but we will not go to those people. for some reason we keep going to the same people. any follow-up? ms. mathis: senator, you know, i

think that is something the v.a. needs to really get a handle on, which is the records issue. the electronic health record system. i believe i probably misspoke. i believe this dod are probably easier to speak to each other. but when you talk about community care and v.a. is where you have the rug, where you have the issue. records are not coming back into v.a. from community care and they are not going out. save for a mammogram. if i go for a mammogram three years in a row i go to the same provider, right? and then v.a. sends me to another provider, that provider that is going to look at that radiograph needs to see the previous other images, not just the report. and so, then the onus is on the

veteran to transfer those records and images from one provider to the next or from the provider to v.a. that is where we need to have an interoperable system. sen. tuberville: we have the same problem in the dav just as bad as the v.a., of information coming back and forth? ms. mathis: in dav? sen. tuberville: yeah, the same problem, information-wise? the exchanging of information from one entity to another? ms. mathis: you mean from v.a.? from v.a. to dod they have actually worked on that with oracle. but really the issue is from community to entity. sen. tuberville: thank you, mr. chairman.

>> thank you, mr. chairman and i want to welcome the witnesses for being here. our family numbers and caregivers. thank you for standing by your husband. as far as dav you hold my power of attorney as well. [laughter] it says something. and, mr. eaton, there might be a conflict of interest. mr. eaton, i think i was the first female patient to receive one of the backpacks that wounded warrior project handed out at walter reed. i think i was one of the first. unfortunately, it had jockey shorts, socks, and a shaving kit. [laughter] none of which i could use, but my husband thanks you for them. the kids are much better now because they are now what the presence of women they took my advice and readjusted. but certainly the wounded warrior project was there for me early on. i do want to take a moment to

bring attention to the outrageous eeo that donald trump signed last night and my colleagues touched on briefly. that this pause of all federal grants today, we are in a hearing room full of citizens dedicated to the veterans, but let me tell you what this means for you and your loved ones. this eo will pause critical and life-changing v.a. grants, including those that aid in v.a.'s mission, ranging from immunity-based suicide prevention efforts to rural veterans telehealth access and transportation services, to hiring and retention of services, to adaptive housing, assistive technology, and so much more. it is ironic we are here today to discuss expanding access to care, meanwhile the trump administration is preparing to restrict their access in just a few hours' time. what happens in the meantime to veterans who rely on these grants? what happens to rural veterans

who rely on v.a. transportation services? it happens to veterans who rely on these grants to live independently? this eeo, which is illegal, creates chaos and threatens the stability of programs that in many cases offer lifelines to people who sacrifice for their country. congress alone has the power of the purse and trump freezing billions of dollars of federal grants that congress already approved is unconstitutional and will hurt millions of people across this country. i hope the republican colleagues and the courts have the spine to stand up to trump in the face of this cruel, chaotic, and on's constitutional order that hurts everyday americans, including veterans. i cannot agree more with the frustrations that have been described with trying to access care through v.a.. within v.a. itself, as well as through community care. i have both. i get care in the community because the v.a. cannot provide me care without extremely

advanced prosthetic devices i use. i should have the right and i do have the right to choose the prosthesis that provides me with that care. it is ironic, because the v.a. provides care for my left leg but my processes in the community provide care for my right leg. it is important that they talk to each other, because otherwise it makes it difficult to walk. ms. mathis, i think you are touching on this communication piece is critically important. when i went from dod to v.a. i was given a cd-rom. i had to wait 90 days to go talk to v.a., at which point i went and saw a physician assistant whose job it was to determine whether or not i was still an amputee. it was a waste of his time, it was a waste of my time. he wanted to be taking care of veterans yet he had to go through this rigmarole. to this day they lack good transferring of information from the dod to the v.a..

it is also compounded when you go to community care. i do think that we need to do much more to allow veterans to make their own decisions. stu golic, i appreciated your attention to this issue, about veterans being able to make the decisions. in your opinion how should the v.a. be ensuring that veterans are getting the information they need to make appropriate decisions about their care, including the choice to receive direct care at v.a.? because v.a. needs to be a medical center home. i think you should go to v.a., that is your medical center home, and they look at you and say, ok, you are an iraq veteran, we are going to take care of your mental health, but also you may have respiratory illnesses. if you want to go to community to get the care that should be made seamless. can you speak to that? mr. golnick: yes, senator. i think it is an education thing. on the ground level, and both of you has seen this before, where the clinicians at v.a. want to do the right thing.

they want to get veterans into care immediately. i think where it gets going to up is when it gets up to a different level, right? it starts going up to the visit level, they are putting the referral in. in terms of educating a think there needs to be an education of, these are your options, these are the things that are out there. he was what we can provide. here is what we cannot provide or it is going to take too long and here is how you get there and here is the process to do it. i think there needs to be an education on the ground level and it needs to go all the way up to the visit level. chair moran: senator blackburn. sen. blackburn: let me indicate there is a vote at noon and we have less flexibility than we used to have in rolling the timeframe so i'm going to try to keep everybody to their five minutes. senator blackburn. sen. blackburn: i appreciate what senator tuberville said and senator duckworth just alluded to this.

that it is very difficult for the veteran to get their records. and i think one of the things we should look at is who owns those records. it would be so much more helpful if the veteran himself controlled those records. if individually we owned our health care records. every one of us. and then that way you would not have the problem you are talking about. the veteran would be in charge of their records. and would be able to take it, whether they are in community care, whether they are in tricare, whether because we have seen just an inordinate amount of waste. in trying to build the electronic health records. whether it is cerner, epic, oracle, it is like they cannot figure this out. in nashville we have a lot of help for i.t. innovators so they

can figure this out. when way to do it is to let individuals -- not the doctor -- not the insurance company -- not an agency -- owned their health care records. i also want to say i find it very sad that for many of our vets wounded warrior or the people that can help them get help. because the v.a. can't figure out how to do their job. they are still working remote. they do not show up. it takes forever. that is why there are 950 6000 claims in the queue and nearly 300,000 over 120,000 -- 120 days and veterans cannot get a response from these people. i know a lot of it is because the union that is there at the v.a. that is stifling access to this care and benefits. and i find it just as something

that should not be tolerated and it is frustrating to the veterans that we are trying to serve, and it is why community care is so vitally important. thank you for speaking to that. mr. golnick, i want to come to you. and thank you for your service. and thank you for what you are doing with forge. and trying to solve a problem. because the v.a. has thrown up barriers to health care. and you are trying to get around that and improve access, so i want you to give, like, a 1, 2, 3 point. what could this committee require the v.a. to do to improve that access? mr. golnick: thank you, senator. i am representing myself.

but i will say there are things, and to your point, i think there is a lot of friction points that are preventing veterans getting access to care. especially when you're talking about mental health. with this committee could do is work with the v.a. to ensure that they are educating veterans, that the v.a. is educating veterans on what their options are. but two would be the administrative side of this, ensuring that the access standards are codified so the people within the v.a. system no, ok, if asked, then why, right? it is as simple as that. then i think ensuring that there is some oversight on certain v.a.'s and certain visits in terms of that care, making sure the veteran is the true north star. it is not what their local budget is, it is not anything else. care of veterans should be the northstar of all veterans. sen. blackburn: i agree.

that is why i have this v.a. health care freedom act. that would remove those obstacles and really put the criteria in the -- and the mission act for eligibility for community care and give full choice to veterans in select regions. let's roll this out as a pilot project and put it on the four-your path to fully implement it. so a veteran can get what they need when they need it, where they need it, show their v.a. card, and the v.a. gets the bill. not the veteran. and that would solve this and this enormous backlog that we have. give the veteran the choice. put them at the center of this. thank you, mr. chairman. chair moran: senator king. sen. king: in answer to senator tuberville's questions, i think

this records problems started with a no-bid contract about five years ago, six years ago it was extended by the last administration. and i still don't understand why we don't go out to the market. i'm sorry you mentioned epic, because epic is a successful medical records system that i observed in my system. well, ok. in any case, it seems to me in order to analyze the issue of the relationship between v.a. direct care and community care we need more data. we know exactly the v.a. wait times and all of those kinds of things. we don't have that kind of data in terms of the private sector. i know in the private sector in maine it is hard to get an appointment. and particularly with a specialist. i think in order to make policy here, mr. chairman, we need some information. we need to have cost

comparisons, we need to have time comparisons, wait times, so everybody is nodding, but that will not show up in the record. could somebody say, yes, senator, you are right? ms. mathis: yes, senator. i agree. there is no data coming back into v.a., and there is no sort of accountability either when the records don't show up act v.a.. so, you have a provider, a primary care provider at v.a. that may have sent a patient out to the community for specialized care and the information, when the patient comes -- comes back to v.a. the information is not coming back. therefore that provider is not able to provide an accurate treatment plan for that patient. sen. king: so we don't have a handle on cost, quality, or time, is that correct? ms. mathis: cracked, senator. -- correct, senator. sen. king: by the way, when we

are talking about v.a.'s responsibility and backlogs, a staff freeze is not going to help the problem. if there are fewer people to answer the phone, fewer people to process claims that is only going to exacerbate the problem, not get any better. i note that the administration the other day appeared to walk back part of the hiring freeze with regard to direct care providers. but to leave a hiring freeze in effect that has fewer people responding, processing claims, and those kind of things, that is in effect a denial of benefits itself, is it not? mr. eaton: yes. that is where we come in. senator duckworth mentioned the backpack. we received our start in 2003 providing backpacks to the first injured wounded warriors coming back from iraq and afghanistan. we made a promise, so we will continue that promise that we will be there for their needs. we are doing that today, and in

times where we can be a constant to support them and remove barriers to increasing access to care. sen. king: one other factor we need to talk about is that there are huge shortages in the private sector. one of my major hospitals in maine is down something like 800 nurses. and so, to say it is -- it is not enough to say community can take care of it when there are shortages in the community in terms of cna's, nurses, psychiatrists, psychologists, and i think we need to recognize that. that there is no simple answer to this. to me the answer is better coordination, better data, and understanding the results we want for veterans. that is really the goal. is that correct?

>> yes, senator. absolutely. even the commercial players are not collecting this data because it makes them look bad if the wait times are bad. sen. king: i want to be sure we are comparing apples to apples when we are deciding policy here and we don't move toward a policy that in the real world does not necessarily improve things for the veterans. and i just am concerned that we not hollow out the v.a. capacity and then say, look, the v.a. is not doing very well, when we have made it impossible for them to do it, to do the work they have been charged to do. so, i appreciate you all joining us here today and look forward to continuing to work with you. because i think this is an issue that needs attention. thank you, mr. chairman. chair moran: senator, thank you. the elizabeth bill act requires

significant data collection regarding community care. so, maybe we will have some information and we can make that analysis. i also want to point out that i have argued with the v.a. about when the wait time starts. when the appointment is made, not when the veterans ask for the appointments. sen. king: that's got to start with the call. chair moran: senator. >> thank you for your testimony. so, a couple of things come to mind. one of the things with regard to senator king's shortage of workforce, that is a real problem. that is a problem in health care. it is a problem in manufacturing. but it is particularly challenging in health care. which is why the cms rule, the staffing rule is so all. because it literally -- literally -- provides less opportunity because it runs the risk of shutting down health

care providers simply because they do not have a 24 hour a day, seven day a week are in -- rn. access is not just about the quality of the care, it is about access, period. so, while standards are important now would also submit -- i do not share some of my friends' view that it should not be competitive. i think the best way to improve care is competition. whether it is a competition against -- between the private sector and public sector, two private sectors or two public sector agencies. a little bit of competition is fine. i agree i do not want to got v.a.'s direct care. there are unique things. i know several of my veterans, i have a veteran who would drive 300 miles to fargo every day before he would see a local provider. particularly for counseling. all of that said, there are all

kinds of barriers to community care. a lot of it is the bureaucracy itself. even in north dakota where we have quite a cooperative va hospital in fargo, we hear many stories of roadblocks being put up to community care. they check all of boxes except one. or you know, they only check 99 out of the 100 boxes. i just think we need to make it -- i agree with what senator blackburn said. if we put the choice in the hands of the veteran the market will determine where they go. the type of care they get will determine where they go. how long a wait will determine where they go. the little bit about north dakota. we have one ba in fargo. that is right on the red river. i mean, literally on the shores of the red river, which is the barrier, the border to

minnesota. that means if you are in williston or you might be for hundred miles away. from the va hospital. we have eight c boxes and 37 critical access hospitals. critical access care hospitals or their own purpose and it has to do with access, right? and they are reimbursed by cms, a particular formula. and we have veterans -- by the way, i think it is just a handful of those are in the same community. as a critical access hospital. what i would like to see us do -- and i have the proposal to do this and you will be hearing more about it eventually. if training is required i am all for it. but for many of these critical access hospitals their margins are this then. they are barely hanging in there. and two or three more patients, or five more patients in the

community might be what keeps that hospital open. and if it is 50 miles to the next hospital or 350 miles to the va hospital that access might be the only provider that can save a veteran. i would like to make this automatic. we can no doubt smart people can figure out the records thing. maybe i will start with you, mr. golic. is that plausible? my someplace in the ballpark for a possible solution in a very rural place? mr. lorraine: yes sir. i know how rural it is. sen. cramer: that is one of our biggest cities. mr. lorraine: one of the things i spoke about was continuity of care. not only continuity of care as a health care provider. i want the physical therapist nearby. i want the staff. we talk about mental health and substance abuse, but it is more than that. we are talking about access to

health care. it is surgery. how many total knees are done in this location? the answer is, we need to look at what is the best long-term outcome for a veteran in terms of getting their care? it may be the v.a. in their community, it may be your local hospital. the family can be present, the staff is invested, and it is all one. thank you. sen. cramer: i would just rather have it easy rather than confusing. and then likely a denial. thank you. chair moran: senator hassan. sen. hassan: thinks to all of our witnesses for being here today. whether you have served, been an advocate, or both, we appreciate your support for and commitment to our veterans and our nation. i appreciate that this hearing is focused on community care. it is a really important component of providing care to

our veterans, especially in a state like new hampshire. which does not have a full-service va hospital of its own. it matters that we get this right and ensure that veterans who qualify community care really get prompt access to it, understanding, as senator king has pointed out, that access in the revit community health care system is challenging for private citizens as well. but before i get to any questions i want to take a moment to discuss what are -- what are illegal and unconstitutional acts by this administration because of the way they affect issues we are talking about today. as senator duckworth referenced the administration last night ordered a full halt on a whole lot of federal funds, including some states are now locked out of medicaid funds. community care in rural areas that senator cramer was talking about will not exist if we -- if rural hospitals don't exist and they are very dependent on medicaid. but the administration appears to be halting that funding as it is halting critical funding

today for veterans in rural areas that depend on it. the administration also took an illegal act when it decided to unilaterally try to fire inspector generals, contrary to law. this is really troubling for a lot of reasons, just for example, the v.a. inspector general's office just released a report last fall on community care scheduling delays in the v.a. health service. but the administration is unilaterally deciding to fire all of these inspector general. the report that that inspector general date concluded that leaders had failed to focus on the patient, respond to staff concerns and get to the root cause of concerns regarding delayed scheduling of urgent consults. this type of work, holding government accountable and making sure that our system operates as efficiently as it can, is at the heart of what

independent inspectors general do. that is why i am really concerned why president trump's illegal firing of at least 17 inspectors general over the weekend, including v.a. inspect general michael mu saul, who was confirmed with unanimous consent. by the united states senate. the letter to these priorities were changing, that is what the donald trump administration said. what greater priority is their event to ensure that taxpayer dollars are used well? is in the interest of every american that these public servants people to investigate waste, fraud and abuse without political interference and be able to stand up to powerful interests without fear of losing their jobs. we owe that to our country and especially to our veterans. i have time for a couple of questions. i want to start, mr. eaton, with you. in your written testimony discussed some of the optical veterans encounter when seeking mental health care in particular, identified that more

providers are needed regardless of whether they are in the community or in the va system. can you please speak to the need for veterans to have access to stable, high-quality mental health treatment and how increasing the number of mental health providers to support that? >> when you think about an effective care team and we understand first of all, personal journey that it takes to get to that first appointment, building a relationship report -- rapport, so as va employees or even community care employees are transitioning, it leaves the veteran to navigate that system again on their own. as we piloted here today, not only the veteran, but also as civilians in general, mental health is a shortage area. looking at ways to incentivize providers, create environments where practicing medicine and mental health is a thriving

environment really important. >> i appreciate that, thank you very much. community care provides a chance to receive timely quality care close to home for many veterans who don't live near va facilities. this is especially true for rural veterans and veterans who live in states like new hampshire that don't have a full-service hospital. could you please discuss the importance of ensuring timely access to local care for the role that community care plays in ensuring that veterans get the care that they need and deserve? >> absolutely. as outlined in the mission act, it should be complementary. we believe that access to community care is essential, especially in a rural community where you're fighting with the community to get specialized care, so yes, absolutely, access

is critically important and really could be lifesaving. >> thank you mr. chairman. health care organizations get more frustrating and impersonal the bigger they get. we can all agree on that. the veterans health administration is the largest hospital system in the country. why do you think the va is so bureaucratic and what can congress do to change that culture? >> that is a tough question. every large health care system is frustrating. there are a lot of things that were structurally in place that i think are important things that are safety, especially when you're talking about mental health. clinicians should have a certain criteria. i don't think it is on the clinical side that we are seeing the issues. where i see the issues are when we get up into the administrative. i think the processes that are in place right now between the

va, intercommunity care and back-and-forth, but my colleague has been talking about, that is really where i think there could be some good work done in codifying those access standards so that everybody in this bureaucracy, i look at things as a naval officer, the only safety instructions are written in blood because there needs to be very clear line that shows if x, then what? >> as a navy officer you understand culture, so how do we change the culture and what can i do and what can members of congress do to force that culture to change? >> i think usually jewish -- i think the ability to ensure where they said i give

directives, sometimes things are not just followed. i think will be streamlined in codifying things in a more clean manner and having those things in place is going to ensure that people are following the letter of those instructions. >> we hear a lot about community care being too expensive. it accounts for about 40% of veterans health care and about 25% of the budget. that sounds like a pretty good deal, doesn't it? >> i don't think we've given enough chance to measure the long-term impact of local, meaningful, well-rounded health care. the other thing if i could just add to the question that you asked eric, in my opinion, the veteran needs to be the center of the universe for the va, not the va the center of the universe for the veteran. >> well put.

i support giving the va the resources it needs to take care of our veterans, but there are only so many doctors and nurses to hire. how do you think the apartment could deliver more health care with the personnel it already has? >> they needs to be not managed health care, but coordinated care. coordinated care, somebody needs to take responsibility for the veteran and connect them to private organizations like public health care providers in the community care network in the va to look for the best opportunity, but to unify, to coordinate the care for the best outcome. it doesn't just need to be in the va. >> we want community care and va care to complement each other, not compete as the hand over the past decade. what policies need to change to make that happen? >> thank you for the question. i would say again we had standard access across the board. we think about the largest

integrated health network, and these are cultivated networks created in partnership with the administrators that have been found to call for high-quality, veteran-centric care. having the same can -- standards of care throughout the entire system would be a great first step. >> the va has 120 seven mental health rehab facilities, and veterans and crisis are waiting about three weeks to get placed. it takes the va 3-5 years to release a new facility. do you face they could ever open enough residential rehab facilities to fully meet veterans needs? >> i think if we take a step back that is why the community care network exists, to really complement areas where there's gaps, higher demand, ember veterans needs are most sought. i think if we take a step back and look at all inputs as well as the community care network, we will have all the data points

to make that informed decision. > if somebody else watching the door, we have a couple of questions. caller: we no longer have the flexibility because we are attempting to enforce the vote only lasting 15 minutes, and we used to be able to do this much differently but we cannot. >> i have a few questions which i think are answerable by yes or no, because what i'm hearing as was said so well, the veteran ought to be the center of the universe. veterans choices should be respected. their decisions should be informed. so that their medical interest is put first. and informed decision can't be made by a veteran based on an

advertisement she sees on television saying go get this drug. anybody watching tv today, there is a deluge of as -- ads that depict certain drugs as cure-all's. the veteran should not be permitted to say give me this opioid. i assume all of you would agree. >> i would agree with that, senator. >> and i'm taking the absence of a disagreement as a yes. let me pose another question to you real quickly. my fear as i stated at the very beginning is that there would be an erosion, a starving of the va because the attempt to shift care to the community without veterans having choices will mean less investment in the

system, and in connecticut we are rebuilding our facility in west haven. it will provide for a new surgical suite, new parking, new care facilities, particularly for women. that kind of investment will make the care better than it is now. i assume all of you would agree that we need to make those capital investments in facilities across the country. and maybe build facilities in parts of kansas that right now don't have any, would you all agree? >> i disagree. i don't think that we can build enough facilities to meet the needs of every veteran in the united states. i think there needs to be a merging between good facilities and -- i don't mean to use of your time. >> and you're absolutely right. and i was unclear, i'm not saying that facilities should be billed for every veteran who need some community care, no

question about it. but the facilities that exist right now serving veterans in connecticut or kansas should be the gold standard. they ought to be top-flight. we want to give veterans the best care possible, would you agree with that one? >> 100%. >> thank you. let me just conclude by saying you know, this conversation seems a little bit surreal this morning because i'm getting emails from health care groups in connecticut whose funding has been frozen. these are suicide prevention, they are addiction treatment, they are payrolls that are halted. their budgets are in danger. we are talking about community care, potentially decimated. there's chaos and confusion as a result of this freezing of on

this. in my prior life as attorney general, and the state of connecticut i would be in court saying that this action is illegal, it's unconstitutional. congress has the power of the purse, it is a procedure of power, monarchical and autocratic and it is a violation , but put aside the galleries, is potentially devastating to health care for veterans. the foxed suicide prevention program that is mentioned is just one of literally tens, maybe hundreds of programs that are in peril right now, so i call my colleagues to join in protesting and opposing. once again, i asked veterans to rise up and say please, mr.

president, codify that you are not going to make veterans the victims of this illegal policy. in the same point i would make as to the firing of inspectors general. accountability for community care as well as veterans care. that's put veterans care first and foremost, including holding accountable the va. they ought to have their feet to the fire, as michael missile has done as inspector general. he saved $40 billion. that is a rough estimate. and there was a mention of the electronics record program. there was a provision that would have provided more accountability for the program. apparently it was deleted at the last moment. i think we can included --

include it in whatever standards and criteria are applied and eliminate wait times whether at the va or in community care. mr. chairman, i really appreciate your leadership. i know you made reference to inspectors general in that hearing recently. i think this cause could be bipartisan, and a hiring freeze can be clarified so that it doesn't affect the va and our veterans care. >> thank you, ranking member. there are five minutes left in the vote, but i still have questions. so we are about done. both wood and warrior project and american warrior partnership indicate basing trends over the last year indicating pressures

from va administrators and providers cannot place referrals . when one or both of you explain what you've seen? >> thank you for the question. what we are hearing from clinicians is really that pressure from an administrative perspective to minimize referrals, and the decision being made at the administrative level vs. a clinical level. this could mean that instead of going out into the community for care, they could also result in a different level of care than initially indicated. so whether an individual we shifted into a group setting, which is really not aligned with what the veteran was looking for. >> and for me to point out what i think is obvious, that could very well be contrary to what is in the best interest of the veteran patient. and who, including their administrators, ought to be the

most interested in the quality and not only the timeliness, the quality of the care it veteran receives? >> i spoke about this, and it bothers me because for my involvement in veterans issues for as long as i've been in congress, i sometimes can get individual cases altered. fix a problem for a veteran, but it doesn't seem like when i do that it fixes the problem for the system, for every other veteran who is experiencing the same thing. i highlighted on the senate floor the veteran in my hometown who is receiving cancer treatment. 60 treatments, he was receiving them in the community at the authorization of the va. he had 59 treatments of the 60 needed and the va called him back. the other example, i've indicated somebody times that

what i think i know is based upon what i hear from veterans. you had a veteran who is been receiving chiropractic care with the same chiropractor for months and years, but the va says no, that is no longer permissible, community care will not cover your visit to a chiropractor. come back to the va. those decisions can't be made based upon what is in the best interest of the health care and well-being of the veteran. so the va, i was involved in the creation of the mission act. one of the components by which a person can be referred to community care is what is in the best interest of the veteran. and we intentionally defined best interest of the veteran to be determined by the veteran and his or her provider, not an administrator at the va, so that

the decision is made on the best health care interest of the veteran, not on the financial well-being or the caseload of the va. i mean, i am all interested in seeing the law is complied with. and that is what i've spent so much time trying to convince in recent months the va to utilize the mission act in the way that it was not only intended, but in many instances, actually written. so we are trying to get the law to be the law and i appreciate the testimony that we heard today. i think there is a take away for me and i hope others, that this is particularly important when it comes to mental health, suicide ideation, all the care for veterans matters, but there are certain things in which the timeliness and the consistency and the personal nature of the

care determines the outcome and whether there is success, so i take your testimony very seriously and trying to be a better advocate for not just community care or the mission act, but community care and the mission act as it may save a life and improve the quality of life for veterans who can't get what they need within the va. i wanted to talk about residential treatment that i don't have the time. it has captured my attention as well, what did the department of veterans do to provide more longer-term care for veterans? i'm going to conclude the hearing with an expression of gratitude for all of your presentations and your willingness to visit with us. we will try to be a committee that listens to those who tell us what the challenges are and respond appropriately. each member of our committee has five legislative days in which to revise and extend their

remarks, what we all said. and they ask any senator who would like to submit a question to you to do so in a timely manner, and we like for you to respond to the record following today's hearing in a timely manner as well.